Abstract

Background: Investigators have tested interventions delivered by specialty palliative care (SPC) clinicians, or by clinicians without palliative care specialization (primary palliative care, PPC).
Objective: To compare the characteristics and outcomes of randomized clinical trials (RCTs) of SPC and PPC interventions.
Design: Systematic review secondary analysis.
Setting/Subjects: RCTs of palliative care interventions.
Measurements: Interventions were classified SPC if delivered by palliative care board-certified or subspecialty trained clinicians, or those with extensive clinical experience; all others were PPC. We abstracted data for each intervention: delivery setting, delivery clinicians, outcomes measured, trial results, and Cochrane's Risk of Bias. We conducted narrative synthesis for quality of life, symptom burden, and survival.
Results: Of 43 RCTs, 27 tested SPC and 16 tested PPC interventions. SPC interventions were more comprehensive (4.2 elements of palliative care vs. 3.1 in PPC, p = 0.02). SPC interventions were delivered in inpatient (44%) or outpatient settings (52%) by specialty physicians (44%) and nurses (44%); PPC interventions were delivered in inpatient (38%) and home settings (38%) by nurses (75%). PPC trials were more often of high risk of bias than SPC trials. Improvements were demonstrated on quality of life by SPC and PPC trials and on physical symptoms by SPC trials.
Conclusions: Compared to PPC, SPC interventions were more comprehensive, were more often delivered in clinical settings, and demonstrated stronger evidence for improving physical symptoms. In the face of SPC workforce limitations, PPC interventions should be tested in more trials with low risk of bias, and may effectively meet some palliative care needs.

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References

1. Kavalieratos D, Corbelli J, Zhang D, et al.: Association between palliative care and patient and caregiver outcomes: A systematic review and meta-analysis. JAMA 2016;316:2104–2114.
2. Temel JS, Greer JA, Muzikansky A, et al.: Early palliative care for patients with metastatic non–small-cell lung cancer. N Engl J Med 2010;363:733–742.
3. Bakitas M, Lyons KD, Hegel MT, et al.: Effects of a Palliative Care Intervention on Clinical Outcomes in Patients With Advanced Cancer: The Project ENABLE II randomized controlled trial. JAMA 2009;302:741.
4. Lupu D: Estimate of current hospice and palliative medicine physician workforce shortage. J Pain Symptom Manage 2010;40:899–911.
5. Murray SA, Boyd K, Sheikh A, et al.: Developing primary palliative care. BMJ 2004;329:1056–1057.
6. Kamal AH, Maguire JM, Meier DE: Evolving the palliative care workforce to provide responsive, serious illness care. Ann Intern Med 2015;163:637.
7. Morrison R, Meier D: America's Care of Serious Illness. New York, New York, 2015.
8. Quill TE, Abernethy AP: Generalist plus specialist palliative care—Creating a more sustainable model. N Engl J Med 2013;368:1173–1175.
9. Kelley AS, Bollens-Lund E: Identifying the population with serious illness: The “denominator” challenge. J Palliat Med 2018;21(S2):S7–S16.
10. Sleeman KE, de Brito M, Etkind SM, et al.: The escalating global burden of serious health-related suffering: Projections to 2060 by world regions, age groups, and health conditions. Lancet Glob Heal 2019;7:e883–e892.
11. Kamal AH, Bull JH, Wolf SP, et al.: Prevalence and Predictors of Burnout Among Hospice and Palliative Care Clinicians in the U.S. J Pain Symptom Manage 2016;51:690–696.
12. Groot MM, Vernooij-Dassen MJFJ, Verhagen SCA, et al.: Obstacles to the delivery of primary palliative care as perceived by GPs. Palliat Med 2007;21:697–703.
13. Gelfman LP, Kavalieratos D, Teuteberg WG, et al.: Primary palliative care for heart failure: What is it? How do we implement it? HHS Public Access. Heart Fail Rev 2017;22:611–620.
14. Ferrell BR, Temel JS, Temin S, et al.: Integration of palliative care into standard oncology care: American Society of Clinical Oncology Clinical Practice Guideline Update. J Clin Oncol 2017;35:96–112.
15. Spetz J, Dudley N, Trupin L, et al.: Few hospital palliative care programs meet national staffing recommendations. Health Aff 2016;35:1690–1697.
16. Ferrell B, Connor SR, Cordes A, et al.: The National Agenda for Quality Palliative Care: The National Consensus Project and the National Quality Forum. J Pain Symptom Manag 2007;33:737–744.
17. JPT Higgins, S Green: Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0. https://training.cochrane.org/handbook. 2011. (Last accessed October 8, 2018).
18. Bannon M, Ernecoff NC, Nicholas Dionne-Odom J, et al.: Comparison of palliative care interventions for cancer versus heart failure patients: A secondary analysis of a systematic review. J Palliat Med 2019;22:966–969.
19. Higginson IJ, Bausewein C, Reilly CC, et al.: An integrated palliative and respiratory care service for patients with advanced disease and refractory breathlessness: A randomised controlled trial. Lancet Respir Med 2014;2:979–987.
20. Rummans TA, Clark MM, Sloan JA, et al.: Impacting quality of life for patients with advanced cancer with a structured multidisciplinary intervention: A randomized controlled trial. J Clin Oncol 2006;24:635–642.
21. Zimmermann C, Swami N, Krzyzanowska M, et al.: Early palliative care for patients with advanced cancer: A cluster-randomised controlled trial. Lancet 2014;383:1721–1730.
22. Bakitas MA, Tosteson TD, Li Z, et al.: Early versus delayed initiation of concurrent palliative oncology care: Patient outcomes in the ENABLE III randomized controlled trial. J Clin Oncol 2015;33:1438–1445.
23. Bekelman DB, Plomondon ME, Carey EP, et al.: Primary results of the patient-centered disease management (PCDM) for heart failure study. JAMA Intern Med 2015;175:725.
24. Grudzen CR, Richardson LD, Johnson PN, et al.: Emergency department-initiated palliative care in advanced cancer. JAMA Oncol 2016;2:591.
25. Clark MM, Rummans TA, Atherton PJ, et al.: Randomized controlled trial of maintaining quality of life during radiotherapy for advanced cancer. Cancer 2013;119:880–887.
26. Sidebottom AC, Jorgenson A, Richards H, et al.: Inpatient palliative care for patients with acute heart failure: Outcomes from a randomized trial. J Palliat Med 2015;18:134–142.
27. Wong FKY, Ng AYM, Lee PH, et al.: Effects of a transitional palliative care model on patients with end-stage heart failure: A randomised controlled trial. Heart 2016;102:1100–1108.
28. Aiken LS, Butner J, Lockhart CA, et al.: Outcome evaluation of a randomized trial of the PhoenixCare intervention: Program of case management and coordinated care for the seriously chronically ill. J Palliat Med 2006;9:111–126.
29. Given B, Given CW, McCorkle R, et al.: Pain and fatigue management: results of a nursing randomized clinical trial. Oncol Nurs Forum 2002;29:949–956.
30. McCorkle R, Jeon S, Ercolano E, et al.: An advanced practice nurse coordinated multidisciplinary intervention for patients with late-stage cancer: A cluster randomized trial. J Palliat Med 2015;18:962–969.
31. Northouse L, Kershaw T, Mood D, Schafenacker A: Effects of a family intervention on the quality of life of women with recurrent breast cancer and their family caregivers. Psychooncology 2005;14:478–491.
32. Dyar S, Lesperance M, Shannon R, et al.: A nurse practitioner directed intervention improves the quality of life of patients with metastatic cancer: Results of a randomized pilot study. J Palliat Med 2012;15:890–895.
33. Radwany SM, Hazelett SE, Allen KR, et al.: Results of the promoting effective advance care planning for elders (PEACE) randomized pilot study. Popul Health Manag 2014;17:106–111.
34. Northouse LL, Mood DW, Schafenacker A, et al.: Randomized clinical trial of a brief and extensive dyadic intervention for advanced cancer patients and their family caregivers. Psychooncology 2013;22:555–563.
35. Farquhar MC, Prevost AT, McCrone P, et al.: The clinical and cost effectiveness of a Breathlessness Intervention Service for patients with advanced non-malignant disease and their informal carers: Mixed findings of a mixed method randomised controlled trial. Trials 2016;17:185.
36. Edmonds P, Hart S, Wei Gao, et al.: Palliative care for people severely affected by multiple sclerosis: Evaluation of a novel palliative care service. Mult Scler 2010;16:627–636.
37. Gade G, Venohr I, Conner D, et al.: Impact of an inpatient palliative care team: A randomized controlled trial. J Palliat Med 2008;11:180–190.
38. Investigators P: A controlled trial to improve care for seriously ill hospitalized patients. J Am Med Assoc 1995;274:1591–1598.
39. Jordhøy MS, Fayers P, Saltnes T, Ahlner-Elmqvist M, Jannert M, Kaasa S. A palliative-care intervention and death at home: A cluster randomised trial. Lancet (London, England) 2000;356:888–893.
40. Bekelman DB, Allen LA, McBryde CF, et al.: Effect of a collaborative care intervention vs usual care on health status of patients with chronic heart failure. JAMA Intern Med 2018;178:511.
41. Engelhardt JB, McClive-Reed KP, Toseland RW, et al.: Effects of a program for coordinated care of advanced illness on patients, surrogates, and healthcare costs: A randomized trial. Am J Manag Care 2006;12:93–100.
42. Hughes SL, Cummings J, Weaver F, et al.: A randomized trial of the cost effectiveness of VA hospital-based home care for the terminally ill. Health Serv Res 1992;26:801–817.
43. Kamal AH, Bull JH, Swetz KM, et al.: Future of the palliative care workforce: Preview to an impending crisis. Am J Med 2017;130:113–114.
44. Johnson KS: Racial and ethnic disparities in palliative care. J Palliat Med 2013;16:1329–1334.
45. Samuel CA, Landrum MB, McNeil BJ, et al.: Racial disparities in cancer care in the Veterans Affairs health care system and the role of site of care. Am J Public Health 2014;104 Suppl 4(S4):S562–S571.
46. Hoerger M, Greer JA, Jackson VA, et al.: Defining the elements of early palliative care that are associated with patient-reported outcomes and the delivery of end-of-life care. J Clin Oncol 2018;36:1096–1102.
47. Hannon B, Swami N, Pope A, et al.: Early palliative care and its role in oncology: A qualitative study. Oncologist 2016;21:1387–1395.
48. Back AL, Park ER, Greer JA, et al.: Clinician roles in early integrated palliative care for patients with advanced cancer: A qualitative study. J Palliat Med 2014;17:1244–1248.
49. Kavalieratos D: Reading past the p <0.05's: The secondary messages of systematic reviews and meta-analyses in palliative care. Palliat Med 2019;33:121–122.
50. Di Pollina L, Guessous I, Petoud V, et al.: Integrated care at home reduces unnecessary hospitalizations of community-dwelling frail older adults: A prospective controlled trial. BMC Geriatr 2017;17:53.
51. Daaleman TP, Ernecoff NC, Kistler CE, et al.: The impact of a community-based serious illness care program on healthcare utilization and patient care experience. J Am Geriatr Soc 2019;67:825–830.
52. Kamal AH: Letters “‘who does what?’” ensuring high-quality and coordinated palliative care with our oncology colleagues. J Pain Symptom Manage 2016;52:e1–e2.
53. Lowther K, Selman L, Simms V, et al.: Nurse-led palliative care for HIV-positive patients taking antiretroviral therapy in Kenya: A randomised controlled trial. Lancet HIV 2015;2:e328–e334.
54. Northouse LL, Mood DW, Schafenacker A, et al.: Randomized clinical trial of a family intervention for prostate cancer patients and their spouses. Cancer 2007;110:2809–2818.
55. Brännström M, Boman K: Effects of person-centred and integrated chronic heart failure and palliative home care. PREFER: A randomized controlled study. Eur J Heart Fail 2014;16:1142–1151.
56. Cheung W, Aggarwal G, Fugaccia E, et al.: Palliative care teams in the intensive care unit: A randomised, controlled, feasibility study. Crit Care Resusc 2010;12:28–35.
57. Farquhar MC, Prevost AT, McCrone P, et al.: Is a specialist breathlessness service more effective and cost-effective for patients with advanced cancer and their carers than standard care? Findings of a mixed-method randomised controlled trial. BMC Med 2014;12:194.
58. Hopp FP, Zalenski RJ, Waselewsky D, et al.: Results of a hospital-based palliative care intervention for patients with an acute exacerbation of chronic heart failure. J Card Fail 2016;22:1033–1036.
59. Pantilat SZ, O'Riordan DL, Dibble SL, Landefeld CS: Hospital-based palliative medicine consultation: A randomized controlled trial. Arch Intern Med 2010;170:2038.
60. Rabow MW, Dibble SL, Pantilat SZ, McPhee SJ. The comprehensive care team. Arch Intern Med 2004;164:83.
61. Wallen GR, Baker K, Stolar M, et al.: Palliative care outcomes in surgical oncology patients with advanced malignancies: A mixed methods approach. Qual Life Res 2012;21:405–415.
62. Zimmer JG, Groth-Juncker A, McCusker J: Effects of a physician-led home care team on terminal care. J Am Geriatr Soc 1984;32:288–292.
63. Chapman DG, Toseland RW: Effectiveness of advanced illness care teams for nursing home residents with dementia. Soc Work 2007;52:321–329.
64. Grande GE, Todd CJ, Barclay SI, Farquhar MC: Does hospital at home for palliative care facilitate death at home? Randomised controlled trial. BMJ 1999;319:1472–1475.
65. McCorkle R, Benoliel JQ, Donaldson G, et al.: A randomized clinical trial of home nursing care for lung cancer patients. Cancer 1989;64:1375–1382.
66. Steel JL, Geller DA, Kim KH, et al.: Web-based collaborative care intervention to manage cancer-related symptoms in the palliative care setting. Cancer 2016;122:1270–1282.
67. Ahronheim JC, Morrison RS, Morris J, et al.: Palliative care in advanced dementia: A randomized controlled trial and descriptive analysis. J Palliat Med 2000;3:265–273.
68. Brumley R, Enguidanos S, Jamison P, et al.: Increased satisfaction with care and lower costs: Results of a randomized trial of in-home palliative care. J Am Geriatr Soc 2007;55:993–1000.
69. Hanks GW, Robbins M, Sharp D, et al.: The imPaCT study: A randomised controlled trial to evaluate a hospital palliative care team. Br J Cancer 2002;87:733–739.
70. Jordhøy MS, Fayers P, Loge JH, et al.: Quality of life in palliative cancer care: results from a cluster randomized trial. J Clin Oncol 2001;19:3884–3894.
71. Kane RL, Wales J, Bernstein L, et al.: A randomised controlled trial of hospice care. Lancet (London, England) 1984;1:890–894.

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Published In

cover image Journal of Palliative Medicine
Journal of Palliative Medicine
Volume 23Issue Number 3March 2020
Pages: 389 - 396
PubMed: 31644399

History

Published in print: March 2020
Published online: 20 February 2020
Published ahead of print: 23 October 2019
Accepted: 13 September 2019

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Natalie C. Ernecoff, PhD, MPH [email protected]
Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.
Devon Check, PhD
Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina.
Duke Cancer Institute, Durham, North Carolina.
Megan Bannon, BA
School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.
Laura C. Hanson, MD, MPH
Cecil G. Sheps Center for Health Services Research, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina.
Division of Geriatric Medicine & Palliative Care Program, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina.
James Nicholas Dionne-Odom, PhD, APRN
School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama.
Jennifer Corbelli, MD, MS
Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.
Michele Klein-Fedyshin, MSLS, BSN, RN
Health Sciences Library System, University of Pittsburgh, Pittsburgh, Pennsylvania.
Yael Schenker, MD, MAS
Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.
Camilla Zimmermann, MD, PhD
Division of Palliative Care, University Health Network, Toronto, Ontario, Canada.
School of Medicine, University of Toronto, Toronto, Ontario, Canada.
Robert M. Arnold, MD
Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.
Dio Kavalieratos, PhD
Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.

Notes

Address correspondence to: Natalie C. Ernecoff, PhD, MPH, Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, 3600 Forbes Avenue, Suite 405, Pittsburgh, PA 15213 [email protected]

Author Disclosure Statement

No competing financial interests exist.

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