Danielle M Goodwin

Do hospital-based palliative teams improve care for patients or families at the end of life?

To determine whether hospital-based palliative care teams improve the process or outcomes of care for patients and families at the end of life, a systematic literature review was performed employing a qualitative meta-synthesis and quantitative meta-analysis. Ten databases were searched. This was augmented by hand searching specific journals, contacting authors, and examining the reference lists of all papers retrieved. Studies were included if they evaluated palliative care teams working in hospitals. Data were extracted by two independent reviewers. Studies were graded using two independent hierarchies of evidence. A Signal score was used to assess the relevance of publications. Two analyses were conducted. In a qualitative meta-synthesis data were extracted into standardized tables to compare relevant features and findings. In quantitative meta-analysis we calculated the effect size of each outcome (dividing the estimated mean difference or difference in proportions by the samples standard deviation). Nine studies specifically examined the intervention of a hospital-based palliative care team or studies. A further four studies considered interventions that included a component of a hospital or support team, although the total intervention was broader. The nature of the interventions varied. The studies were usually in large teaching hospitals, in cities, and mainly in the United Kingdom. Outcomes considered symptoms, quality of life, time in hospital, total length of time in palliative care, or professional changes, such as prescribing practices. Only one of the studies was a randomized controlled trial and this considered a hospital team as part of other services. Most method scores indicated limited research quality. Comparison groups were subject to bias and the analyses were not adjusted for confounding variables. In addition, there were problems of attrition and small sample sizes. Nevertheless, all studies indicated a small positive effect of the hospital team, except for one study in Italy, which documented deterioration in patient symptoms. The Signal scores indicated that the studies were relevant. No study compared different models of hospital team. This review suggests that hospital-based palliative care teams offer some benefits, although this finding should be interpreted with caution. The study designs need to be improved and different models of providing support at the end of life in hospital need comparison. Standardized outcome measures should be used in such research and in practice.

Effectiveness of Palliative Day Care in Improving Pain, Symptom Control, and Quality of Life

To evaluate the effectiveness of palliative day care in improving pain, symptom control, and quality of life (QOL), 120 consecutive new referrals to five specialist palliative day care centers were recruited into a prospective comparative study. Fifty-three comparison patients were identified as those patients receiving usual palliative care services (home care, inpatient care), but did not attend day care. Patients were assessed at 3 interviews (baseline, 6-8 weeks, and 12-15 weeks) using measures of health-related quality of life: McGill Quality of Life Questionnaire (MQOL) and Palliative Care Outcome Scale (POS). There were two main analyses: 1) patient demographic data were analyzed using chi-square (chi(2)), and 2) QOL data were compared, based on distribution of scores, using the Mann-Whitney test (MQOL and POS), and Wilcoxon Signed Rank for within group differences (POS data only); P < 0.05 was taken as significant. The patients were representative of those attending palliative day care in the UK. At baseline, the day care group were (non-significantly) worse than the comparison group in the MQOL support domain (P = 0.065). The comparison group had marginally more severe pain at baseline (P = 0.053) and more severe symptoms at second assessment (P = 0.025). Both patient groups maintained overall health-related quality of life during the three months of the study. Palliative day care was not found to improve overall health-related quality of life. The limitations of the QOL measures in identifying the effects (patient outcomes) of palliative day care and the differences between the two patient groups (age, employment, unequal sample sizes) were limitations of the study and indicate the need for further research in this area.

Efficiency of Searching the Grey Literature in Palliative Care

A systematic review into palliative care team effectiveness was undertaken which has, inherent in its methodology, grey literature searching. Over 100 letters were written to a systematically chosen range of service providers, commissioners, and experts in combination with requests for information in six UK national cancer/palliative care organization newsletters. In addition, the System for Information on Grey Literature (SIGLE ) database was searched. As a result, 25 document hard copies were received. The documents were, in all but one case (this one study was also highlighted by the SIGLE search), not relevant as they were predominated by annual reports, service descriptions, and needs assessments. In terms of obtaining unpublished studies for possible inclusion in the review, this comprehensive search was unsuccessful and, therefore, it would appear that grey literature searching is not a useful tool in palliative care systematic reviews.

Palliative day care: what does it cost to run a centre and does attendance affect use of other services?

Aim: To describe the cost of palliative day care (PDC), assessing the value of all resources whether paid for or not. To examine different patterns of resource use resulting from attending PDC. Methods: Five PDC centres in southern England provided detailed cost and resource use data, both paid and unpaid for. The PDC group were consecutive new referrals to a PDC centre who were well enough to be interviewed. The comparison group were recruited from home care teams. Data were collected at baseline, six to eight weeks and 12–15 weeks, on health and social care utilization in the month prior to interview. Data were divided into cohorts based on time from first interview to death and analysed separately. Main outcomes: Annual cost of running a day care centre, and cost per patient per day. Use of all health and social care resources over time, stratified by time from death. Comparison of health and social care by stage of illness, and by PDC attendance. Results: PDC cost around £54 per person per day in 1999, rising to £75 including unpaid resources. 145 patients had data on health and social care use. The patterns of care showed that, overall, patients accessed few services other than PDC. Comparison group patients did not access similar services elsewhere. PDC might substitute home nursing and GP care for patients who attend PDC at least three months before death but this data is not conclusive. Inpatient care was negligible for both groups. Conclusions: A full economic evaluation could not be undertaken without robust evidence of the effectiveness of PDC. PDC centres made use of resources that were not paid for and shared resources with inpatient units, reducing costs. Service use was different for patients who attended compared with patients who did not. Similar services were not accessed elsewhere in the community; PDC does not appear to replicate other services for this group of patients.

Workgroup 4: research

The workgroup condensed the main research issues into three broad questions, with an emphasis on obtaining timely results and identifying matters that might lend themselves to joint exploration in the USA and the UK.