Southern Adelaide Palliative Services (SAPS) provides consultative community and hospital based support to general practitioners, community nurses, other specialists and allied health practitioners caring for people with a life-limiting illness. More than 1100 people with a life-limiting illness and their families are referred each year from a population of 350,000 people. People referred to the service are from all age groups with a diverse range of life-limiting illnesses.
SAPS in conjunction with the Repatriation General Hospital, Flinders University Department of Palliative and Supportive Services, Southern Adelaide Division of General Practice, Adelaide Healthcare Alliance and Aged Care and Housing Inc. carried out the Palliative Care Trial between April 2002 and November 2004. It was funded by the Australian Government through the Rural and Palliative Care Branch of the Department of Health and Ageing.
The Palliative Care Trial is the largest randomised controlled trial in the world exploring palliative care service provision where participants were individually consented. It is one of a handful of studies that have rigorously explored case conferencing.
Aim
To improve the provision of palliative care in the community.
Objectives
- To assess the impact of case conferencing (as defined in the Medical Benefits Schedule)
- To assess structured educational interventions (using pain as the topic around which the intervention was built) with key messages from evidencebased literature for both general practitioners and patients.
Outcomes
Primary
- Level of function measured by Australian Modified Karnofsky Performance status (AKPS)
- Pain control measured on numeric rating scale.
Secondary
- Cost and place of care, quality of life, pain, total symptom burden.
Methodology
A randomised controlled trial where each participant was randomised three times to:
- Routine care with or without case conferencing
- Routine care with or without educational outreach visiting for the general practitioner
- Routine care with or without patient (and caregiver) educational visiting.
The study was completed by incorporating interventions and data collection into routine clinical care. Pilot testing of the feasibility and acceptability were a crucial component in achieving the study’s outcomes. A separate nurse was employed and trained to recruit patients and their general practitioners to the study.
Participants were any people referred to SAPS who in the past 3 months had pain and were willing to participate in the study. Having obtained the participant consent, their general practitioner was then separately consented. The inclusion criteria were broad to ensure that the 461 participants in this study reflected the people routinely referred to SAPS.
Data were collected prospectively fortnightly for 3 months and then at least monthly from the time of referral until death including data from Medicare Australia, private health funds and the South Australian Database for hospital usage. This created a dataset of more than 2 million data items which were available for analysis.
The trial concluded that a single case conference or patient educational visit, conducted at a time when the patient’s physical performance status had started to decline to the point of needing a caregiver (AKPS<70%) could maintain function by 5-10% compared to the control group (mean area under the curve 55 (intervention) versus 46 (usual care), p=0.01). For this group, life expectancy was 266 days after the census point in the study. There was a ceiling effect for this benefit, such that combining the two effective interventions did not provide additional benefits to functional status. Likewise, the number of hospital admissions for the groups who received case conferencing or patient educational visiting was significantly lower (case conferencing mean 1.4 vs usual care 1.9, p=0.0002; patient educational visiting 1.4 vs usual care 1.8, p=0.0078).
Analysis of the economic outcomes together with the medication utilisation continues.
Implications for practice
This study's result strongly support the timely use of case conferencing and patient educational visiting in improving objective outcomes valued by patients and their caregivers. Bringing health professionals together even for a short period of time to discuss care and future contingencies enhances the care offered. Focused patient education has significant benefit to the consumer.
This landmark study has implications for practice well beyond palliative care. It’s application has relevance to service provision for people with a wide range of chronic and complex health issues where complex patient and caregiver needs rather than the primary diagnosis define resource utilisation.
This page was created on 27 April 2007 and is due tor review in April 2009