title: Populations and Interventions for Palliative and End-of-Life Care: A Systematic Review.
abstract: Evidence supports palliative care effectiveness. Given workforce constraints and the costs of new services, payers and providers need help to prioritize their investments. They need to know which patients to target, which personnel to hire, and which services best improve outcomes.
  
  
  
  To inform how payers and providers should identify patients with "advanced illness" and the specific interventions they should implement, we reviewed the evidence to identify (1) individuals appropriate for palliative care and (2) elements of health service interventions (personnel involved, use of multidisciplinary teams, and settings of care) effective in achieving better outcomes for patients, caregivers, and the healthcare system.
  
  
  
  Systematic searches of MEDLINE, EMBASE, PsycINFO, Web of Science, and Cochrane Database of Systematic Reviews databases (1/1/2001-1/8/2015).
  
  
  
  Randomized controlled trials (124) met inclusion criteria. The majority of studies in cancer (49%, 38 of 77 studies) demonstrated statistically significant patient or caregiver outcomes (e.g., p < 0.05), as did those in congestive heart failure (CHF) (62%, 13 of 21), chronic obstructive pulmonary disease (COPD; 58%, 11 of 19), and dementia (60%, 15 of 25). Most prognostic criteria used clinicians' judgment (73%, 22 of 30). Most interventions included a nurse (70%, 69 of 98), and many were nurse-only (39%, 27 of 69). Social workers were well represented, and home-based approaches were common (56%, 70 of 124). Home interventions with visits were more effective than those without (64%, 28 of 44; vs. 46%, 12 of 26). Interventions improved communication and care planning (70%, 12 of 18), psychosocial health (36%, 12 of 33, for depressive symptoms; 41%, 9 of 22, for anxiety), and patient (40%, 8 of 20) and caregiver experiences (63%, 5 of 8). Many interventions reduced hospital use (65%, 11 of 17), but most other economic outcomes, including costs, were poorly characterized. Palliative care teams did not reliably lower healthcare costs (20%, 2 of 10).
  
  
  
  Palliative care improves cancer, CHF, COPD, and dementia outcomes. Effective models include nurses, social workers, and home-based components, and a focus on communication, psychosocial support, and the patient or caregiver experience. High-quality research on intervention costs and cost outcomes in palliative care is limited.
authors.affiliation: 1 David Geffen School of Medicine, University of California at Los Angeles , Los Angeles, California.|2 RAND Corporation , Santa Monica, California.
authors.forename: Adam E
authors.initials: AE
authors.lastname: Singer
authors.affiliation: 3 School of Nursing, California State University , Long Beach, Long Beach, California.
authors.forename: Joy R
authors.initials: JR
authors.lastname: Goebel
authors.affiliation: 4 Division of Research, Kaiser Permanente Northern California , Oakland, California.
authors.forename: Yan S
authors.initials: YS
authors.lastname: Kim
authors.affiliation: 5 Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health , Baltimore, Maryland.
authors.forename: Sydney M
authors.initials: SM
authors.lastname: Dy
authors.affiliation: 2 RAND Corporation , Santa Monica, California.
authors.forename: Sangeeta C
authors.initials: SC
authors.lastname: Ahluwalia
authors.affiliation: 2 RAND Corporation , Santa Monica, California.
authors.forename: Megan
authors.initials: M
authors.lastname: Clifford
authors.affiliation: 6 Division of Hospital Medicine, University of California at San Francisco , San Francisco, California.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Dzeng
authors.affiliation: 2 RAND Corporation , Santa Monica, California.|7 Pardee RAND Graduate School , RAND Corporation, Santa Monica, California.
authors.forename: Claire E
authors.initials: CE
authors.lastname: O'Hanlon
authors.affiliation: 2 RAND Corporation , Santa Monica, California.
authors.forename: Aneesa
authors.initials: A
authors.lastname: Motala
authors.affiliation: 1 David Geffen School of Medicine, University of California at Los Angeles , Los Angeles, California.|2 RAND Corporation , Santa Monica, California.|8 Veterans Affairs Greater Los Angeles Healthcare System , Los Angeles, California.
authors.forename: Anne M
authors.initials: AM
authors.lastname: Walling
authors.affiliation: 9 Supportive Care Medicine, Cedars-Sinai Medical Center , Los Angeles, California.
authors.forename: Jaime
authors.initials: J
authors.lastname: Goldberg
authors.affiliation: 10 Department of Preventive Medicine, University of Southern California , Los Angeles, California.
authors.forename: Daniella
authors.initials: D
authors.lastname: Meeker
authors.affiliation: 11 Cedars-Sinai Medical Center , Los Angeles, California.
authors.forename: Claudia
authors.initials: C
authors.lastname: Ochotorena
authors.affiliation: 2 RAND Corporation , Santa Monica, California.
authors.forename: Roberta
authors.initials: R
authors.lastname: Shanman
authors.affiliation: 12 RAND Corporation , Pittsburgh, Pennsylvania.
authors.forename: Mike
authors.initials: M
authors.lastname: Cui
authors.affiliation: 2 RAND Corporation , Santa Monica, California.|13 Stanford University School of Medicine , Stanford, California.
authors.forename: Karl A
authors.initials: KA
authors.lastname: Lorenz
mesh_terms: D017028:Caregivers; D003704:Dementia; D017048:Health Care Costs; D006801:Humans; D010166:Palliative Care; D013727:Terminal Care