Improving palliative care: A 2x2x2 factorial cluster randomized controlled trial of case conferencing and educational outreach visiting

Abstract

8517 Background: Evidence-based palliative care service delivery models are needed. General practitioner (GP) and patient-centered case conferences may increase multidisciplinary interaction and enhance patient care. Educational outreach visiting in pain management may empower learners and improve care. Methods: Three interventions were tested against a routine care control in a 2×2×2 cluster factorial randomized controlled trial. Interventions were case conferencing, educational visiting for GPs, and educational visiting for patients. Subjects were adult patients referred to palliative care services in southern Adelaide, Australia, with any pain in the preceding 3 months. Participants were followed longitudinally until death. Main outcomes included performance status (Australian-modified Karnofsky Performance Status (AKPS)) and hospitalization rates. Longitudinal intention-to-treat analyses using cluster-specific methods were conducted. The sample goal was 460. Results: 461 participants were enrolled from 4/02–6/04. Mean age was 71 yrs, 50% were male, 91% had cancer. Mean and median survival was 146 and 87 days; median baseline AKPS was 60%. When participants had AKPS <70 (i.e. required a caregiver) at referral, those randomized to case conferencing or patient education had higher mean performance status than routine care (case conferencing: average daily AKPS, 54.9% vs 46.3%, p=0.0106; patient education: 54.7% vs 46.4%, p=0.0120). GP education did not improve performance status. Both case conferencing and patient education significantly decreased hospitalization rates compared to routine care (case conferencing: least-squares mean number of hospitalizations, 1.4 (standard error (SE) 0.1) vs 1.9 (SE 0.1), p=0.0002; patient education: 1.4 (SE 0.1) vs 1.8 (SE 0.1), p=0.0078). The addition of both interventions decreased hospitalizations to 1.2 (SE 0.1). Conclusion: At a time when declining function and higher healthcare utilization is the norm, palliative care that includes a case conference or patient educational visiting for pain leads to improved performance status and decreased hospitalizations. Patients with deteriorating performance status derive the greatest benefit. No significant financial relationships to disclose.