MedicalResearch: Why did you conduct this study?
Dr. Seow: While palliative care has gained recognition as a service that can improve patient outcomes and reduce health care costs at the end of life, especially in hospitals and hospices, much less attention has focused on providing inter-disciplinary palliative care in the community and home. There have been several randomized trials that showed mixed evidence that inter-disciplinary teams of specialist palliative care providers can reduce acute care utilization in the community; however team size and team composition varied in prior trials. This variation has not been researched as a cause for the mixed outcomes.
MedicalResearch: What did your study do?
Dr. Seow: We examined eleven community-based specialist palliative care teams, in one health care system, which had varying team size and composition. We retrospectively examined whether decedents exposed to the specialist teams, compared to decedents receiving usual end-of-life homecare services, had lower risk of being in hospital or the emergency department in the last two weeks of life, or dying in hospital. We used propensity score matching to identify a control cohort that had the same propensity to receive the specialist team, but did not, thus simulating a randomized trial design.
MedicalResearch: What are the main findings of the study?
Dr. Seow: Our pooled study showed that community-based specialist palliative care teams, despite variation in team composition and geographies, are effective at reducing the risk of being in hospital, having an emergency department visit, or dying in hospital, at the end of life.
MedicalResearch: Were any of the findings unexpected?
Dr. Seow: Yes. We expected that there was a singular optimal model of team composition that would lead to less acute care use. But despite the fact that teams varied in their size, composition, geographies served, and manner of integration with family physicians, we found the majority of the teams led to lower acute care use at the end of life.
MedicalResearch: What should clinicians and patients take away from your report?
Dr. Seow: There are 2 key take home messages.
First, that the core intervention of community-based palliative care–i.e. 24/7 access, educating and preparing patients and families on what to expect next, and being proactive to manage complex symptoms–was effective at reducing acute care utilization despite different team models. The services mattered more than the model.
Second, each team was configured specific to their regional needs. This means every region can have its own unique team, and we should not aim to replicate one model in every community.
MedicalResearch: What recommendations do you have for future research as a result of this study?
Dr. Seow: To me, this study shows that integrated palliative care teams are more effective at reducing unnecessary acute care use at the end of life, and has high potential to improve patient quality, rather than just usual end of life nursing home care alone. Future research ought to focus more on how to create, spread, and sustain such community-based models, the factors that are essential to implementation and success, rather than continue to focus on proving their efficacy.
Seow H ,Brazil K ,Sussman J ,Pereira J ,Marshall D ,Austin PC ,et al. Impact of community based, specialist palliative care teams on hospitalisations and emergency department visits late in life and hospital deaths: a pooled analysis. BMJ 2014;348:g3496