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

Results

From September 2002 through March 2004, 718 patients were referred to the study. Of these, 408 were excluded; 196 did not meet study eligibility criteria, 67 were eligible for and admitted to hospice care, 59 refused, 38 died before enrollment, 26 were part of another research project terminating their eligibility for participation in this study, and 22 moved out of the area or could not be contacted. As a result, 310 terminally ill participants were randomly assigned to usual care (n=155) or the in-home palliative care program (n=155). Of these, eight intervention group members died before receiving any palliative care, and five usual care members withdrew from the study, leaving 297 available for analysis (Figure 1).

Figure 1.

Patient flowchart. *Other reasons includes those referred to hospice (n=67), those who died (n=38), those who were already in another study (n=26), and those who moved out of the area or could not be contacted (n=22).

The sample consisted of almost equal numbers of men (51%) and women (49%), with a mean age ± standard deviation of 74 ± 12.0. Thirty-seven percent belonged to an ethnic minority group; 18% were Asian/Pacific Islanders, 13% Hawaiian, 4% Latino, and 2% other. Fifty-two percent were married, 29% widowed, and 15% single or divorced. Forty-seven percent were referred to the program with a diagnosis of cancer, 33% with CHF, and 21% with COPD. Seventy-six percent lived in their own home or apartment, and 8% lived in the home of a family member; 74% resided with a family member, primarily a spouse or a child, and 26% lived alone. Thirty-three percent reported having an annual income of $20,000 or less. Participants came from an array of educational backgrounds; approximately 22% did not complete high school, 41% were high school graduates, and 36% had some college or postgraduate education ( Table 1 ).

Overall, the majority of the sample demographics were consistent at both study sites, although there was some variation. Sixty-three percent of participants in Hawaii were minorities, compared with 10% in Colorado. This difference in ethnic distribution is reflective of the larger demographics within each of the states. Eighty-two percent of participants in Hawaii were living with a family member, compared with 72% in Colorado. Finally, 27% of participants in Colorado suffered from COPD, versus 15% of participants in Hawaii. There were no significant differences between sites in age, education, marital status, income, or housing status ( Table 1 ).

During the course of the study, 75% (n=225) of the participants died. There were no significant differences between study groups in terms of the portion of patients dying during the study period, although differential survival periods after enrollment in the study were found using independent-sample t tests, with those enrolled in the intervention surviving an average of 196 ± 164 days and those in usual care surviving an average of 242 ± 200 days (P=.03). Results of the Kaplan-Meier survival analysis did not show significant differences in survival time between study groups (log rank test=2.98; P=.08), although subsequent analysis controlled for survival days due to the strong trend toward differences and its potential effect on use of medical services and costs of medical care.

Baseline Measures

There were no significant differences between study groups in baseline measures other than satisfaction. Satisfaction with services was measured at baseline after study assignment. Those randomized to intervention demonstrated significantly higher satisfaction with services at baseline than those assigned to usual care (P=.03). Member awareness of the results of randomization may have influenced the higher level of satisfaction at baseline in those in the palliative care group.

Satisfaction with Care. Analysis of satisfaction data included satisfaction at baseline (n=277) and 30 days (n=216), 60 days (n=168), and 90 days (n=149) after study enrollment. Significant reduction in sample size at 120 days (n=136) resulted in the exclusion of this data in analyses. There was no significant difference in the portion of participants according to study group reporting to be very satisfied at baseline or at 60 days after enrollment (odds ratio (OR)=1.79; 95% confidence interval (CI)=0.65–4.96; P=.26), although rates of satisfaction increased in the intervention group at 30 days (OR=3.37, 95% CI=1.42–8.10; P=.006) and 90 days (OR=3.37, 95% CI=0.65–4.96; P=.03) after enrollment, with 93% of those enrolled in the palliative care group very satisfied with care at 90 days after enrollment, compared with 81% of usual care patients (Figure 2).

Table 1.

 

Baseline Characteristics

Service Use. Bivariate analysis revealed significant differences between groups in terms of service use. Twenty percent of palliative care members went to the emergency department, compared with 33% of usual care members (P=.01; Cramer's V=.15). Similarly, 36% of those receiving palliative care were hospitalized, compared with 59% of those enrolled in usual care (P < .001; Cramer's V=.23). Number of days in the study was significantly different according to study group, as well. Those enrolled in the IHPC group remained in the study for 196 days on average, whereas those in the usual care group were in the study an average of 242 days. Because of these differences, additional analysis was conducted after controlling for length of time on the program (survival), age, and severity of illness. Linear regression revealed that enrollment in the IHPC reduced hospital days by 4.36 (P < .001; R 2=0.14) and emergency department visits by 0.35 (P=.02; R 2=0.04) after adjusting for survival, age, and severity of illness.

Although enrollment in hospice was not a specific aim of this project, rates of enrollment were reviewed. Hospice data were available from one of the study sites, with analysis of differences between the portions enrolled in hospice (25% of intervention vs 36% of usual care, P=.15) and days in hospice (t=.52; P=.60) before death revealing no significant differences between study groups.

Costs of Care. Significant differences between palliative and usual care members in cost of care (t=−3.63, P < .001) were noted. Owing to differences in time enrolled in the study, a linear regression was conducted to determine the portion of costs explained by study group, controlling for days on service (survival), age, severity of illness (measured using the Palliative Performance Scale), and primary disease. Days enrolled was significantly correlated with age and severity of illness, although the associations between these variables were weak (r=0.22 and 0.20, respectively). Three variables were significant in the regression model: age (although the effect size was small), days enrolled (survival), and enrollment in the IHPC program ( Table 2 ). This analysis revealed that overall costs of care for those enrolled in the IHPC program were 33% less than those receiving standard care (P=.03; 95% CI=−$12,411 to −$780; R 2=0.16). The adjusted mean cost for patients enrolled in the palliative care group was $12,670 ± $12,523, compared with $20,222 ± $30,026 for usual care. Figure 3 represents the average cost of care per member per day according to study group. The average cost per day incurred by palliative care recipients ($95.30) was significantly lower than that of usual care group members ($212.80) (t=−2.417; P=.02).

Table 1.

 

Baseline Characteristics

Site of Death. During the course of the study, 75% of study members included in the final analysis died. For 98% of these persons, site of death data were available. Seventy-one percent of IHPC participants died at home, compared with 51% of those receiving usual care (P < .001). Bivariate logistic analysis confirmed that patients enrolled in the IHPC program were significantly more likely to die at home and less likely to die in an acute care facility. Furthermore, after controlling for age, survival time, and medical conditions, IHPC participants were 2.2 times as likely to die at home as those receiving usual care (OR=2.20, 95% CI=1.3–3.7; R 2=0.27, P < .001).

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