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Are some palliative care delivery systems more effective and efficient than others: a systematic review of comparative studies |
Critchley P, Jadad A R, Taniguchi A, Woods A, Stevens R, Reyno L, Whelan T J |
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Authors' objectives To assess the effectiveness of different models of palliative care delivery systems.
Searching The following sources were searched to March 1997: MEDLINE (from 1966), HealthSTAR (from 1975), CINAHL (from 1982), Cancerlit (from 1982), and the Cochrane Library (Issue 2, 1997). Search strategies, which were adapted for all databases, included the terms 'palliat', 'hospice', 'terminally ill', 'end stage disease' and 'delivery of health care'. In addition, the reference lists of available texts and retrieved articles were searched for eligible studies. Only full reports, published in any language and in peer-reviewed journals, were included.
Study selection Study designs of evaluations included in the reviewComparative studies of any methodological design were included.
Specific interventions included in the reviewThe participants had to be receiving palliative care, which took the form of medical, nursing and psychosocial support, or help with the activities of daily living. The authors do not report specific details regarding the precise nature of the interventions. Patients received home care, care in in-patient hospices, or conventional oncology care. Studies had to compare at least two ways of providing care.
Participants included in the reviewThe participants were described as palliative, or having end stage or terminal illnesses. In the four studies concerned with effectiveness, all participants were patients with cancer. No specific details of participant characteristics such as age and gender were reported.
Outcomes assessed in the reviewThe outcomes were patient-related (e.g. quality of life, pain and satisfaction with care), family-related (e.g. anxiety, burden and post-death distress), and system-related (e.g. costs).
How were decisions on the relevance of primary studies made?At least two reviewers reviewed titles and abstracts for initial eligibility. Full articles were ordered if there was uncertainty about eligibility. The final decision on inclusion was made by consensus and based on the full report.
Assessment of study quality The authors do not report a method for assessing the validity of non-randomised studies. Methodological quality of randomised controlled trials (RCTs) was assessed by the Jadad scale (see Other Publications of Related Interest). The authors do not state how the papers were assessed for validity, or how many of the reviewers performed the validity assessment.
Data extraction After independent review of articles, reviewers met in pairs to agree a data set for each article. Disagreements were resolved through discussion or through recourse to a third reviewer. A third reviewer checked the accuracy of data extraction by reviewing a random subset of articles.
Methods of synthesis How were the studies combined?A narrative synthesis was provided. The authors do not report a method for assessing publication bias.
How were differences between studies investigated?Neither between- nor within-study variation was investigated.
Results of the review Forty-one studies met the inclusion criteria. However, only 4 studies met the a priori effectiveness criteria necessary to guide clinical or policy decisions. Only these studies are discussed below. The 4 included studies were all non-randomised comparative studies (n=4,135): 2 with contemporaneous controls (n=2,711) and 2 with historical controls (n=1,424).
Quality: there were 11 RCTs within the original 41 studies, 5 of which had quality scores compatible with high quality. None of the RCTs included an adequate description of allocation concealment. The quality of other study designs included in the review, such as those reporting effectiveness data, were not reported by the authors.
Patient-related: no significant differences were found between any of the comparisons for patient quality of life measures or satisfaction with services. Patients preferred to die at home, though pain relief and symptom control were marginally better in in-patient hospices.
Family-related: no significant differences were found between any of the comparisons for satisfaction with services. No benefit in terms of family outcomes was found in the different hospice approaches, i.e. in- and out-patient hospices.
Cost information One study reported that traditional home care services were approximately 30% more costly to Medicare programmes during the last 24 weeks of cancer illness than hospice home care or conventional oncology care (p<0.001).
Authors' conclusions The authors' conclusions appear to state that there is a need for more, better quality research.
CRD commentary The review question was stated clearly and supported by study inclusion criteria. The search for published literature was adequate, though no attempt to identify unpublished material was made. The extent to which the review represents accurately the available literature is, therefore, unclear. Details of primary data were limited, particularly with respect to participant characteristics such as age and gender. There was no validity assessment of studies that provided effectiveness data. The included studies lacked appropriate synthesis; studies were discussed individually and little attempt at synthesis was offered.
Details of the review methodology were adequately reported, though the authors' conclusions are not highlighted clearly. Given the above limitations, the results of this review should be interpreted with caution.
Implications of the review for practice and research Practice: The authors do not state any implications for practice.
Research: The authors state that there is a need for well-conducted and appropriately reported RCTs.
Bibliographic details Critchley P, Jadad A R, Taniguchi A, Woods A, Stevens R, Reyno L, Whelan T J. Are some palliative care delivery systems more effective and efficient than others: a systematic review of comparative studies. Journal of Palliative Care 1999; 15(4): 40-47 Other publications of related interest Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ, Gavaghan DJ, et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials 1996;17:1-12.
Indexing Status Subject indexing assigned by NLM MeSH Home Care Services; Hospice Care; Hospitalization; Humans; Long-Term Care; Neoplasms /therapy; Palliative Care /methods; Quality of Health Care; Quality of Life AccessionNumber 12000000388 Date bibliographic record published 30/11/2001 Date abstract record published 30/11/2001 Record Status This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn. |
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