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.

Cochrane Database Syst Rev. 2013 Jun 6; 6: CD007760
Gomes B, Calanzani N, Curiale V, McCrone P, Higginson IJ

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 We contacted 17 experts and researchers for unpublished data.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. HubMed – rehab


Survey of the Reporting Characteristics of Systematic Reviews in Rehabilitation.

Phys Ther. 2013 Jun 6;
Gianola S, Gasparini M, Agostini M, Castellini G, Corbetta D, Gozzer P, Li LC, Sirtori V, Taricco M, Tetzlaff JM, Turolla A, Moher D, Moja L

BACKGROUND: Systematic reviews (SRs) have become increasingly important for informing clinical practice; however little is known about the reporting characteristics and the quality of the SRs relevant to practice of rehabilitation health professionals. OBJECTIVE: To examine the reporting quality of a representative sample of published SRs on rehabilitation. We focused on the descriptive, reporting and bias-related characteristics. METHODS: We performed a cross-sectional study searching Medline for aggregative and configurative SRs indexed in 2011, focused on rehabilitation as restoring of functional limitations. Two reviewers independently screened and selected the SRs and extracted data using a 38-item data collection form derived from PRISMA. The data were analyzed descriptively. RESULTS: We sampled 88 SRs published in 59 journals. The median compliance with the PRISMA items were 17 (63%) out of 27 items (IQR range 13 to 22 [48% to 82%]). Two-thirds (n=66) focused on interventions whom efficacy is best addressed through RCT design and almost all SRs included RCTs (63/66 [95%]). Over two-thirds of SRs assessed the quality of primary studies (74/88 [84%]). Twenty-eight reviews (28/88 [32%]) meta-analyzed the results for at least one outcome. One half of SRs founded a positive significance (46%) whereas a detrimental result was present only in one review. CONCLUSIONS: Our sample of SRs in the rehabilitation field shows heterogeneous characteristics and a moderate quality of reporting. Poor control of potential source of bias might be improved if more widely agreed upon evidence-based reporting guidelines will be actively endorsed and adhered to by authors and journals. HubMed – rehab


[Home-based rehabilitation in the functional recovery of patients with cerebrovascular disease].

Rev Neurol. 2013 Jun 16; 56(12): 601-7
Lopez-Liria R, Ferre-Salmeron R, Arrebola-Lopez C, Granados-Valverde R, Gobernado-Cabero MA, Padilla-Gongora D

INTRODUCTION. The study of the effectiveness of rehabilitation treatment applied to patients with sequelae following a cerebrovascular disease (CVD) plays a decisive role nowadays in planning their management in public healthcare and to improve existing guidelines regarding assessment and treatment. AIM. To describe the characteristics presented by patients who have suffered a CVD and were treated in mobile rehabilitation-physiotherapy units (MRPU) and how such treatment affects their functional recovery. PATIENTS AND METHODS. Descriptive, prospective study conducted on 124 patients referred to the MRPUs in the province of Almeria between 2008 and 2011. The variables analysed (both pre- and post-treatment) included personal history and characteristics, Barthel index, Modified Ashworth Spasticity Scale, pain (shoulder) and the Canadian Neurological Scale. RESULTS. The final sample consisted of 106 participants (mean age: 73.72 years). The disabling process was ischaemic in 77.4% and hypertension was the most prevalent risk factor (81%). The mean initial Barthel index was 31.04 and the mean final index was 57.62 (t = -11.75; p < 0.001). The Canadian Neurological Scale showed a favourable progression in the level of consciousness, orientation and language (p < 0.001). Altogether 56.2% of the patients were discharged as a result of the improvement of their condition, and did not require any further outpatient rehabilitation. CONCLUSIONS. The results obtained reflect an important functional improvement in patients treated in the MRPUs. Home-based rehabilitation is considered a necessary tool for persons with greater clinical vulnerability and no access to outpatient care, which provides them with the benefits of effective treatment. HubMed – rehab


Knee pain after anterior cruciate ligament reconstruction: evaluation of a rehabilitation protocol.

Eur J Orthop Surg Traumatol. 2013 Jun 7;
Gadea F, Monnot D, Quélard B, Mortati R, Thaunat M, Fayard JM, Sonnery-Cottet B

INTRODUCTION: Anterior knee pain (AKP) is a rare and difficult complication following anterior cruciate ligament (ACL) reconstruction. This disabling pain is persistent with conventional rehabilitation protocols. The aim of this work is to validate a new rehabilitation protocol that may improve the patients and allow return to daily activities including sports. MATERIALS AND METHODS: Forty-three patients identified with functional AKP after ACL reconstruction was enrolled in the rehabilitation protocol between 2009 and 2011. The series included twenty-six patients with hamstring grafting and seventeen patients with patellar tendon transplant. This study compares the functional outcomes and pain scores before and after the isokinetic protocol until the last follow-up at an average of 25.7 months after surgery. The evaluation was performed according to the International Knee Documentation Committee (IKDC) and included a pain assessment using the visual analog scale. Statistical analysis used Student’s t-test for unpaired data and the Pearson correlation test for the variables. The IKDC scores were compared by the Wilcoxon test. RESULTS: Functional outcomes and pain are significantly improved (p < 0.0001). The average IKDC score improved with 28 points and the pain improved with 3.2 points on the visual analog scale (VAS). The results are correlated with the follow-up time (p = 0.008) but not correlated with the delay between the surgery and the beginning of the isokinetic protocol. DISCUSSION: Isokinetic rehabilitation provides a significant improvement in the knee function as measured by the IKDC score and by the VAS, regardless of the painful period preceding the program. The function improvement continues after the end of the protocol, but the pain may not completely disappear. The isokinetic rehabilitation program may resume functional AKP related to muscular deficit and may be used as the starter of other physical therapy protocols. LEVEL OF EVIDENCE: IV. HubMed – rehab