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Implications for practice and research
This review found evidence of the benefits of providing home-based palliative care, supporting people to die at home, particularly those with advanced cancer.
It is possible for service planners to calculate the levels of service required and project future need; however, planning is complex and multifactorial.
Further meta-analytic studies are required on cost-effectiveness, caregiver grief, symptom burden and other aspects of care.
Even though most people would prefer to die at home, institutional death is increasingly more common in many countries. In reviewing all known studies, this review by Gomes and colleagues highlights the impact home-based palliative care provision has on whether the death occurs at home, while also considering the impact it has on the management of symptom burden as well as carer distress. This review has gone further than previous studies, to include patients with any malignant or non-malignant advanced illness and to specifically address effectiveness and cost-effectiveness of home care services.
Twelve electronic databases, four textbooks and recent conference abstracts were searched for studies describing home-based palliative care to patients with advanced disease and their caregivers. The inclusion criteria was that the studies needed to have four elements: (1) patients with advanced disease which is unresponsive to treatment; (2) support of patients and their carers in non-institutional environments; (3) patients in receipt of palliative care and (4) the care is aimed at the physical and psychological aspects of care. Primary, secondary and economic outcome measures were sought. Researchers known to be working in this area were contacted for any unpublished data. The studies were reviewed by two independent reviewers.
The search resulted in 23 studies (16 randomised controlled trials (RCTs), four cluster controlled trials, two non-randomised controlled before and after studies and one interrupted time series) conducted in the USA (11), the UK (5), Europe (5), Australia (1) and Canada (1) and included 37 561 patients and 4042 family caregivers. There was clear evidence of the benefit of home-based palliative care services compared with usual care in doubling the chance of death at home and reducing symptom burden without increasing the grief intensity of family caregivers after patients’ death. However, evidence of cost-effectiveness, pain control, satisfaction with care and other outcomes was inconclusive.
Gomes and colleagues are to be commended on their critical analysis of three decades’ worth of research on the effectiveness of home-based palliative care on the patient and caregiver outcomes. That the evidence was conclusive in only 3 of 12 outcomes highlights the typical challenges in palliative care research. Where findings may or may not be significant depends on many factors that vary between countries, settings, type of usual care delivered, the population group and the study design.1–3 While only 23 studies were deemed suitable for inclusion, many dated from the 1980s and 1990s. The quantity and quality of the palliative care literature were highlighted by Hui et al4 in a systematic review of 1213 articles, spanning a period of 6 months in 2004 and 2009. They found a significant decrease in the proportion of palliative care studies in the oncology literature between the two time periods and only 6% of all palliative care studies were RCTs. The authors concluded that there are serious critical concerns about the current state of knowledge conception, with the overall methodological quality of RCTs being poor. Therefore, there is a great need for high-quality evidence to support everyday clinical practice and this review is an important contribution to filling this gap. To influence clinical practice in palliative care, clinicians need to have access to the ‘best’ evidence. However, acquiring this evidence presents particular problems and the discipline of palliative care urgently requires a wider evidence base.1
Competing interests None.