Catherine J Evans1, Anna E Bone2, Deokhee Yi3, Wei Gao4, Myfanwy Morgan5, Shamim Taherzadeh6, Matthew Maddocks7, Juliet Wright8, Fiona Lindsay9, Carla Bruni10, Richard Harding11, Katherine E Sleeman12, Barbara Gomes13, Irene J Higginson14. 1. King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabiliation, Bessemer Road, London, SE 9PJ, England; Martlets Hospice, Wayfield Avenue, Hove BN3 7LW, England; Sussex Community National Health Service Foundation Trust, Brighton General Hospital, Elm Grove, Brighton, BN2 3EW, England. Electronic address: Catherine.evans@kcl.ac.uk. 2. King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabiliation, Bessemer Road, London, SE 9PJ, England. Electronic address: Anna.bone@kcl.ac.uk. 3. King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabiliation, Bessemer Road, London, SE 9PJ, England. Electronic address: Deok_hee.yi@kcl.ac.uk. 4. King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabiliation, Bessemer Road, London, SE 9PJ, England. Electronic address: wei.gao@kcl.ac.uk. 5. Institute of Pharmaceutical Science, King's College London, Franklin-Wilkins Building, Stamford Street, London SE1 9NH, England. Electronic address: myfanwy.morgan@kcl.ac.uk. 6. Northbourne Medical Centre, 193A Upper Shoreham Road, Shoreham-by-Sea, BN43 6BT, England. Electronic address: dr.shamimt@gmail.com. 7. King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabiliation, Bessemer Road, London, SE 9PJ, England. Electronic address: Matthew.maddocks@kcl.ac.uk. 8. University of Sussex, Brighton and Sussex Medical School, Falmer, Brighton, BN1 9RH, England. Electronic address: Juliet.Wright@bsuh.nhs.uk. 9. Martlets Hospice, Wayfield Avenue, Hove BN3 7LW, England; Sussex Community National Health Service Foundation Trust, Brighton General Hospital, Elm Grove, Brighton, BN2 3EW, England. Electronic address: fiona.lindsay@nhs.net. 10. Sussex Community National Health Service Foundation Trust, Brighton General Hospital, Elm Grove, Brighton, BN2 3EW, England. Electronic address: C.bruni@nhs.net. 11. King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabiliation, Bessemer Road, London, SE 9PJ, England. Electronic address: Richard.harding@kcl.ac.uk. 12. King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabiliation, Bessemer Road, London, SE 9PJ, England. Electronic address: Katerine.sleeman@kcl.ac.uk. 13. King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabiliation, Bessemer Road, London, SE 9PJ, England. Electronic address: Barbara.gomes@kcl.ac.uk. 14. King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabiliation, Bessemer Road, London, SE 9PJ, England. Electronic address: Irene.higginson@kcl.ac.uk.
Abstract
BACKGROUND: Globally, a rising number of people live into advanced age and die with multimorbidity and frailty. Palliative care is advocated as a person-centred approach to reduce health-related suffering and promote quality of life. However, no evidence-based interventions exist to deliver community-based palliative care for this population. AIM: To evaluate the impact of the short-term integrated palliative and supportive care intervention for older people living with chronic noncancer conditions and frailty on clinical and economic outcomes and perceptions of care. DESIGN: Single-blind trial with random block assignment to usual care or the intervention and usual care. The intervention comprised integrated person-centred palliative care delivered by multidisciplinary palliative care teams working with general practitioners and community nurses. Main outcome was change in five key palliative care symptoms from baseline to 12-weeks. Data analysis used intention to treat and complete cases to examine the mean difference in change scores and effect size between the trial arms. Economic evaluation used cost-effectiveness planes and qualitative interviews explored perceptions of the intervention. SETTING/PARTICIPANTS: Four National Health Service general practices in England with recruitment of patients aged ≥75 years, with moderate to severe frailty, chronic noncancer condition(s) and ≥2 symptoms or concerns, and family caregivers when available. RESULTS: 50 patients were randomly assigned to receive usual care (n = 26, mean age 86.0 years) or the intervention and usual care (n = 24, mean age 85.3 years), and 26 caregivers (control n = 16, mean age 77.0 years; intervention n = 10, mean age 77.3 years). Participants lived at home (n = 48) or care home (n = 2). Complete case analysis (n = 48) on the main outcome showed reduced symptom distress between the intervention compared with usual care (mean difference -1.20, 95% confidence interval -2.37 to -0.027) and medium effect size (omega squared = 0.071). Symptom distress reduced with decreased costs from the intervention compared with usual care, demonstrating cost-effectiveness. Patient (n = 19) and caregiver (n = 9) interviews generated themes about the intervention of 'Little things make a big difference' with optimal management of symptoms and 'Care beyond medicines' of psychosocial support to accommodate decline and maintain independence. CONCLUSIONS: This palliative and supportive care intervention is an effective and cost-effective approach to reduce symptom distress for older people severely affected by chronic noncancer conditions. It is a clinically effective way to integrate specialist palliative care with primary and community care for older people with chronic conditions. Further research is indicated to examine its implementation more widely for people at home and in care homes. TRIAL REGISTRATION: Controlled-Trials.com ISRCTN 45837097 Tweetable abstract: Specialist palliative care integrated with district nurses and GPs is cost-effective to reduce symptom distress for older people severely affected by chronic conditions.
BACKGROUND: Globally, a rising number of people live into advanced age and die with multimorbidity and frailty. Palliative care is advocated as a person-centred approach to reduce health-related suffering and promote quality of life. However, no evidence-based interventions exist to deliver community-based palliative care for this population. AIM: To evaluate the impact of the short-term integrated palliative and supportive care intervention for older people living with chronic noncancer conditions and frailty on clinical and economic outcomes and perceptions of care. DESIGN: Single-blind trial with random block assignment to usual care or the intervention and usual care. The intervention comprised integrated person-centred palliative care delivered by multidisciplinary palliative care teams working with general practitioners and community nurses. Main outcome was change in five key palliative care symptoms from baseline to 12-weeks. Data analysis used intention to treat and complete cases to examine the mean difference in change scores and effect size between the trial arms. Economic evaluation used cost-effectiveness planes and qualitative interviews explored perceptions of the intervention. SETTING/PARTICIPANTS: Four National Health Service general practices in England with recruitment of patients aged ≥75 years, with moderate to severe frailty, chronic noncancer condition(s) and ≥2 symptoms or concerns, and family caregivers when available. RESULTS: 50 patients were randomly assigned to receive usual care (n = 26, mean age 86.0 years) or the intervention and usual care (n = 24, mean age 85.3 years), and 26 caregivers (control n = 16, mean age 77.0 years; intervention n = 10, mean age 77.3 years). Participants lived at home (n = 48) or care home (n = 2). Complete case analysis (n = 48) on the main outcome showed reduced symptom distress between the intervention compared with usual care (mean difference -1.20, 95% confidence interval -2.37 to -0.027) and medium effect size (omega squared = 0.071). Symptom distress reduced with decreased costs from the intervention compared with usual care, demonstrating cost-effectiveness. Patient (n = 19) and caregiver (n = 9) interviews generated themes about the intervention of 'Little things make a big difference' with optimal management of symptoms and 'Care beyond medicines' of psychosocial support to accommodate decline and maintain independence. CONCLUSIONS: This palliative and supportive care intervention is an effective and cost-effective approach to reduce symptom distress for older people severely affected by chronic noncancer conditions. It is a clinically effective way to integrate specialist palliative care with primary and community care for older people with chronic conditions. Further research is indicated to examine its implementation more widely for people at home and in care homes. TRIAL REGISTRATION: Controlled-Trials.com ISRCTN 45837097 Tweetable abstract: Specialist palliative care integrated with district nurses and GPs is cost-effective to reduce symptom distress for older people severely affected by chronic conditions.
Keywords:
Aged; Community Health Nursing; Costs and Cost Analysis; General Practice; Palliative care; Qualitative interviews; Randomized Controlled Trial
Authors: Francesco Blasi; Enrico Gianluca Caiani; Matteo Giuseppe Cereda; Daniela Donetti; Marco Montorsi; Vincenzo Panella; Gaia Panina; Felicia Pelagalli; Elisabetta Speroni Journal: Front Public Health Date: 2022-06-29
Authors: Kim de Nooijer; Lara Pivodic; Nele Van Den Noortgate; Peter Pype; Catherine Evans; Lieve Van den Block Journal: Palliat Med Date: 2021-08-22 Impact factor: 4.762