Increased Satisfaction with Care and Lower Costs: Results of a Randomized Trial of In-Home Palliative Care

Richard Brumley, MD; Susan Enguidanos, PhD, MPH; Paula Jamison, BA; Rae Seitz, MD; Nora Morgenstern, MD; Sherry Saito, MD; Jan McIlwane, MSW; Kristine Hillary, RNP; Jorge Gonzalez, BA

Disclosures

J Am Geriatr Soc. 2007;55(7):993-1000. 

In This Article

Abstract and Introduction

Abstract

Objectives: To determine whether an in-home palliative care intervention for terminally ill patients can improve patient satisfaction, reduce medical care costs, and increase the proportion of patients dying at home.
Design: A randomized, controlled trial.
Setting: Two health maintenance organizations in two states.
Participants: Homebound, terminally ill patients (N=298) with a prognosis of approximately 1 year or less to live plus one or more hospital or emergency department visits in the previous 12 months.
Intervention: Usual versus in-home palliative care plus usual care delivered by an interdisciplinary team providing pain and symptom relief, patient and family education and training, and an array of medical and social support services.
Measurements: Measured outcomes were satisfaction with care, use of medical services, site of death, and costs of care.
Results: Patients randomized to in-home palliative care reported greater improvement in satisfaction with care at 30 and 90 days after enrollment (P < .05) and were more likely to die at home than those receiving usual care (P < .001). In addition, in-home palliative care subjects were less likely to visit the emergency department (P=.01) or be admitted to the hospital than those receiving usual care (P < .001), resulting in significantly lower costs of care for intervention patients (P=.03).
Conclusion: In-home palliative care significantly increased patient satisfaction while reducing use of medical services and costs of medical care at the end of life. This study, although modest in scope, presents strong evidence for reforming end-of-life care.

Introduction

It has been widely recognized that our current medical care structure is inadequate in meeting the needs of terminally ill patients and reducing the cost of care at the end of life.[1] Despite the existence of hospice as a Medicare benefit for nearly 2 decades, the program remains underused. Approximately 60% of all deaths occur in the hospital,[2] yet most patients express a preference to die at home.[3,4,5,6] Although hospice programs aim to provide palliative services in the last 6 months of life, the median length of stay in the program is 22 days, and 35% of patients die within the first 7 days after hospice admission.[7] Hospice patients with a short length of stay often require intensive care to initiate the care plan, resulting in higher per diem costs of care than for patients who receive longer periods of stabilized, low-cost palliative care.[8,9] The low enrollment in hospice services and the short length of time enrolled before death attest to the need for end-of-life care programs that address these access barriers. In addition, recent studies have found that more end-of-life programs are needed to provide alternatives to hospice that do not require forgoing life-sustaining treatment.[10]

Although several studies have reported that end-of-life care programs improve patient outcomes, these studies have significant methodological weaknesses, limiting their generalizability.[11] Specifically, there has been a noticeable lack of comprehensive empirical evidence confirming the clinical benefits and demonstrating the cost effectiveness of these models of care. The absence of rigorous research evaluating the effectiveness of these programs has restricted the ability and motivation of healthcare providers to replicate and adopt these models as standard practice.

The purpose of this study was to test an in-home palliative care model at two sites using a randomized, controlled design. Standard care was compared with standard care plus an in-home palliative care program to determine the program's ability to improve patient outcomes and reduce the costs of medical care at the end of life. Specifically, it was hypothesized that the palliative care program would increase patient satisfaction, reduce costs of medical care, and increase the proportion of terminally ill patients dying at home.

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