Intensity of Integrated Primary and Specialist Home-Based Palliative Care for Chronic Diseases in Northeast Italy and Its Impact on End-of-Life Hospital Access

Ferroni, Eliana; Avossa, Francesco; Figoli, F.; Cancian, Maurizio; Chirico, Cosimo De; Pinato, Elisabetta; Pellizzari, Michele; Fedeli, Ugo; Saugo, Mario; Mantoan, Domenico

doi:10.1089/jpm.2016.0158

Cited by 14 publications

(19 citation statements)

References 27 publications

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“…The HomePal study is highly responsive to the imperative from collaborating stakeholders to move beyond the four clinic walls and provide PC in patients' homes, especially when high symptom burden is coupled with significant functional limitations, making clinic visits too burdensome for both patients and caregivers. It also addresses gaps in the current state of the science in PC 36 and HBPC in particular, [37][38][39][40][41][42][43][44] with regard to rigorous evaluations of telehealth integration. In close partnership with stakeholders across multiple representative groups, we refined the comparators, prioritized, and refined measures and study conduct, and optimized rigor and statistical approaches.…”

Section: Discussionmentioning

confidence: 99%

Protocol for a Noninferiority Comparative Effectiveness Trial of Home-Based Palliative Care (HomePal)

Nguyen

Mularski

Edwards

et al. 2019

Journal of Palliative Medicine

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Introduction: As health care systems strive to meet the growing needs of seriously ill patients with high symptom burden and functional limitations, they need evidence about how best to deliver home-based palliative care (HBPC). We compare a standard HBPC model that includes routine home visits by nurses and prescribing clinicians with a tech-supported model that aims to promote timely interprofessional team coordination using video consultation with the prescribing clinician while the nurse is in the patient's home. We hypothesize that tech-supported HBPC will be no worse compared with standard HBPC. Methods: This study is a pragmatic, cluster randomized noninferiority trial conducted across 14 Kaiser Permanente sites in Southern California and the Pacific Northwest. Registered nurses (n = 102) were randomized to the two models so that approximately half of the participating patient-caregiver dyads will be in each study arm. Adult English or Spanish-speaking patients (estimate 10,000) with any serious illness and a survival prognosis of 1-2 years and their caregivers (estimate 4800) are being recruited to the HomePal study over *2.5 years. The primary patient outcomes are symptom improvement at one month and days spent at home. The primary caregiver outcome is perception of preparedness for caregiving. Study Implementation-Challenges and Contributions: During implementation we had to balance the rigors of conducting a clinical trial with pragmatic realities to ensure responsiveness to culture, structures, workforce, workflows of existing programs across multiple sites, and emerging policy and regulatory changes. We built close partnerships with stakeholders across multiple representative groups to define the comparators, prioritize and refine measures and study conduct, and optimize rigor in our analytical approaches. We have also incorporated extensive fidelity monitoring, mixed-method implementation evaluations, and early planning for dissemination to anticipate and address challenges longitudinally. Trial Registration: ClinicalTrials.gov: NCT#03694431.

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Section: Discussionmentioning

confidence: 99%

Protocol for a Noninferiority Comparative Effectiveness Trial of Home-Based Palliative Care (HomePal)

Nguyen

Mularski

Edwards

et al. 2019

Journal of Palliative Medicine

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“…[ 1 – 6 ] Historically palliative care research has focussed on patients with advanced cancers, however it is now clear that specialist palliative care, home-based or hospital-based, also benefits people with non-cancer chronic and life-limiting conditions. [ 7 – 10 ] Despite this, access to specialist palliative care for non-cancer conditions is generally considered sub-optimal [ 11 – 14 ] although there are signs that this is improving. [ 14 , 15 ]…”

Section: Introductionmentioning

confidence: 99%

“…[ 5 ] An Italian study reported that the intensity of specialist home-based palliative care delivered to a cohort of patients with non-cancer chronic disease was associated with reduced hospital stays. [ 7 ] A large Canadian study reported a reduction in hospitalisations in the week following home nursing with end-of-life intent in a cohort of cancer patients followed for the last six months of life. [ 16 ]…”

Section: Introductionmentioning

confidence: 99%

The impact of community-based palliative care on acute hospital use in the last year of life is modified by time to death, age and underlying cause of death. A population-based retrospective cohort study

et al. 2017

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ObjectiveCommunity-based palliative care is known to be associated with reduced acute care health service use. Our objective was to investigate how reduced acute care hospital use in the last year of life varied temporally and by patient factors.MethodsA retrospective cohort study of the last year of life of 12,763 Western Australians who died from cancer or one of seven non-cancer conditions. Outcome measures were rates of hospital admissions and mean length of hospital stays. Multivariate analyses involved time-to-event and population averaged log-link gamma models.ResultsThere were 28,939 acute care overnight hospital admissions recorded in the last year of life, an average of 2.3 (SD 2.2) per decedent and a mean length of stay of 9.2 (SD 10.3) days. Overall, the rate of hospital admissions was reduced 34% (95%CI 1–66) and the mean length of stay reduced 6% (95%CI 2–10) during periods of time decedents received community-based palliative care compared to periods of time not receiving this care. Decedents aged <70 years receiving community-based palliative care showed a reduced rate of hospital admission around five months before death, whereas for older decedents the reduction in hospital admissions was apparent a year before death. All decedents who were receiving community-based palliative care tended towards shorter hospital stays in the last month of life. Decedents with neoplasms had a mean length of stay three weeks prior to death while not receiving community-based palliative care of 9.6 (95%CI 9.3–9.9) days compared to 8.2 (95% CI 7.9–8.7) days when receiving community-based palliative care.ConclusionRates of hospital admission during periods of receiving community-based palliative care were reduced with benefits evident five months before death and even earlier for older decedents. The mean length of hospital stay was also reduced while receiving community-based palliative care, mostly in the last month of life.

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“…Recent observational studies show promising associations between exposure to home‐based PC and reduced acute care use and costs in the last year of life . However, a notable gap in the US‐based studies where the hospice benefit is only available to patients with a prognosis of 6 months or less is a comparison of outcomes between decedents who were exposed to home‐based PC and those who only received hospice because the presumption is that home‐based PC provides supportive services more upstream and may be associated with higher quality end‐of‐life care.…”

mentioning

confidence: 99%

“…4 Recent observational studies show promising associations between exposure to home-based PC and reduced acute care use and costs in the last year of life. [5][6][7][8][9][10][11] However, a notable gap in the US-based studies where the hospice benefit is only available to patients with a prognosis of 6 months or less is a comparison of outcomes between decedents who were exposed to home-based PC and those who only received hospice because the presumption is that home-based PC provides supportive services more upstream and may be associated with higher quality end-of-life care. Building on nearly 10 years of home-based PC (HomePal) implementation in our healthcare system, 12,13 the purpose of this observational study was to extend previous work by comparing end-of-life care in decedents who received HomePal with two comparator cohorts that either received hospice only (HO) or did not receive HomePal or hospice (No HomePal-HO).…”

mentioning

confidence: 99%

End‐of‐Life Care in Patients Exposed to Home‐Based Palliative Care vs Hospice Only

Wang

Liu

Lee

et al. 2019

J American Geriatrics Society

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OBJECTIVES The current evidence base regarding the effectiveness of home‐based palliative care (HomePal) on outcomes of importance to multiple stakeholders remains limited. The purpose of this study was to compare end‐of‐life care in decedents who received HomePal with two cohorts that either received hospice only (HO) or did not receive HomePal or hospice (No HomePal‐HO). DESIGN Retrospective cohorts from an ongoing study of care transition from hospital to home. Data were collected from 2011 to 2016. SETTING Kaiser Permanente Southern California. PARTICIPANTS Decedents 65 and older who received HomePal (n = 7177) after a hospitalization and two comparison cohorts (HO only = 25 102; No HomePal‐HO = 22 472). MEASUREMENTS Utilization data were extracted from administrative, clinical, and claims databases, and death data were obtained from state and national indices. Days at home was calculated as days not spent in the hospital or in a skilled nursing facility (SNF). RESULTS Patients who received HomePal were enrolled for a median of 43 days and had comparable length of stay on hospice as patients who enrolled only in hospice (median days = 13 vs 12). Deaths at home were comparable between HomePal and HO (59% vs 60%) and were higher compared with No HomePal‐HO (16%). For patients who survived at least 6 months after HomePal admission (n = 2289), the mean number of days at home in the last 6 months of life was 163 ± 30 vs 161 ± 30 (HO) vs 149 ± 40 (No HomePal‐HO). Similar trends were also noted for the last 30 days of life, 25 ± 8 (HomePal, n = 5516), 24 ± 8 (HO), and 18 ± 11 (No HomePal‐HO); HomePal patients had a significantly lower risk of hospitalizations (relative risk [RR] = .58‐.87) and SNF stays (RR = .32‐.77) compared with both HO and No HomePal‐HO patients. CONCLUSION Earlier comprehensive palliative care in patients’ home in place of or preceding hospice is associated with fewer hospitalizations and SNF stays and more time at home in the final 6 months of life. J Am Geriatr Soc, 2019.

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Intensity of Integrated Primary and Specialist Home-Based Palliative Care for Chronic Diseases in Northeast Italy and Its Impact on End-of-Life Hospital Access

Abstract: The intensity of integrated HPCCD plans of care was associated with a reduction in EOL hospital stay and in hospital death.

Cited by 14 publications

References 27 publications

Protocol for a Noninferiority Comparative Effectiveness Trial of Home-Based Palliative Care (HomePal)

Protocol for a Noninferiority Comparative Effectiveness Trial of Home-Based Palliative Care (HomePal)

The impact of community-based palliative care on acute hospital use in the last year of life is modified by time to death, age and underlying cause of death. A population-based retrospective cohort study

End‐of‐Life Care in Patients Exposed to Home‐Based Palliative Care vs Hospice Only

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