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In-home palliative care increased patient satisfaction and reduced use and costs of medical services

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S Enguidanos

Correspondence to: Dr S Enguidanos, Partners in Care Foundation, San Fernando, CA, USA; senguidanos{at}picf.org

QUESTION

Does an in-home palliative care (IHPC) programme plus usual care increase patient satisfaction and reduce use and costs of medical services compared with usual care alone?

METHODS

Design:

randomised controlled trial.

Allocation:

concealed.

Blinding:

blinded (data collectors).

Follow-up period:

to death or end of study period.

Setting:

2 health maintenance organisations in Hawaii and Colorado, USA.

Patients:

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 (ED) or hospital within the previous year; and scored ⩽70% on the Palliative Performance Scale.

Intervention:

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, chaplain, pharmacist, or dietitian). 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. Usual care followed Medicare guidelines for home health care to provide various amounts and levels of home health services, acute care services, primary care services, and hospice care.

Outcomes:

patient satisfaction, use and costs (in 2002 US dollars) of medical services, site of death, and survival.

Patient follow-up:

96%.

MAIN RESULTS

More patients in the IHPC group were “very satisfied” with patient care at 30 and 90 days, but groups did not differ at 60 days (table). Fewer patients in the IHPC group visited the ED and were admitted to hospital (table). 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 v usual care only*

CONCLUSION

An in-home palliative care programme plus usual care increased patient satisfaction and reduced use and costs of medical services compared with usual care alone.

A modified version of this abstract appears in ACP Journal Club.

ABSTRACTED FROM

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: Home nursing 6/7; Oncology 5/7; Palliative care 6/7

Commentary

The study by Brumley et al provides new information about the effects of an IHPC programme on patient satisfaction and medical care use and costs. Methodological strengths include the RCT design and high follow-up rate. The concept of interdisciplinary IHPC and inclusion of patients with multiple chronic diseases are important contributions to clinical practice.

The findings support the development of IHPC programmes since IHPC resulted in lower costs of care, fewer ED visits and hospital admissions, a greater likelihood of dying at home, and greater satisfaction with care. These outcomes are important from both patient and healthcare provider perspectives.

Use of health maintenance organisation closed-system managed care and proxy costing methods limits generalisability of findings to other countries. Nurses may also struggle with when to enrol patients in IHPC programmes because of difficulties in determining prognoses for chronic diseases such as chronic obstructive pulmonary disease and congestive heart failure.1 It would have been helpful to have more information about the frequency and duration of contacts provided by IHPC team members.

IHPC programmes provide an important mechanism through which nurses can advance palliative care in the home, particularly by sensitising others to patient preferences with respect to where they die and supporting patient and family goals for a “good death.”2 Finally, IHPC programmes provide an opportunity for advanced practice nurses and nurse practitioners to play key roles in coordinating interdisciplinary and shared care for people facing the end of life.

View Abstract

Footnotes

  • Source of funding: Kaiser Permanente Garfield Memorial Fund.

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