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Dr S Enguidanos, Partners in Care Foundation, San Fernando, CA, USA;
randomised controlled trial.
blinded (data collectors).*
2 HMOs in Hawaii and Colorado, USA.
310 patients (mean age 74 y, 51% men) who had a primary diagnosis of congestive heart failure, chronic obstructive pulmonary disease, or cancer; had a life expectancy ⩽ 12 months; had visited the emergency department or hospital within the previous year; and scored ⩽ 70% on the Palliative Performance Scale.
in-home palliative care (IHPC) plus usual care (n = 155) or usual care alone (n = 155). IHPC was provided by an interdisciplinary team including the patient and family; a physician, nurse, and social worker with expertise in symptom management and biopsychosocial intervention; and other team members as needed (eg, spiritual counsellor, pharmacist, dietician). The team coordinated care across all settings and provided assessment, planning, care delivery, follow-up, education, and support. Physicians conducted home visits and were available, along with nursing services, on a 24-hour on-call basis.
patient satisfaction, use and costs (in 2002 US$) of medical services, site of death, and survival.
to death or end of study period.
The table shows the results. IHPC resulted in lower mean total costs of care ($12 670 v $20 222, 95% CI of the difference −$12 411 to −$780) and lower mean daily costs ($95 v $213, p = 0.02). Survival time was shorter in the IHPC group (mean 196 v 242 d, p = 0.03 based on t tests; p = 0.08 based on Kaplan Meier survival analysis), but more patients in the IHPC group died at home (table).
An in-home palliative care (IHPC) programme plus usual care increased patient satisfaction and reduced use and costs of medical services. More IHPC patients died at home.
Abstract and commentary also appear in ACP Journal Club.
Brumley R, Enguidanos S, Jamison P, et al. Increased satisfaction with care and lower costs: results of a randomized trial of in-home palliative care. J Am Geriatr Soc 2007;55:993–1000.
Clinical impact ratings: GP/FP/Primary care 6/7; IM/Ambulatory care 6/7; Geriatrics 6/7; Cardiology 5/7; Oncology—general 5/7; Respirology 5/7
Home hospice has become established as an effective means of improving care for patients with terminal illness, providing better symptom management, increasing patient and family satisfaction, and providing a preferred place of death compared with usual outpatient care, including home health services. However, many patients with advanced illness continue to desire potentially life prolonging or other therapies that do not conform to Medicare’s definition of hospice care or are not provided by traditional hospice programmes. IHPC provides the supportive, interdisciplinary care typically offered by a hospice while allowing patients access to aggressive therapies; therefore, it may be a more effective means of meeting the needs of patients with terminal illness.1
The methodologically sound trial by Brumley et al compared IHPC services with “usual” care. Patients assigned to the fully interdisciplinary in-home palliative care team had increased satisfaction, reduced use and costs of medical care, and a higher percentage of deaths in the home setting compared with usual care. However, the IHPC model used in the study limits the generalisability of these results, particularly costs and care utilisation. Unlike hospice teams, the discipline composition of palliative care teams has not been standardised, giving rise to potential variability across settings.
The reasons for shorter survival time in the IHPC group are important unknowns, but the higher level of patient satisfaction indicates the potential for a high rate of use. Wide scale implementation of IHPC as a care delivery model should be preceded by further evaluation of the survival difference between groups and standardisation of IHPC interdisciplinary team composition. Meanwhile, application of these findings by primary care physicians could focus on suggesting IHPC as an alternative for patients with life limiting illness who are not eligible for or interested in hospice care.
Source of funding: Kaiser Permanente Garfield Memorial Fund.
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