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Increased Satisfaction with Care and Lower Costs: Results of a Randomized Trial of In‐Home Palliative Care
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.
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“Outcomes were worse with first-line erlotinib, followed by an immediate switch to chemotherapy at progression.”
From Systemic Therapy for Stage IV Non–Small-Cell Lung Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update (2015) · cites this paper as [102]
In the citing paper
“There was crossover in this study, so the authors could not analyze the association of mutation status with OS.”
From Systemic Therapy for Stage IV Non–Small-Cell Lung Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update (2015) · cites this paper as [102]
In the citing paper
“In the trial by Gridelli et al,102 which was stopped early and is discussed under Recommendation B1, participants were unselected for EGFR mutation status; 13.8% of the participants in the intervention arm and 14.6% in the control arm had EGFR mutation–positive disease.”
From Systemic Therapy for Stage IV Non–Small-Cell Lung Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update (2015) · cites this paper as [102]
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“of over $7000 when palliative home-based care services were utilized for patients with terminal illnesses [47].”
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“Main inclusion criteria were having a prognosis of a year or less (29, 39-41) or of less than six months (42).”
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“(8) Accounts for the evidence garnered to make a claim for brilliance, or tells, shows, or describes how the notion of evidence is used.”
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“The RCT also found that patients receiving this team care had significantly fewer ED visits (35% less), were more likely to die at home (75% in intervention compared to 51% in control), and expressed greater satisfaction with service.(48) Finally, a newly published trial reported that lung cancer patients assigned to…”
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“40) 0-49 268 (4%) 1000 (5%) 664 (3%) 50-74 1059 (16%) 3570 (17%) 2151 (11%) 75-99 2062 (30%) 6417 (30%) 4898 (24%) 100+ 3433 (50%) 10 110 (48%) 12 325 (62%) Advance care planning Code status (most proximal to death)c Full code 1716 (24%) 5439 (22%) 6886 (31%) DNR 5229 (73%) 17 187 (68%) 14 053 (63%) Missing 232 (3%) 2…”
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“Kaiser-Permanente, an example of a vertically integrated health maintenance organization and insurer, showed that PC improved the quality of care; saved $4,855 per person when started as inpatient;(30) and saved $7,552 per person (233%) when started as outpatient.(10) Furthermore, this analysis compares variable costs…”
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Reflections on Hope and Its Implications for End‐of‐Life Care
Mattes, M. D., & Sloane, M. A. (2015) · Journal of the American Geriatrics Society · doi:10.1111/jgs.13392 · Cited by 33
“Where the individual physician might lose, though, those paying the health costs stand to gain, as palliative care services have been estimated to reduce overall treatment costs for seriously ill individuals by up to 33%.(27) Some individual insurance companies have caught on to this potential to couple quality of lif…”
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“41χ Non-Chinese (Malays and Indians), n (%) 3 (6) 20 (10) –”
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Improving Care Experiences for Patients and Caregivers at End of Life: A Systematic Review
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“Six articles included patient- and/or caregiver-reported experience measures and clinical measures.(19,21,22,24,26,27) Five targeted patient and/or caregiver experiences captured through administrative data (rather than direct report) and clinical measures.”
BackgroundLevel of Palliative Care Complexity in Advanced Cancer Patients: A Multinomial Logistic Analysis
Carrasco-Zafra, M. I., García, R. G., Ocaña‐Riola, R., Martín-Roselló, M. L., & Blanco‐Reina, E. (2020) · Journal of Clinical Medicine · doi:10.3390/jcm9061960 · Cited by 32
“PC is associated with improved care planning [2], greater patient and caregiver satisfaction with the care provided and lower levels of healthcare uptake [2,5,6].”
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Bowman, B. A., Twohig, J. S., & Meier, D. E. (2018) · Journal of Palliative Medicine · doi:10.1089/jpm.2018.0478 · Cited by 32
“Until recent years these programs were operated by a small group of progressive health systems 4 and community agencies, but home-based palliative care programs have proliferated rapidly in the post-ACA era.”
Prevalence of palliative care patients in emergency departments
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The Effect of Community-Based Specialist Palliative Care Teams on Place of Care
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Integrating Palliative Care into Oncology: A Way Forward
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Rethinking Hospice Eligibility Criteria
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“The IHPC program demonstrated a reduction in ED utilization, hospital admission, and increased likelihood in dying in place of choice when compared with usual care.(18,19) Finally, a community-based partnership between a home health program and two private insurers, which also used an interdisciplinary team to facilit…”
BackgroundThe Impact of Integrated Home Palliative Care Services on Resource Use and Place of Death
Bergqvist, J., & Ljunggren, G. (2019) · Journal of Palliative Medicine · doi:10.1089/jpm.2018.0639 · Cited by 29
“Some say HPC is cost-effective 9,20 and some say it is not.”
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“In addition, patients enrolled in the palliative care programme were more likely to die at home than in comparison to group patients [8].”
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Economic Evaluation of a Hospital-Based Palliative Care Program
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“PCU care compared with usual care was cost saving as reported in several other centers,(10,11,33) and we know from prior reports that survival is often the same,(34-36) symptoms are better,(33,37) and patients and families are more satisfied.(9) Theestimates in this analysis areconservative.”
ResultAng, K., Hepgul, N., Gao, W., & Higginson, I. J. (2017) · Palliative Medicine · doi:10.1177/0269216317717369 · Cited by 29
Aslakson, R. A., Chandrashekaran, S., Rickerson, E. M., Fahy, B. N., Johnston, F. M., Miller, J., Conca-Cheng, A. M., Wang, S., Morris, A. M., Lorenz, K., et al. (2019) · Journal of Palliative Medicine · doi:10.1089/jpm.2019.0130 · Cited by 31
Critically ill cancer patient’s resuscitation: a Belgian/French societies’ consensus conference
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Pediatric Hospital Care for Children with Life-threatening Illness and the Role of Palliative Care
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End-of-Life Cancer Care: Temporal Association between Homecare Nursing and Hospitalizations
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“Because I Was Sick”: Seriously Ill Veterans' Perspectives on Reason for 30‐Day Readmissions
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“Another such model found to be effective in improving satisfaction and reducing health care use is home-based palliative care, also provided concurrently with standard medical care.(19) This approach would require a significant restructuring of current healthcare structure and reimbursement streams.”
BackgroundSelf-citationDelivery of Community-Based Palliative Care: Findings from a Time and Motion Study
Bhavsar, N. A., Bloom, K., Nicolla, J., Gable, C. L., Goodman, A., Olson, A., Harker, M. J., Bull, J., & Taylor, D. H. (2017) · Journal of Palliative Medicine · doi:10.1089/jpm.2016.0433 · Cited by 27
“Community-based palliative has been shown to improve quality of care and patient outcomes while potentially reducing costs.(6) However, current fee-forservice payment approaches used by Medicare and other payers do not incentivize the provision of this care.”
BackgroundResource utilisation and costs of palliative cancer care in an interdisciplinary health care model
Johnson, A., Abernathy, T., Howell, D., Brazil, K., & Scott, S. D. (2009) · Palliative Medicine · doi:10.1177/0269216309103193 · Cited by 27
Home care program for patients at high risk of hospitalization.
Levine, S., Steinman, B. A., Attaway, K., Jung, T., & Enguidanos, S. M. (2012) · PubMed · Cited by 26
Self-citationPhilip, R. R., Venables, E. C., Manima, A., Tripathy, J. P., & Philip, S. (2019) · BMC Palliative Care · doi:10.1186/s12904-019-0400-2 · Cited by 26
Building capacity for palliative care delivery in primary care settings
Evans, J. M., MacKinnon, M., Pereira, J. L., Earle, C. C., Gagnon, B., Arthurs, E., Gradin, S., Walton, T., Wright, F. C., & Buchman, S. (2021) · Canadian Family Physician · doi:10.46747/cfp.6704270 · Cited by 27
Hojjat-Assari, S., Rassouli, M., Madani, M., & Heydari, H. (2021) · BMC Palliative Care · doi:10.1186/s12904-021-00795-2 · Cited by 26
Chiang, J., Kao, Y.-H., & Lai, N. (2015) · PLoS ONE · doi:10.1371/journal.pone.0138773 · Cited by 26
Nuño-Solínis, R., Molina, E. H., Flores, S. L., Orueta, J. F., & Cabrera‐León, A. (2016) · Gaceta Sanitaria · doi:10.1016/j.gaceta.2016.06.005 · Cited by 26
Siegel, M., & Bigelow, S. (2017) · Journal of Emergency Medicine · doi:10.1016/j.jemermed.2017.08.004 · Cited by 26
Gomes, B., Higginson, I. J., & McCrone, P. (2009) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd007760 · Cited by 26
Improving outcomes and lowering costs by applying advanced models of in-home care
Boling, P. A., Chandekar, R. V., Hungate, B., Purvis, M. V., Selby-Penczak, R., & Abbey, L. J. (2013) · Cleveland Clinic Journal of Medicine · doi:10.3949/ccjm.80.e-s1.03 · Cited by 24
Murali, K. P., Merriman, J. D., Yu, G., Vorderstrasse, A. A., Kelley, A. S., & Brody, A. A. (2020) · American Journal of Hospice and Palliative Medicine® · doi:10.1177/1049909120928353 · Cited by 28
“Similarly, palliative care provided in the home setting, or home-based palliative care, can improve quality of life and symptom burden and decrease health care utilization and costs in the cancer population.(57,58) A Cochrane systematic review of the effectiveness of home-based palliative care in adults with serious i…”
BackgroundPini, S. A., Hackett, J., Taylor, S., Bekker, H., Kite, S., Bennett, M., & Ziegler, L. E. (2020) · European Journal of Cancer Care · doi:10.1111/ecc.13340 · Cited by 25
“…hospital admissions, minimise aggressive cancer treatments, enable patients to make choices about their end of life care and have survival benefits over standard care (Bakitas et al., 2009; Brumley et al., 2007; Hui et al., 2018; Rabow et al., 2004; Temel et al., 2010; Zimmermann et al., 2014).”
BackgroundDeveloping Successful Palliative Care Teams in Rural Communities: A Facilitated Process
Weng, K., Shearer, J., & Johnson, L. G. (2021) · Journal of Palliative Medicine · doi:10.1089/jpm.2021.0287 · Cited by 25
“Community-based PC programs have been shown to lower costs and reduce hospital and care utilization.(17,18) They also extend the reach of services to nearly anywhere patients live and can be provided in clinics, homes, or nursing facilities.”
BackgroundKawashima, A., & Evans, C. (2023) · BMC Palliative Care · doi:10.1186/s12904-023-01131-6 · Cited by 25
“Six main domains for eligibility criteria were identified, including diagnostic criteria (n = 26 out of 27 included studies, 96%), medical history-based (n = 15, 56%), symptoms (physical and psychological) (n = 14, 52%), prognostic criteria (n = 9, 33%), functional status (n = 8, 30%]), QOL (n = 2 [7%]), and other cri…”
BackgroundMethodInfluentialPalliative care and advance care planning for patients with advanced malignancies.
Ranganathan, A., Gunnarsson, Ö., & Casarett, D. (2014) · PubMed · doi:10.3978/j.issn.2224-5820.2014.07.04 · Cited by 27
“Another study similarly demonstrated assigning homebound terminally ill outpatients to in-home palliative care, led to greater patient satisfaction, decreased emergency department visits, hospitalization days and an increased likelihood of dying at home (38).”
BackgroundHospice eligibility in patients who died in a tertiary care center
Freund, K., Weckmann, M. T., Casarett, D., Swanson, K. M., Brooks, M. K., & Broderick, A. (2011) · Journal of Hospital Medicine · doi:10.1002/jhm.975 · Cited by 25
Shin, J. A., & Temel, J. S. (2013) · Current Opinion in Pulmonary Medicine · doi:10.1097/mcp.0b013e3283620e76 · Cited by 25
Havet, N., Morelle, M., Remonnay, R., & Carrère, M. (2011) · The European Journal of Health Economics · doi:10.1007/s10198-011-0328-9 · Cited by 27
“Although home care has been extensively studied as a possible substitute for hospital care, from the perspective of both costs and health outcomes [10, 11], there is limited information about the attitude of the patients toward home care and especially toward home blood transfusion.”
BackgroundNguyen, H. Q., McMullen, C., Haupt, E. C., Wang, S. E., Werch, H., Edwards, P. E., Andres, G. M., Reinke, L., Mittman, B. S., Shen, E., et al. (2022) · BMJ Supportive & Palliative Care · doi:10.1136/bmjspcare-2020-002553 · Cited by 20
Opening up disruptive ways of management in cancer pain: the concept of multimorphic pain
Lemaire, A., George, B., Maindet, C., Burnod, A., Allano, G., & Minello, C. (2019) · Supportive Care in Cancer · doi:10.1007/s00520-019-04831-z · Cited by 24
The sentinel hospitalization and the role of palliative care
Lin, R. J., Adelman, R. D., Diamond, R., & Evans, A. T. (2014) · Journal of Hospital Medicine · doi:10.1002/jhm.2160 · Cited by 24
Integrating Palliative Care into Critical Care
Kim, C., Friedman, T., Gracely, E. J., & Gasperino, J. (2014) · Journal of Intensive Care Medicine · doi:10.1177/0885066614523923 · Cited by 24
“We believe that with physician education and more integrated models of care delivery, the delay to PCC could be significantly decreased and the change could lead to cost savings and decreased resource utilization as mirrored in other studies.(6-9,19,20) The majority of the patients who received PCC during this period…”
ResultNew Frontiers in Outpatient Palliative Care for Patients with Cancer
Rabow, M. W., Dahlin, C. M., Calton, B. A., Bischoff, K. E., & Ritchie, C. S. (2015) · Cancer Control · doi:10.1177/107327481502200412 · Cited by 25
Sun, Z., Laporte, A., Guerriere, D. N., & Coyte, P. C. (2016) · Health & Social Care in the Community · doi:10.1111/hsc.12413 · Cited by 24
Koski, J., Kelley, M. L., Nadin, S., Crow, M., Prince, H., Wiersma, E. C., & Mushquash, C. J. (2017) · Palliative Care Research and Treatment · doi:10.1177/1178224217719441 · Cited by 24
Nadin, S., Crow, M., Prince, H., & Kelley, M. (2018) · Rural and Remote Health · doi:10.22605/rrh4317 · Cited by 24
Rajdev, K., Loghmanieh, N., Farberov, M. A., Demissie, S., & Maniatis, T. (2018) · Journal of Intensive Care Medicine · doi:10.1177/0885066618811794 · Cited by 24
The Integration of Palliative Care into the Emergency Department
Başol, N. (2015) · Turkish Journal of Emergency Medicine · doi:10.5505/1304.7361.2015.65983 · Cited by 23
“[11] Patients with in-home palliative care were found to be less likely to visit emergency departments (EDs) or to be admitted to hospitals, and more likely to die at home, than those with usual care.[42,43]”
BackgroundHospitalization Pattern in a Hospital-based Palliative Care Program: An Example From Saudi Arabia
Alsirafy, S. A., Hassan, A. A., & Al-Shahri, M. Z. (2008) · American Journal of Hospice and Palliative Medicine® · doi:10.1177/1049909108324819 · Cited by 23
“6) Age (years) Median [range] 52 [3-97] Primary cancer Gastro-intestinal 175 (27.”
Place of Death in Patients with Lung Cancer: A Retrospective Cohort Study from 2004-2013
O'Dowd, E. L., McKeever, T. M., Baldwin, D., & Hubbard, R. (2016) · PLoS ONE · doi:10.1371/journal.pone.0161399 · Cited by 23
“A randomised controlled trial conducted by Brumley et al [17] assigned patients with a terminal prognosis to usual care or in-home palliative care, which comprised not only pain and symptom relief, but a variety of educational, medical and social support services.”
MethodPatient awareness of palliative care: systematic review
Bahrami, M., Bagheri, I., & Salmani, N. (2021) · BMJ Supportive & Palliative Care · doi:10.1136/bmjspcare-2021-003072 · Cited by 23
The Financial Impact of Palliative Care and Aggressive Cancer Care on End-of-Life Health Care Costs
Davis, M. P., Vanenkevort, E. A., Elder, A., Young, A. J., Ordonez, I. D. C., Wojtowicz, M. J., Ellison, H. B., Fernandez, C., Mehta, Z. Y., Behm, B., et al. (2022) · American Journal of Hospice and Palliative Medicine® · doi:10.1177/10499091221098062 · Cited by 24
“It is the community-based palliative care services and outpatient palliative care clinics that are likely to impact healthcare utilization and reduce expenditures as shown by several studies.(28,29,36,47-49) In 1 study community-based palliative care reduced the number of unplanned admissions (relative risk .”
BackgroundChang, A. M., Ho, J. C. S., Yan, B. P., Yu, C., Lam, Y. Y., & Lee, V. W. Y. (2013) · Clinical Cardiology · doi:10.1002/clc.22112 · Cited by 23
Inpatient Palliative Care and Patient Pain: Pre- and Post-Outcomes
Laguna, J., Goldstein, R., Allen, J., Braun, W., & Enguidanos, S. M. (2012) · Journal of Pain and Symptom Management · doi:10.1016/j.jpainsymman.2011.06.023 · Cited by 22
Self-citation
Metadata
- Authors
- Brumley, R., Enguidanos, S., Jamison, P., Seitz, R., Morgenstern, N., Saito, S., McIlwane, J., Hillary, K., & Gonzalez, J.
- Affiliations
- Kaiser Permanente (US)
- Partners in Care Foundation (US)
- ORCID
- Enguidanos, Susan
- Venue
- Journal of the American Geriatrics Society
- Publisher
- Wiley
- Published
- 2007-06-18
- Volume
- 55
- Issue
- 7
- Pages
- 993-1000
- ISSN
- 0002-8614 (ISSN-L)
- 1532-5415
- OpenAlex
- W2108517568
- Cited by
- 845
- References
- 28
- Citations by year
- 2026: 20 · 2025: 20 · 2024: 39 · 2023: 25 · 2022: 46 · 2021: 56 · 2020: 67 · 2019: 54 · 2018: 56 · 2017: 69 · 2016: 76 · 2015: 63 · 2014: 66 · 2013: 54 · 2012: 41
- FWCI
- 19.56
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Journal of the American Geriatrics Society (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative Care and End-of-Life Issues
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative and Oncologic Care
- Health Sciences › Medicine › Anesthesiology and Pain Medicine › Pain Management and Opioid Use
- Keywords
- end-of-life care, patient satisfaction, health care costs, home death, dying patients, homebound patients, emergency department visits, hospitalization, interdisciplinary care teams, symptom management, health maintenance organizations
- MeSH terms
- Aged, Female, Health Maintenance Organizations, Home Care Services, Humans, Male, Palliative Care, Patient Education as Topic, Prognosis, Retrospective Studies, Health Care Costs, Patient Satisfaction, Terminally Ill
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