Impact of Community Based, Specialist Palliative Care Teams
Impact of Community Based, Specialist Palliative Care Teams
Our pooled analysis of 11 specialist palliative care team interventions strongly suggests that exposure to a palliative care specialist team compared with usual care significantly reduces the risk of being in hospital and going to an emergency department in the last two weeks of life by a third and a quarter respectively, and reduces the risk of dying in hospital by half. These results suggest that even in real world, non-controlled settings, with multiple differences between the specialist teams and the geographies they serve, the core of the intervention (nurses, palliative care physicians, and family physicians working together to enhance usual palliative home care) significantly reduces the use of acute care services in late life and allows patients to die outside of hospital.
This study capitalised on a natural experiment in Ontario, Canada, where multiple communities independently developed specialist palliative care teams that differed in geography, team size, and team organisation but had the same core team members with the same roles as prior randomised trials. Thus, a key contribution of this research was to explore whether the core elements of the randomised trials would be effective at reducing use of acute care, even when implemented with different team compositions, while keeping the health system constant. A unique strength of our study was the use of propensity score matching in our observational data to reduce selection bias in the control group. Pooling our data also allowed for a large sample size and sufficient power, which was a limitation of some previous trials.
Our study is limited in that propensity scores cannot adjust for unmeasured covariates, such as patient preferences for hospital care and availability of existing care giver support. Teams were selected because their regions did not have major changes to the palliative care health system during the comparison period, though it is impossible to claim no changes at all. This study’s teams served primarily cancer patients, which limits the generalisability of the intervention effect to teams primarily serving another disease group.
Several trials have examined one community based palliative care intervention using different team compositions, outcomes, and health financing systems making it difficult to compare and generalise; whereas our pooled analysis compared 11 teams with different team compositions but using common outcomes in the same healthcare financing system. Moreover, our pooled study design supports the generalisability of the evidence that community based specialist teams are effective at reducing acute care use at the end of life in other countries. Despite different healthcare financing policies, international research has documented the same issues with end of life care in healthcare systems as those documented in the “usual care” system in Ontario: communication problems between settings and providers, inadequate symptom control, unmet psychological needs, and late referrals to specialist palliative care.
The intervention’s effect likely results from the fact that—unlike usual care at home, where palliative care providers vary considerably in their accessibility, palliative care training, and ability to coordinate care—the specialist palliative care team can help to eliminate the variation and ensure that care is accessible, coordinated, and provided by skilled workers. We believe that the common features of the teams we studied (such as 24/7 coverage and collaboration between nurses, specialist physicians, and family physicians) are not unique to the Canadian system and have similarities to existing models in other countries. Compared with the UK, the community based specialist palliative care teams in Ontario have similarities to palliative care professionals working with hospice at home services and palliative care specialist nurses (such as Marie Curie nurses), as well as primary care teams using the Gold Standard Framework. Indeed, our results are consistent with observational work undertaken in the UK. Compared with the US, the teams resemble home based, visiting hospice programmes under the Medicare Hospice Benefit, though patients in the Ontario do not need to forego other treatment for their terminal illness to access the community specialist teams, which is required in the US.
What services does the core team of providers deliver to patients and families that helps reduce use of acute care services late in life? Care from the teams may help avoid unplanned use by anticipating clinical problems early and making care arrangements in advance. Teams expertly manage, monitor, and rapidly respond to complex symptoms and changes in the patient’s condition. When needed to support the patient or prevent care giver burnout, they directly provide care or advocate for additional care. Moreover, patients and families can access the teams 24/7, a feature especially important on evenings and weekends, when usual care provider’s offices are typically closed. Indeed research shows that emergency department visits and hospitalisations late in life occur because of inadequate symptom control and failure to cope, among other factors.
Of the 11 specialist teams in our study, two (teams 5 and 6) did not have any significant results across the outcomes, which could indicate an ineffective intervention. For example, team 5 had a small team and a part time palliative care physician. Team 6 covered a large, rural area with a small team. However, the non-significant results may also be due to the small sample sizes for individual teams. Four teams (teams 4, 7, 9, and 11) showed significantly positive effects of the intervention across all outcomes despite their number of admissions, teams size, and geography served varied considerably. This result emphasises the importance of the core services the teams provided, which was common across all teams, rather than the team composition or model in which they practiced. The remaining teams demonstrated significantly positive outcomes for one or two outcomes, though we could not determine if acute care use in the non-significant outcomes were medically appropriate.
Using propensity scores to simulate a randomised trial of a specialist palliative care team intervention, our pooled analysis suggests that even in real world, non-controlled settings, where specialist teams vary in team composition and geography served, the specialist team intervention supports more patients to die outside of hospitals and avoid late-life use of acute services compared with usual care. The impact of specialist team interventions on the various non-cancer diagnoses in the community should be investigated further. Future research should also determine the intervention’s impact on other health system outcomes, such as primary care capacity or patient and provider satisfaction, as well as assess how the variation among teams (such as role of additional team members or models of care) are associated with these outcomes.
Discussion
Principal Findings
Our pooled analysis of 11 specialist palliative care team interventions strongly suggests that exposure to a palliative care specialist team compared with usual care significantly reduces the risk of being in hospital and going to an emergency department in the last two weeks of life by a third and a quarter respectively, and reduces the risk of dying in hospital by half. These results suggest that even in real world, non-controlled settings, with multiple differences between the specialist teams and the geographies they serve, the core of the intervention (nurses, palliative care physicians, and family physicians working together to enhance usual palliative home care) significantly reduces the use of acute care services in late life and allows patients to die outside of hospital.
Strengths and Limitations of the Study
This study capitalised on a natural experiment in Ontario, Canada, where multiple communities independently developed specialist palliative care teams that differed in geography, team size, and team organisation but had the same core team members with the same roles as prior randomised trials. Thus, a key contribution of this research was to explore whether the core elements of the randomised trials would be effective at reducing use of acute care, even when implemented with different team compositions, while keeping the health system constant. A unique strength of our study was the use of propensity score matching in our observational data to reduce selection bias in the control group. Pooling our data also allowed for a large sample size and sufficient power, which was a limitation of some previous trials.
Our study is limited in that propensity scores cannot adjust for unmeasured covariates, such as patient preferences for hospital care and availability of existing care giver support. Teams were selected because their regions did not have major changes to the palliative care health system during the comparison period, though it is impossible to claim no changes at all. This study’s teams served primarily cancer patients, which limits the generalisability of the intervention effect to teams primarily serving another disease group.
Comparison With Other Studies
Several trials have examined one community based palliative care intervention using different team compositions, outcomes, and health financing systems making it difficult to compare and generalise; whereas our pooled analysis compared 11 teams with different team compositions but using common outcomes in the same healthcare financing system. Moreover, our pooled study design supports the generalisability of the evidence that community based specialist teams are effective at reducing acute care use at the end of life in other countries. Despite different healthcare financing policies, international research has documented the same issues with end of life care in healthcare systems as those documented in the “usual care” system in Ontario: communication problems between settings and providers, inadequate symptom control, unmet psychological needs, and late referrals to specialist palliative care.
The intervention’s effect likely results from the fact that—unlike usual care at home, where palliative care providers vary considerably in their accessibility, palliative care training, and ability to coordinate care—the specialist palliative care team can help to eliminate the variation and ensure that care is accessible, coordinated, and provided by skilled workers. We believe that the common features of the teams we studied (such as 24/7 coverage and collaboration between nurses, specialist physicians, and family physicians) are not unique to the Canadian system and have similarities to existing models in other countries. Compared with the UK, the community based specialist palliative care teams in Ontario have similarities to palliative care professionals working with hospice at home services and palliative care specialist nurses (such as Marie Curie nurses), as well as primary care teams using the Gold Standard Framework. Indeed, our results are consistent with observational work undertaken in the UK. Compared with the US, the teams resemble home based, visiting hospice programmes under the Medicare Hospice Benefit, though patients in the Ontario do not need to forego other treatment for their terminal illness to access the community specialist teams, which is required in the US.
Policy Implications and Conclusions
What services does the core team of providers deliver to patients and families that helps reduce use of acute care services late in life? Care from the teams may help avoid unplanned use by anticipating clinical problems early and making care arrangements in advance. Teams expertly manage, monitor, and rapidly respond to complex symptoms and changes in the patient’s condition. When needed to support the patient or prevent care giver burnout, they directly provide care or advocate for additional care. Moreover, patients and families can access the teams 24/7, a feature especially important on evenings and weekends, when usual care provider’s offices are typically closed. Indeed research shows that emergency department visits and hospitalisations late in life occur because of inadequate symptom control and failure to cope, among other factors.
Of the 11 specialist teams in our study, two (teams 5 and 6) did not have any significant results across the outcomes, which could indicate an ineffective intervention. For example, team 5 had a small team and a part time palliative care physician. Team 6 covered a large, rural area with a small team. However, the non-significant results may also be due to the small sample sizes for individual teams. Four teams (teams 4, 7, 9, and 11) showed significantly positive effects of the intervention across all outcomes despite their number of admissions, teams size, and geography served varied considerably. This result emphasises the importance of the core services the teams provided, which was common across all teams, rather than the team composition or model in which they practiced. The remaining teams demonstrated significantly positive outcomes for one or two outcomes, though we could not determine if acute care use in the non-significant outcomes were medically appropriate.
Conclusions
Using propensity scores to simulate a randomised trial of a specialist palliative care team intervention, our pooled analysis suggests that even in real world, non-controlled settings, where specialist teams vary in team composition and geography served, the specialist team intervention supports more patients to die outside of hospitals and avoid late-life use of acute services compared with usual care. The impact of specialist team interventions on the various non-cancer diagnoses in the community should be investigated further. Future research should also determine the intervention’s impact on other health system outcomes, such as primary care capacity or patient and provider satisfaction, as well as assess how the variation among teams (such as role of additional team members or models of care) are associated with these outcomes.