Table 3 Systematic reviews evaluating the efficacy of palliative models of care
From: Elements of effective palliative care models: a rapid review
Review | Review question | Studies | Participants | Setting | Interventions | Quality * | Synthesis | Summary of results |
|---|---|---|---|---|---|---|---|---|
[44] | To identify the current evidence on (1) the effectiveness, including cost-effectiveness, of hospices, and hospice care in a patient’s home and in nursing homes and (2) the experiences of those who use and of those who provide such services | Search date: 2003-2009 | People dying from any LLI or their family | Inpatient, RAC, community | EOL care service provided by multidisciplinary team not part of general healthcare | Medium | Narrative | Hospice services are highly valued by patients and their families, reduce general health service use and costs, and increase the likelihood of effective pain management and of death not occurring in hospital |
Designs: comparative and qualitative studies | ||||||||
Number of studies: 18 comparative, 4 qualitative | ||||||||
[41] | To inform future practice, research and policy in specialist palliative day-care by systematically reviewing the evidence for how the structure and process of this form of care relate to outcomes for adults with cancer | Search date: 1872-2003 | Patients with cancer | Day care | Palliative day care | Low | Narrative | There is evidence for high satisfaction among patients selected into day-care, but not yet sufficient to judge whether this improves symptom control or QOL. |
Designs: Any, qualitative or quantitative | ||||||||
Number of studies: 12 | ||||||||
[57] | To evaluate the evidence on the transition process from child to adult services for young people with palliative care needs | Search date: 1990-2008 | Children and young people with LLI | Transition from paediatric to adult services, any setting | Interventions aimed at easing transition | Medium | Narrative | Post-transition patients with cystic fibrosis (and in one study) parents described transition positively |
Designs: any | ||||||||
Number of studies: 92, of which only 2 were evaluative | ||||||||
[45] | To identify the models of inter-professional working that provide the strongest evidence base for practice with community dwelling older people | Search date: 1990:2010 | Older (age 65+) people | Community | Inter-professional case management, collaboration or integrated team models | Medium | Narrative | Weak evidence of effectiveness and cost-effectiveness, although well-integrated and shared care models improved processes of care and have the potential to reduce hospital or nursing/care home use. |
Designs: RCTs | ||||||||
Number of studies: 41 | ||||||||
[51] | To assess whether there was an effect of palliative care teams | Search date: not given | Patients receiving palliative care and their families | Inpatient or community | Multi-disciplinary teams including staff trained to some extent in palliative care | Medium | Narrative and meta-analysis using effect sizes weighted by the square root of sample sizes | Most evidence is available for home care services (improved satisfaction and pain and symptom control with lower costs), with a smaller number of studies of inpatient hospice or palliative care (similar or greater satisfaction, particularly for carers and similar or improved symptom control, quality of life equivocal) and a small number of poor quality studies considering hospital support, although it does seem that these services reduce time in hospital. |
Designs: not defined | ||||||||
Number of studies: 43 | ||||||||
[52] | To identify studies that compare specialised palliative care models between them assessing their effectiveness or cost-effectiveness | Search date: 2003-2006 | Terminally ill patients | Inpatient, community | Four hospice-based models (large free-standing hospice, hospital-based hospice, home-care hospice, telemedicine based hospice), one palliative care unit based at a general hospital and two models of referring specialists at hospital (a full service and a service limited to telephonic support to the staff caring the patient) | Medium | Narrative | No differences were found in control of symptoms, QOL, emotional support or satisfaction between a broad service provided by a team of referring specialists at hospital and telephonic support between specialised PCT and the staff caring for the patient. No differences in effectiveness was found between hospital-based hospices and home-based hospice. |
Designs: Comparative | ||||||||
Number of studies: 4 | ||||||||
[50] | To determine effectiveness of multi-component palliative care service delivery interventions for residents of care homes for older people. | Search date: to Feb 2010 | Elderly people in aged care | RAC | Multi-component palliative care in RAC, including referral to external services or staff training | Good | Narrative | One study reported higher satisfaction with care and the other found lower observed discomfort in residents with end-stage dementia. Two studies reported higher referral to hospice services in their intervention group, one found fewer hospital admissions and days in hospital, the other found an increase in do-not-resuscitate orders and documented advance care plan discussions. |
Designs: Comparative | ||||||||
Number of studies: 3 | ||||||||
[46] | Not stated | Search date: 1975-2001 | Family members or carers of people with cancer or other advanced disease | Community | Home nursing care, respite services, social networks and activity enhancement, problem solving and education, and group work | Medium | Narrative | The current evidence contributes more to understanding feasibility and acceptability than to effectiveness. |
Designs: Any evaluative | ||||||||
Number of studies: 6 | ||||||||
[47] | To update 2003 review to determine the effectiveness of subsequently published intervention studies targeting informal caregivers needs in cancer/advanced disease | Search date: 2001-2010 | Family members or carers of people with cancer or other advanced disease | Community | One-to-one psychological models, Psychological interventions for patient/carer dyads, Palliative care/hospice interventions, Information and training interventions, Respite interventions, Group interventions, Physical interventions | Medium | Narrative | Of 6 studies evaluating palliative care/hospice interventions, one pre/post study found reduced family anxiety about caring at home but increased wakening and poorer physical health, one cross-sectional survey found high satisfaction; the others found no effect. The one study evaluating respite found caregivers to report satisfaction after implementation. |
Designs: Any evaluative | ||||||||
Number of studies: 33 | ||||||||
[58] | To systematically review the evidence base for the effectiveness of palliative care in improving patient outcomes in HIV/AIDS | Search date: 1980-2003 | Patients with HIV requiring symptom control, psychosocial support or terminal care | Inpatient, hospice, community, long-term care | Multidisciplinary advice and support, terminal care, domestic support, care monitoring and planning, | Medium | Narrative | Home palliative care and inpatient hospice care significantly improve patient outcomes in the domains of pain and symptom control, anxiety, insight, and spiritual wellbeing. |
Designs: | ||||||||
Comparative Number of studies: 22 | ||||||||
[43] | To determine whether hospital-based palliative care teams improve the process or outcomes of care for patients and families at the end of life | Search date: 1977-1999 | Patients with a progressive life-threatening illness, and their family, carers, or close friends. | Hospital | Palliative care teams working in hospitals, defined as two or more healthcare workers, at least one of whom had specialist training or worked principally in palliative care. Included interventions with a hospital/support team component within a broader intervention | Good | Narrative and meta-analysis using effect sizes | All studies except one indicated a small positive effect of the hospital team, including improved symptoms, fewer hospital days and better satisfaction, as well as improvements on process measures such as increased referrals, change in prescribing practices. |
Designs: Comparative | ||||||||
Number of studies: 13 | ||||||||
[53] | To determine whether specialist palliative care teams achieve their aims and improve outcomes for patients with advanced cancer and their caregivers, in terms of improving symptoms and quality of life and/or reducing the emotional concerns of family caregivers | Search date: 2000-2009 | Patients with advanced cancer and their caregivers | Inpatient, community, outpatient, day care | Specialist palliative care offered by professionals specifically trained in palliative and hospice care | Medium | Narrative | The evidence (moderate and low) supports SPCTs working in home, hospitals, and inpatient units as a means to improve outcomes for cancer patients, such as pain, symptom control, and satisfaction, and in improving care more widely, including reducing hospital admissions. The benefit is demonstrated quantitatively. |
Designs: Comparative Number of studies: 40 | ||||||||
| Â | Studies indicated either benefit in favour of a palliative care team or no difference. Some studies suggested lower costs. | |||||||
Quality of life, when measured, less often was different between groups and tended to deteriorate over time. | ||||||||
[60] | To explore the use of telehealth in relation to palliative care in the UK | Search date: 1999-2011 | Adults, relatives, or carers with palliative care needs or health professionals in the UK | Inpatient, community, outpatient, RAC | Telehealth | Low | Narrative | Advantages of telehealth include improved access to health professionals and decreased time loss and costs for patients, optimized time use and increased productivity for health professionals, and improved service efficiency for providers. On the negative side, the service becomes depersonalized for both patients and clinicians, confidentiality issues may arise, and potential legal implications for health professionals, including clinical risk management, may be a concern. Clinical staff may be required to perform additional research tasks such as data collection, which might not be considered the main objective when they must compete with the pressures of providing a service. Nonetheless, it appears |
Designs: Any | ||||||||
Number of studies: 27 | ||||||||
to be both feasible and practical to make greater use of telehealth initiatives in order to provide a more equitable palliative care service that is meant not to replace but to enhance the traditional model. | ||||||||
[61] | To provide a comprehensive literature review and critical appraisal of intervention studies with family caregivers of loved ones on hospice | Search date: 1983-2008 | Family caregivers of patients receiving palliative care at home in the US | Community | Videophone support, emotional support, self-care/stress reduction, massage | Low | Narrative | Generally positive findings but limited by methodological weakness and mixed results. |
Designs: Any evaluative | ||||||||
Number of studies: 5 | ||||||||
[54] | To assess evidence about interventions to improve palliative and end-of-life care | Search date: 1990-2005 | People with terminal illness (for example, advanced cancer) and chronic, eventually fatal illness with ambiguous prognosis (for example, advanced dementia) | Any | Case management, coordinated supportive cancer care, nurse care management, in-home support, interventions targeting management and informational and relational aspects of continuity | Medium | Narrative | Moderate evidence supports multidisciplinary interventions that target continuity to affect utilization outcomes. Evidence is strong for reducing readmissions in heart failure, but insufficient evidence was available for other conditions. Successful interventions involved multidisciplinary teaming, addressed patient needs across settings and over time, and facilitated communication by personal and technological means. |
Designs: SRs and any evaluative | ||||||||
Number of studies: 9 SRs and 12 studies focused on continuity | ||||||||
[48] | To establish whether community SPCS offering home nursing increase rates of home death compared with other models | Search date: Earliest records-2011 | People with LLI receiving EOL care | Community | Practical nursing support with or without domestic support, education, transition support, tele-support | COI declared | Meta-analysis using OR | Meta-analysis indicated a significant effect on home deaths for SPCS with home nursing versus other care; however, the only two RCTs found no effect. Symptom management or QOL was not compromised and costs were not higher in any study that measured these. |
Designs: Comparative | ||||||||
Number of studies:9 | ||||||||
[62] | Does case conferencing improve care planning in palliative patients? | Search date: 1990-2005 | Palliative population | Community, inpatient, RAC | Case conferencing between GPs and other healthcare professionals and families | Medium | Narrative | Case conferences were generally acceptable to GPs. Participant perceived benefits included: improved communications between participants; increased GP knowledge about the patient’s illness; interactive discussions with other healthcare professionals as a result of the face-to-face communication; improved inter-professional respect particularly as GPs often did not have a good idea of the roles played by other health providers; a learning opportunity for all participants; a mechanism for de-briefing, particularly when dealing with particularly difficult patients; reduced professional isolation; increased team building and promotion of a team approach to caring for terminally ill patients. Patient outcomes included: assisting in discharge from hospital; improved practice; reduced inappropriate medications, including identification of medication-related problems; increase patient and carer awareness of services; identification and resolution of problems; reduced primary care visits; maintenance of function and independence; increased use of services. No effect observed on quality of life or survival; effect seemed to be limited to outcomes the care teams had direct influence on. |
Designs: Any evaluative | ||||||||
Number of studies: 20 | ||||||||
[59] | To test the efficacy of a palliative care model in patients with dementia | Search date: 1966-2003 | People with advanced dementia | RAC, acute hospital | Dementia Special Care Unit (DSCU), palliative care plans aimed at maximising comfort and minimising invasive or aggressive treatment (including hospitalisation) | Medium | Narrative | Patients in the DSCU had lower discomfort and fewer transfers to acute medical setting but higher mortality; the study in the acute hospital setting found no effect on length of hospital stay or reduction in painful interventions. |
Designs: Any evaluative | ||||||||
Number of studies: 2 | ||||||||
[49] | To determine if providing home-based end of life care reduces the likelihood of dying in hospital and what effect this has on patients’ symptoms, quality of life, health service costs and care givers compared with inpatient hospital or hospice care. | Search date: 1950-2009 | Adults receiving terminal care at home who would otherwise require hospital or hospice inpatient care. | Community | EOL care at home providing active treatment for continuous periods of time by multidisciplinary healthcare professionals | Medium | Meta-analysis using risk ratio | Those receiving home-based end of life care were statistically significantly more likely to die at home. There was some evidence of increased patient satisfaction with home-based end of life care, and little evidence of the impact this form of care has on caregivers. No statistically significant differences were found for functional status, psychological well-being or cognitive status. |
Designs: Comparative | ||||||||
Number of studies:4 | ||||||||
[42] | To determine whether the provision of palliative day care services (PDS) have a measurable effect on attendees’ wellbeing | Search date: 1978-2009 | Patients with LLI | Day care | Holistic, individualized palliative care, including medical and nursing care, allied health and complementary therapies, social support, | Medium |  | Little evidence of impact on QOL but people report that attending PDS is a valuable experience that allows them to engage with others and to be supported in a restorative environment. |
Designs: Any evaluative | ||||||||
Number of studies:35 | ||||||||
[63] | To review the impact of the Gold Standards Framework (GSF) since its introduction to the UK in 2001 | Search date: NR-2008 | People receiving EOL care | Primary care | Toolkit to improve the quality, coordination and organisation of EOL care | Medium | Narrative | Evaluation to date has focused on the GSF’s impact on care processes rather than outcomes. The GSF has proven acceptability and can influence multidisciplinary collaboration, communication, assessment and care planning |
Designs: Any | ||||||||
Number of studies:27 | ||||||||
[55] | To identify and analyse all published RCTs that focus on the organization of EOL care provided to persons who are terminally ill, near death, or dying | Search date: NR | People who are terminally ill, near death or dying | Inpatient, community | Multidisciplinary care, staff training | Low | Narrative | Community or home-based EOL care compares favourably with more traditional or conventional hospital-based and episodic medical care in improving symptoms and in the opinions of patients and caregivers |
Designs: RCTs | ||||||||
Number of studies:23 | ||||||||
[56] | To systematically review the evidence for effectiveness of specialized palliativecare | Search date: earliest records-2007 | Terminally ill | Community, inpatients, outpatients | Multidisciplinary care and support, education, caregiver support, coordination, | Medium | Narrative | Evidence was most consistent for effectiveness of SPC in improvement of family satisfaction with care (7 of 10 studies). Only 4 of 13 studies assessing QOL and 1 of 14 assessing symptoms showed a significant benefit of the intervention; however, most studies lacked statistical power. There was evidence of significant cost savings in only 1 of 7 studies that assessed this outcome. |
Designs: RCTs | ||||||||
Number of studies: 22 |