Improving palliative care: a 2x2x2 factorial cluster randomised controlled trial of case conferencing and educational outreach

Background: Evidence-based palliative care service delivery models are needed. General Practitioner (GP) and patient-centred case conferences may increase multi-disciplinary interaction and enhance patient care. Educational outreach visiting in pain management may empower learners and improve care.

Methods: Three interventions were tested against a routine care control in a 2x2x2 cluster factorial randomised controlled trial. Interventions were case conferencing, educational visiting for GPs, and educational visiting for patients. Subjects were adult patients referred to palliative care services in southern Adelaide, Australia, with any pain in the preceding 3 months. Participants were followed longitudinally until death. Main outcomes included performance status (Australian modified Karnofsky Performance Status (AKPS)) and hospitalisation rates. Longitudinal intention to treat analyses using cluster-specific methods were conducted. The sample goal was 460.

Results: 461 participants were enrolled from 4/02-6/04. Mean age was 71 yrs, 50% were male, 91% had cancer. Mean and median survival was 146 and 87 days; median baseline AKPS was 60%. Participants randomised to case conferencing had higher mean performance status scores than those in routine care (average daily AKPS, 57.3% vs 51.7%, p=0.0368). Impact of case conferencing was greatest when baseline AKPS <70 at referral (average daily AKPS, 55.0% vs 46.5%, p=0.0143). Similarly, participants with baseline AKPS <70 at referral who were randomised to patient educational visiting had higher performance status than those in routine care (54.7% vs 46.8%, p=0.0206). There was no additive effect for these 2 interventions. Case conferencing significantly decreased hospitalisation rates compared to routine care (case conferencing: least squares mean number of hospitalisations, 1.26 (standard error (SE) 0.1) vs 1.70 (SE 0.1), p=0.0069). GP education did not improve any of these outcomes.

Conclusion: At a time when declining function and higher healthcare utilisation is the norm, palliative care that includes a case conference leads to improved performance status and decreased hospitalisations. Patients with deteriorating performance status derive the greatest benefit. Patients with deteriorating performance status also derive benefit from patient educational visiting for pain.