title: Delivery strategies to optimize resource utilization and performance status for patients with advanced life-limiting illness: results from the "palliative care trial" [ISRCTN 81117481].
abstract: BACKGROUND
  Evidence-based approaches are needed to improve the delivery of specialized palliative care.
  
  
  OBJECTIVE
  The aim of this trial was to improve on current models of service provision.
  
  
  METHODS
  This 2×2×2 factorial cluster randomized controlled trial was conducted at an Australian community-based palliative care service, allowing three simultaneous comparative effectiveness studies. Participating patients were newly referred adults, experiencing pain, and who were expected to live >48 hours. Patients enrolled with their general practitioners (GPs) and were randomized three times: 1) individualized interdisciplinary case conference including their GP vs. control, 2) educational outreach visiting for GPs about pain management vs. control, and 3) structured educational visiting for patients/caregivers about pain management vs. control. The control condition was current palliative care. Outcomes included Australia-modified Karnofsky Performance Status (AKPS) and pain from 60 days after randomization and hospitalizations.
  
  
  RESULTS
  There were 461 participants: mean age 71 years, 50% male, 91% with cancer, median survival 179 days, and median baseline AKPS 60. Only 47% of individuals randomized to the case conferencing intervention received it; based on a priori-defined analyses, 32% of participants were included in final analyses. Case conferencing reduced hospitalizations by 26% (least squares means hospitalizations per patient: case conference 1.26 [SE 0.10] vs. control 1.70 [SE 0.13], P=0.0069) and better maintained performance status (AKPS case conferences 57.3 [SE 1.5] vs. control 51.7 [SE 2.3], P=0.0368). Among patients with declining function (AKPS <70), case conferencing and patient/caregiver education better maintained performance status (AKPS case conferences 55.0 [SE 2.1] vs. control 46.5 [SE 2.9], P=0.0143; patient/caregiver education 54.7 [SE 2.8] vs. control 46.8 [SE 2.1], P=0.0206). Pain was unchanged. GP education did not change outcomes.
  
  
  CONCLUSIONS
  A single case conference added to current specialized community-based palliative care reduced hospitalizations and better maintained performance status. Comparatively, patient/caregiver education was less effective; GP education was not effective.
authors.affiliation: Division of Medical Oncology, Duke University Medical Center, Durham, North Carolina, USA. amy.abernethy@duke.edu
authors.forename: Amy P
authors.initials: AP
authors.lastname: Abernethy
authors.forename: David C
authors.initials: DC
authors.lastname: Currow
authors.forename: Tania
authors.initials: T
authors.lastname: Shelby-James
authors.forename: Debra
authors.initials: D
authors.lastname: Rowett
authors.forename: Frank
authors.initials: F
authors.lastname: May
authors.forename: Gregory P
authors.initials: GP
authors.lastname: Samsa
authors.forename: Roger
authors.initials: R
authors.lastname: Hunt
authors.forename: Helena
authors.initials: H
authors.lastname: Williams
authors.forename: Adrian
authors.initials: A
authors.lastname: Esterman
authors.forename: Paddy A
authors.initials: PA
authors.lastname: Phillips
mesh_terms: D000368:Aged; D001315:Australia / Q000453:epidemiology; D002908:Chronic Disease / Q000401:mortality* / Q000451:nursing*; D059350:Chronic Pain / Q000401:mortality* / Q000451:nursing* / Q000517:prevention & control; D015897:Comorbidity; D005260:Female; D015276:Health Care Rationing / Q000379:methods / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D010147:Pain Measurement / Q000706:statistics & numerical data; D010166:Palliative Care / Q000706:statistics & numerical data*; D015995:Prevalence; D018570:Risk Assessment; D016019:Survival Analysis; D015996:Survival Rate; D013727:Terminal Care / Q000706:statistics & numerical data*; D016896:Treatment Outcome; D014600:Utilization Review