Results of the Promoting Effective Advance Care Planning for Elders (PEACE) Randomized Pilot Study

Abstract

The specific aim of the PEACE pilot study was to determine the feasibility of a fully powered study to test the effectiveness of an in-home geriatrics/palliative care interdisciplinary care management intervention for improving measures of utilization, quality of care, and quality of life in enrollees of Ohio's community-based long-term care Medicaid waiver program, PASSPORT. This was a randomized pilot study (n=40 intervention [IG], n=40 usual care) involving new enrollees into PASSPORT who were >60 years old. This was an in-home interdisciplinary chronic illness care management intervention by PASSPORT care managers collaborating with a hospital-based geriatrics/palliative care specialist team and the consumer's primary care physician. This pilot was not powered to test hypotheses; instead, it was hypothesis generating. Primary outcomes measured symptom control, mood, decision making, spirituality, and quality of life. Little difference was seen in primary outcomes; however, utilization favored the IG. At 12 months, the IG had fewer hospital visits (50% vs. 55%, P=0.65) and fewer nursing facility admissions (22.5% vs. 32.5%, P=0.32). Using hospital-based specialists interfacing with a community agency to provide a team-based approach to care of consumers with chronic illnesses was found to be feasible. Lack of change in symptom control or quality of life outcome measures may be related to the tools used, as these were validated in populations closer to the end of life. Data from this pilot study will be used to calculate the sample size needed for a fully powered trial.

Association Between Palliative Care and Patient and Caregiver Outcomes

“…Quality of life was assessed in 24 studies (55.8%) (4576 patients), of those 12 9,10,20,32,35,44,48,51–55 were at high risk; 5, 11,13,31,42,56 unclear risk; and 7, 8,12,33,57–60 low risk of bias. Sixteen trials (67%) exclusively comprised patients with cancer.…”

“…Of the 29 trials involving 10105 patients and assessing physical symptoms, 17 had a high risk of bias, 9,10,20,43–45,47–49,51,52,54,55,61–64 5 had an unclear risk of bias, 37,42,46,50,65 and 7 had a low risk 8,12,33,57–60 of bias. Ten trials reported statistically significant reductions in specific physical symptoms or a composite symptom indicator.…”

“…Survival was assessed in 17 trials involving 8196 patients;10 trials were judged as having high risk of bias, 9,20,34,39,49,52,55,60,67,68 5 as unclear risk, 11,13,50,65,66 and 2 as low risk. 12,57 One trial specified survival as a primary outcome.…”

“…Of the 23 trials, 13 were judged as high risk, 9,20,35,43–45,47,48,51,55,62–64 5 as unclear risk, 11,13,37,42,56 and 5 as low risk of bias. 12,57–60 Overall, 7 trials reported statistically significant improvements in mood related to palliative care 9,13,48,57–60 ; of these, 4 were at low risk of bias.…”

“…Advance care planning was assessed in 10 trials involving 6525 patients; 7 trials were judged as having high risk of bias, 9,39,48,49,55,61,68 2 as unclear risk, 65,66 and 1 as low risk. 60 Among the 5 trials that reported statistically significant improvements, 9,39,61,65,66 3 were at high risk of bias 9,39,61 and 2 were of unclear risk of bias.…”