Abstract and Introduction
Abstract
Objective To determine the pooled effect of exposure to one of 11 specialist palliative care teams providing services in patients’ homes.
Design Pooled analysis of a retrospective cohort study.
Setting Ontario, Canada.
Participants 3109 patients who received care from specialist palliative care teams in 2009-11 (exposed) matched by propensity score to 3109 patients who received usual care (unexposed).
Intervention The palliative care teams studied served different geographies and varied in team composition and size but had the same core team members and role: a core group of palliative care physicians, nurses, and family physicians who provide integrated palliative care to patients in their homes. The teams’ role was to manage symptoms, provide education and care, coordinate services, and be available without interruption regardless of time or day.
Main outcome measures Patients (a) being in hospital in the last two weeks of life; (b) having an emergency department visit in the last two weeks of life; or (c) dying in hospital.
Results In both exposed and unexposed groups, about 80% had cancer and 78% received end of life homecare services for the same average duration. Across all palliative care teams, 970 (31.2%) of the exposed group were in hospital and 896 (28.9%) had an emergency department visit in the last two weeks of life respectively, compared with 1219 (39.3%) and 1070 (34.5%) of the unexposed group (P<0.001). The pooled relative risks of being in hospital and having an emergency department visit in late life comparing exposed versus unexposed were 0.68 (95% confidence interval 0.61 to 0.76) and 0.77 (0.69 to 0.86) respectively. Fewer exposed than unexposed patients died in hospital (503 (16.2%) v 887 (28.6%), P<0.001), and the pooled relative risk of dying in hospital was 0.46 (0.40 to 0.52).
Conclusions Community based specialist palliative care teams, despite variation in team composition and geographies, were effective at reducing acute care use and hospital deaths at the end of life.
Introduction
Home based palliative care teams are meant to help patients manage symptoms, improve quality of life, and prevent avoidable hospitalisations, which are documented issues at end of life. Moreover, policy makers internationally want to deliver integrated palliative care in the home and community, since many patients prefer to be cared for at home, community care is often less expensive than hospital care, and acute care hospitals are overwhelmed. However, policy makers are unsure of optimal models of care delivery based on interdisciplinary teams. Although studies have evaluated specialist palliative care teams in hospitals, only nine randomised controlled trials specifically investigated specialist teams in the community. The community based teams studied in these trials involved a core group of interdisciplinary team members, specifically palliative care physicians, nurses, and family physicians who provide integrated palliative care to patients in their homes. A common role of the teams was to manage symptoms, provide education, coordinate care, and provide additional or enhanced support and care. Teams were also available to care providers, patient, and family 24/7 (available without interruption regardless of time or day). However, variations existed within core team members, such as the extent of involvement of the family physicians, ranging from minimal (such as a single consultation) to extensive (such as substitution of usual family physician with palliative care physician) depending on the team. In addition, teams may have included other members such as a psychosocial counsellor or social worker, varying their team compositions.
While the nine community based trials of specialist palliative care teams consistently reported improved symptom management, satisfaction, and quality of life, the evidence for reducing hospital and emergency department visits was mixed. Three trials demonstrated that patients cared for by specialist teams had significantly fewer hospitalisations or emergency department visits compared with usual care, whereas four trials did not. Three trials also found that specialist teams significantly increased the likelihood of patients dying at home, but one meta-analysis (examining community based, specialist, palliative care teams providing nursing services) found inconclusive evidence for the same outcome. Variations among the teams in the nine trials—including the health financing system, team size, and team composition—may have contributed to the mixed evidence, but this has not been researched. Thus, research has not clearly explained why some teams reduced acute care use while others did not.
A natural experiment exists in Ontario, Canada, where several regions have independently developed their own community based, specialist, palliative care teams. These different palliative care teams serve different catchment areas, vary in team composition, but have the same core team members and are within the same health financing system. Thus, they represent a unique opportunity to assess the generalisability of effectiveness of specialist palliative care teams in real world conditions. Specifically, this study investigates the pooled association of reducing use of acute care late in life and hospital death among those exposed to one of several community based specialist palliative care teams compared with usual care in the community.