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Lessons From the Palliative Care Trial: Commentary on Abernethy et al.
Vol. 45 No. 3 March 2013
Journal of Pain and Symptom Management
487
Promoting Evidence in Practice Series Editor: Sydney M. Dy, MD, MS
Lessons From the Palliative Care Trial: Commentary on Abernethy et al. Geoffrey K. Mitchell, MBBS, PhD, FRACGP, FAChPM University of Queensland School of Medicine, Ipswich, Queensland, Australia
The study by Abernethy et al.1 is highly important because it is the world’s largest palliative care trial. It delivers valuable recommendations for palliative care practice and confirms the importance of early referral to palliative care. It also shows that high-quality randomized controlled trials of communitybased health service interventions are feasible. Three interventions were evaluated: 1) a single case conference between the patient’s general practitioner (GP) (or primary care physician in North American terms) and the specialist palliative care team; 2) academic detailing on palliative pain relief delivered to a specific patient’s GP; and 3) education interventions on pain and other symptom management provided to the patient and primary carer, delivered by palliative care nurses. Only patients who survived 60 days or more were analyzed for evidence of intervention effects. A single case conference reduced hospitalization rates by 0.5 per patient. A similar but smaller impact was noted for patient/carer interventions. Furthermore, case conferences maintained a 10% improved performance status compared with normal care from 60 days until death. The greatest benefit in terms of performance status occurred when the Australian Karnofsky Performance Scale was greater than 70, that is, when the patient could not manage without help.2 The patient/carer education delivered significant but smaller Address correspondence to: Geoffrey K. Mitchell, MBBS, PhD, FRACGP, FAChPM, University of Queensland School of Medicine, Ipswich Campus, Salisbury Road, Ipswich, Queensland 4305, Australia. E-mail: [email protected] Accepted for publication: January 9, 2013. Ó 2013 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.
improvements in performance status. Formal GP education on pain relief did not improve pain levels or performance status. The study confirms the benefits of close collaboration between palliative care services and the patient’s GP previously reported3 as well as the importance of carer and patient education. The nature of the case conferences was to focus on engaging the GP in the team and meeting any knowledge gaps the GP may have. The greatest benefit of a case conference arises when the patient’s condition begins to deteriorate. These findings suggest that specialist palliative care services should seriously consider well-timed routine case conferences with the patient’s GP and offer the patient and carer targeted education based on their clinical needs. Finally, the study confirms the World Health Organization recommendation that palliative care should be introduced early in the course of lifelimiting conditions and not at the last minute.
References 1. Abernethy AP, Currow DC, Shelby-James T, et al. Delivery strategies to optimize resource utilization and performance status for patients with advanced life-limiting illness: results from the ‘‘Palliative Care Trial’’ [ISRCTN 81117481]. J Pain Symptom Manage 2013;45:488e505. 2. Abernethy AP, Shelby-James T, Fazekas BS, Woods D, Currow DC. The Australia-modified Karnofsky Performance Status (AKPS) scale: a revised scale for contemporary palliative care clinical practice [ISRCTN 81117481]. BMC Palliat Care 2005;4:7. 3. Mitchell GK, Del Mar CB, O’Rourke PK, Clavarino AM. Do case conferences between general practitioners and specialist palliative care services improve quality of life? A randomised controlled trial (ISRCTN 52269003). Palliat Med 2008;22:904e912. 0885-3924/$ - see front matter http://dx.doi.org/10.1016/j.jpainsymman.2013.01.001
Journal of Pain and Symptom Management
487
Promoting Evidence in Practice Series Editor: Sydney M. Dy, MD, MS
Lessons From the Palliative Care Trial: Commentary on Abernethy et al. Geoffrey K. Mitchell, MBBS, PhD, FRACGP, FAChPM University of Queensland School of Medicine, Ipswich, Queensland, Australia
The study by Abernethy et al.1 is highly important because it is the world’s largest palliative care trial. It delivers valuable recommendations for palliative care practice and confirms the importance of early referral to palliative care. It also shows that high-quality randomized controlled trials of communitybased health service interventions are feasible. Three interventions were evaluated: 1) a single case conference between the patient’s general practitioner (GP) (or primary care physician in North American terms) and the specialist palliative care team; 2) academic detailing on palliative pain relief delivered to a specific patient’s GP; and 3) education interventions on pain and other symptom management provided to the patient and primary carer, delivered by palliative care nurses. Only patients who survived 60 days or more were analyzed for evidence of intervention effects. A single case conference reduced hospitalization rates by 0.5 per patient. A similar but smaller impact was noted for patient/carer interventions. Furthermore, case conferences maintained a 10% improved performance status compared with normal care from 60 days until death. The greatest benefit in terms of performance status occurred when the Australian Karnofsky Performance Scale was greater than 70, that is, when the patient could not manage without help.2 The patient/carer education delivered significant but smaller Address correspondence to: Geoffrey K. Mitchell, MBBS, PhD, FRACGP, FAChPM, University of Queensland School of Medicine, Ipswich Campus, Salisbury Road, Ipswich, Queensland 4305, Australia. E-mail: [email protected] Accepted for publication: January 9, 2013. Ó 2013 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.
improvements in performance status. Formal GP education on pain relief did not improve pain levels or performance status. The study confirms the benefits of close collaboration between palliative care services and the patient’s GP previously reported3 as well as the importance of carer and patient education. The nature of the case conferences was to focus on engaging the GP in the team and meeting any knowledge gaps the GP may have. The greatest benefit of a case conference arises when the patient’s condition begins to deteriorate. These findings suggest that specialist palliative care services should seriously consider well-timed routine case conferences with the patient’s GP and offer the patient and carer targeted education based on their clinical needs. Finally, the study confirms the World Health Organization recommendation that palliative care should be introduced early in the course of lifelimiting conditions and not at the last minute.
References 1. Abernethy AP, Currow DC, Shelby-James T, et al. Delivery strategies to optimize resource utilization and performance status for patients with advanced life-limiting illness: results from the ‘‘Palliative Care Trial’’ [ISRCTN 81117481]. J Pain Symptom Manage 2013;45:488e505. 2. Abernethy AP, Shelby-James T, Fazekas BS, Woods D, Currow DC. The Australia-modified Karnofsky Performance Status (AKPS) scale: a revised scale for contemporary palliative care clinical practice [ISRCTN 81117481]. BMC Palliat Care 2005;4:7. 3. Mitchell GK, Del Mar CB, O’Rourke PK, Clavarino AM. Do case conferences between general practitioners and specialist palliative care services improve quality of life? A randomised controlled trial (ISRCTN 52269003). Palliat Med 2008;22:904e912. 0885-3924/$ - see front matter http://dx.doi.org/10.1016/j.jpainsymman.2013.01.001