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Article pour les cliniciens

Efficacité et rapport coût-efficacité des services de soins palliatifs à domicile pour les adultes souffrant d'une maladie à un stade avancé et leurs soignants.



  • Gomes B
  • Calanzani N
  • Curiale V
  • McCrone P
  • Higginson IJ
Cochrane Database Syst Rev. 2013 Jun 6;2013(6):CD007760. doi: 10.1002/14651858.CD007760.pub2. (Review)
PMID: 23744578
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Disciplines
  • - Neurologie
    Relevance - 6/7
    Intérêt médiatique  - 6/7
  • Oncology - Palliative and Supportive Care
    Relevance - 6/7
    Intérêt médiatique  - 6/7
  • Médecine familiale (MF)/Médecine générale (MG)
    Relevance - 6/7
    Intérêt médiatique  - 4/7
  • Médecine interne générale - Soins primaires
    Relevance - 6/7
    Intérêt médiatique  - 4/7
  • Intérêt spécial - Douleur - Médecin
    Relevance - 6/7
    Intérêt médiatique  - 3/7
  • - Cardiologie
    Relevance - 5/7
    Intérêt médiatique  - 5/7
  • Médecin hospitalier/Hospitaliste
    Relevance - 5/7
    Intérêt médiatique  - 5/7
  • Médecine interne (voir sous-spécialités ci-dessous)
    Relevance - 5/7
    Intérêt médiatique  - 5/7
  • - Respirologie/Pneumologie
    Relevance - 5/7
    Intérêt médiatique  - 4/7
  • - Maladies infectieuses
    Relevance - 4/7
    Intérêt médiatique  - 5/7

Résumé (en anglais)

BACKGROUND: Extensive 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.

OBJECTIVES: 1. 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 METHODS: We 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 We contacted 17 experts and researchers for unpublished data.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 CRITERIA: We 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 ANALYSIS: One 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 RESULTS: We 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' CONCLUSIONS: The 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.


Commentaires cliniques (en anglais)

Hospital Doctor/Hospitalists

For my practice, this study does not really change management; most patients strongly prefer to be at home as it is, and the rate limiting step is usually not that we don't believe in the effectiveness, but in providing the services and finding family who will support this disposition.

Internal Medicine

The study addresses an interesting and relevant question. However, the definitions of, standard for, and availability of home palliative care varies very much between countries.

Neurology

This review is very interesting. The home care services are proven to be beneficial for patients with terminal stage. The systematic process of collecting and appraising evidence is the strength of this review. We must consider good and well performed home care services in this group of patients.

Neurology

As a neurologist, I find these results important and useful. They justify helping families and friends help loved ones with terminal illnesses die peacefully at home.

Neurology

The most important point from this paper is that is focused on not only a patient's pain but a family's grief and burden. Detailed data will be useful for our home care support.

Respirology/Pulmonology

Cochrane review indicates that there is more likelihood of a patient dying at home, and with better symptom control, if home hospice services are available for patients with cancer. The data are insufficient for patients with other end stage non-cancer illnesses. Whether or not home hospice is cost effective remains to be seen.

Respirology/Pulmonology

This study clearly justifies providing home palliative care for patients who wish to die at home. A useful systematic review which provides good quality 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.

Special Interest - Pain -- Physician

In an analysis of the literature, the authors established that patients would prefer to die at home. To accomplish this goal, special home palliative care must be available. The problem is that this analysis will include patients prior to death. It is not possible to study preference at the time of death. While the results seem inherently correct, one must also consider this point.

Special Interest - Pain -- Physician

These are sensible and largely predictable findings. The only surprise is "evidence on cost-effectiveness (six studies) is inconclusive". Certainly in the UK, greater cost-effectiveness of home care is beyond doubt. Although, this may in part be because, unlike in hospital, non-nursing and medical care (eg laundary, feeding and toilet needs) is usually provided by the family or separate social care agencies who will charge those who can afford to pay.

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