The latest in the Agency for Healthcare Research and Quality’s excellent series of state of the evidence reports focuses on quality improvement in end-of-life and hospice care. (AHRQ Report) The researchers examined 93 studies, most of which had interventions aimed at continuity and coordination of care, pain, distress, communication and decision-making or examining a particular care setting. The population under study was people who were seriously ill, with a strong likelihood of dying fairly soon. Key outcomes included patient and family satisfaction with and perceptions of care; patient symptoms, distress and quality of life; health care utilization; quality of care process measures and family issues.
In regard to continuity and coordination of care, of the studies with quality of life as an outcome, 33% found a significant improvement from the intervention; for patient satisfaction, 67% showed such improvement and none showed an impact on patient symptoms. Most did find an effect on utilization. For those with pain reduction as an outcome, about half the studies found that the intervention worked but in most of these studies that also looked at quality of life, no effect occurred. Studies with distress as a primary outcome had about a 30% success rate for the intervention in reducing distress. The research with communication and decision-making as an outcome had a low rate of improving family or patient satisfaction with these processes, but almost 75% showed utilization reductions.
The very sparse research in hospice or nursing home settings suggested some interventions could improve care, but the evidence was very limited. As is often the case in these reviews, AHRQ finds many of the studies to have design issues, including poor choice of outcomes and other design flaws. The authors make suggestion for improving study design, and urge more studies be done in the hospice setting. It is encouraging, however, that at least moderate evidence exists for value from many interventions, interventions which apparently improve patient satisfaction and quality of life as well as showing potential for reducing utilization and costs.