The effectiveness and cost-effectiveness of hospital palliative care for adults affected by advanced illness and breathlessness: a systematic review and meta-analysis

Abstract

Background: Breathlessness leads to emergency hospital attendances, making a hospital death more likely. This systematic review compared the effectiveness and cost-effectiveness of Hospital Palliative Care (HPC). Methods: Population: Adult patients with advanced disease and breathlessness; Intervention: HPC divided into 1) ward based 2) inpatient consult 3) outpatient 4) hospital outreach and 5) HPC delivered across multiple settings (eg hospital and community); Comparator: Usual care; Outcome measures: Quality of life and symptom burden measures including breathlessness; Study Design: Randomised Controlled Trials (RCTs); Data sources: Included six electronic databases to August 2018. This review was conducted as part of a larger Cochrane review. Results: 38 RCTs involving 6571 patients were included with 10 RCTs (1203 participants) measuring breathlessness. HPC improved breathlessness (SMD -0.30, 95% CI -0.57 to -0.03; I2 = 80%) with the inpatient consult model most effective (n = 2 studies, SMD -1.06, 95% CI -1.34 to -0.77; I2 = 0%). Multi-disciplinary team led services were more effective than nurse led in reducing breathlessness (n = 8 studies, SMD -0.27, 95% CI -0.40 to -0.14; I2 = 82%) vs (n = 2 studies, SMD 0.02, 95% CI -0.24 to 0.28; I2 = 40%). 3 out of 4 studies presenting cost data for breathless patients showed HPC to be cost-saving (with the 4th cost neutral). Importantly, HPC did not appear to cause harm. Conclusions: HPC improves breathlessness whilst appearing to be cost-saving. Inpatient consult and MDT led models of HPC may be the most effective for breathless patients.