Effectiveness and cost-effectiveness of home palliative care services for adults with advanced illness and their caregivers
Effectiveness and cost-effectiveness of home palliative care services for adults with advanced illness and their caregivers
复制标题
DOI：
10.1002/14651858.cd007760.pub2
复制
发表时间：
2016-02-01
影响因子：
1.4
通讯作者：
Brito, Maja de
中科院分区：
文献类型：
--
作者：
Gomes, Barbara;Calanzani, Natalia;Brito, Maja de
背景大量证据表明，超过50%的人更愿意在环境允许的情况下在家中得到照顾和死亡。尽管尽了最大的努力和政策，在世界上许多国家，三分之一或更少的死亡发生在家中。目的：1.量化晚期成人患者及其家庭照顾者的家庭姑息治疗服务对患者在家死亡几率的影响。探讨居家姑息照护服务对病患及其照顾者之其他成效，如症状控制、生活品质、照顾者困扰及照护满意度等之临床成效;比较与这些服务有关的资源使用和成本; 4.批判性地评价和总结成本效益的现有证据。检索方法我们检索了截至2012年11月的12个电子数据库。我们检查了所有纳入研究的参考文献列表，49篇相关系统综述，4本关键教科书和最近的会议摘要。我们联系了17位专家和研究人员，以获取未发表的数据。选择标准我们包括随机对照试验（RCT）、对照临床试验（CCT）、前后对照研究（CBA）和中断时间序列（ITS），以评估家庭姑息治疗服务对晚期疾病成人或其家庭照顾者结局的影响，数据收集和分析一位综述作者评估了确定的标题和摘要。两名独立的评审员对所有潜在相关研究进行了评估，数据提取和方法学质量评估。我们在适当的情况下进行了荟萃分析，并计算了主要结局的获益治疗所需的数量（NNTBs）主要结果我们确定了23项研究（16项RCT，6项高质量），包括37，561名参与者和4042名家庭护理人员，主要患有晚期癌症，但也患有充血性心力衰竭（CHF），慢性阻塞性肺病（COPD），艾滋病毒/艾滋病和多发性硬化症（MS）等疾病。Meta分析显示，（OR = 2.21，95% CI 1.31~3.71; Z = 2.98，P值= 0.003; Chi（2）= 20.57，自由度（df）= 6，P值= 0.002; I-2 = 71%; NNTB 5，95% CI 3 - 14（7项试验，1222名受试者，3项高质量）。此外，叙述性综合显示，与常规护理相比，家庭姑息治疗服务对减轻患者症状负担的有益影响较小，但具有统计学显著性（3项试验，2项高质量，1项CBA，2107名参与者），对照顾者悲伤没有影响（3项RCT，2项高质量，1项CBA，2113名照顾者）。关于成本效益的证据（六项研究）是不确定的。作者的结论结果提供了明确和可靠的证据，表明家庭姑息治疗增加了在家中死亡的机会，减少了症状负担，特别是癌症患者，而不影响照顾者的悲伤。这证明为希望在家中死亡的患者提供家庭姑息治疗是合理的。需要做更多的工作来研究成本效益，特别是对非恶性疾病患者，评估死亡地点和对这些人群的变化敏感和有效的适当结果，并在动力研究中比较不同的家庭姑息治疗模式。
BackgroundExtensive evidence shows that well over 50% of people prefer to be cared for and to die at home provided circumstances allow choice. Despite best efforts and policies, one-third or less of all deaths take place at home in many countries of the world.Objectives1. To quantify the effect of home palliative care services for adult patients with advanced illness and their family caregivers on patients' odds of dying at home; 2. to examine the clinical effectiveness of home palliative care services on other outcomes for patients and their caregivers such as symptom control, quality of life, caregiver distress and satisfaction with care; 3. to compare the resource use and costs associated with these services; 4. to critically appraise and summarise the current evidence on cost-effectiveness.Search methodsWe searched 12 electronic databases up to November 2012. We checked the reference lists of all included studies, 49 relevant systematic reviews, four key textbooks and recent conference abstracts. We contacted 17 experts and researchers for unpublished data.Selection criteriaWe included randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs) and interrupted time series (ITSs) evaluating the impact of home palliative care services on outcomes for adults with advanced illness or their family caregivers, or both.Data collection and analysisOne review author assessed the identified titles and abstracts. Two independent reviewers performed assessment of all potentially relevant studies, data extraction and assessment of methodological quality. We carried out meta-analysis where appropriate and calculated numbers needed to treat to benefit (NNTBs) for the primary outcome (death at home).Main resultsWe identified 23 studies (16 RCTs, 6 of high quality), including 37,561 participants and 4042 family caregivers, largely with advanced cancer but also congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), HIV/ AIDS and multiple sclerosis (MS), among other conditions. Meta- analysis showed increased odds of dying at home (odds ratio (OR) 2.21, 95% CI 1.31 to 3.71; Z = 2.98, P value = 0.003; Chi(2) = 20.57, degrees of freedom (df) = 6, P value = 0.002; I-2 = 71%; NNTB 5, 95% CI 3 to 14 (seven trials with 1222 participants, three of high quality)). In addition, narrative synthesis showed evidence of small but statistically significant beneficial effects of home palliative care services compared to usual care on reducing symptom burden for patients (three trials, two of high quality, and one CBA with 2107 participants) and of no effect on caregiver grief (three RCTs, two of high quality, and one CBA with 2113 caregivers). Evidence on cost- effectiveness (six studies) is inconclusive.Authors' conclusionsThe results provide clear and reliable evidence that home palliative care increases the chance of dying at home and reduces symptom burden in particular for patients with cancer, without impacting on caregiver grief. This justifies providing home palliative care for patients who wish to die at home. More work is needed to study cost- effectiveness especially for people with non- malignant conditions, assessing place of death and appropriate outcomes that are sensitive to change and valid in these populations, and to compare different models of home palliative care, in powered studies.