Title: Systematic review and meta-analysis of the effectiveness and cost-effectiveness of inpatient specialist palliative care in acute hospitals for adults with advanced illness and their caregivers
Funder: Department of Health and Social Care

Abstract: Background: The global burden of disease has increased with increasing longevity and reduced mortality. This change is placing considerable strain on healthcare systems with increases in healthcare costs observed globally, despite efforts to reduce acute hospital expenditure. Specialist palliative care in acute hospitals is common. Most adults die in hospitals and most die from advanced chronic illness. With an ageing population, the demand for specialist palliative care is likely to continue. Evidence shows that specialist palliative care improves clinical outcomes and quality of care, can reduce hospital costs, and help contain costs in the last year of life. A review of the evidence of the effectiveness and cost-effectiveness of specialist palliative care has the potential to aid the future development, funding and implementation of evidenced based inpatient specialist palliative care. Aim: To determine the effectiveness (on improving pain and other symptoms) and cost-effectiveness of inpatient specialist palliative care for patients with advanced illness and their unpaid caregivers. Methods Design: Cochrane Systematic review, meta-analysis and meta-synthesis. Participants: 1) adult patients admitted to an acute hospital receiving inpatient specialist palliative care or in a control group or 2) unpaid caregivers of these patients Intervention: Inpatient specialist palliative care. Comparator: Best usual care Outcome: Primary Outcome- Pain measured using validated assessment scales. Secondary outcomes- Other symptoms, quality of life, experience/satisfaction of care, patient mortality/survival, caregiver burden, mental health and bereavement outcomes, health economic evaluation and adverse effects. Studies: We will include studies that examine inpatient specialist palliative care. Search methods: We will identify studies through electronic searches (1947 to present) and appropriate health economic databases (1980-present), hand searching, electronic citation tracking, personal contact and searching of grey literature. We will use an adapted MEDLINE search strategy for all databases. Data extraction and management: Two researchers will assess studies for bias and independently extract and enter data from all included studies using a data extraction form. Disagreements will be resolved by discussion and consensus with a third researcher. Quality assessment will follow Cochrane handbook methods. Analysis: If appropriate, we will undertake meta-analysis of the primary and secondary outcomes. We will conduct all analysis as per the Cochrane Collaboration handbook. We will present characteristics of the included health economics studies. We will also present point estimates of measures of items of resource use and cost and point estimates of incremental costs and/or cost-effectiveness, with associated measures of uncertainty. We will identify and report incremental cost per QALY (or equivalent) and cost-benefit ratios where relevant. We will conduct further cost-effectiveness analysis depending on the level of data retrieved. Should the eligible studies not be sufficiently homogenous to permit meta-analysis, we will extract quantitative data and techniques used in narrative synthesis will be employed to analyse the data. Where possible, we will include qualitative data from nested or embedded qualitative studies.

Lay abstract: Why are we doing this research? We are carrying out this research to try and find out if hospital palliative care teams (teams focussing on improving symptoms and quality of life) are useful and provide good value for money. Why is this research needed? There is an increased burden on healthcare internationally. This is because people are less likely to die in childhood and more likely to live longer. Despite attempts to reduce the cost of hospital care, it continues to increase. In addition, there has been a recent growth of palliative care teams in hospitals. What we don’t know is whether palliative care teams in hospital are useful in improving patients’ pain and other symptoms and whether they are good value for money. In addition we don’t know which part of the service delivered by palliative care teams in hospital is most useful. If we knew which parts of the service were most useful, we could concentrate on developing those elements. This may then improve care and reduce hospital costs. How will we do the research? A synthesis of evidence will be conducted. We will look at studies involving palliative care teams in hospital and we will look at the effect of palliative care on both patients and carers. We will look at the effect on pain and other symptoms including anxiety and depression. Importantly, we will also look to see if palliative care services cause any harm to patients and carers. We will describe all studies, present results and where possible undertake analysis combining results together. How will we involve patients and public in our research? Patients and carers have been involved in identifying the most appropriate questions to ask and putting this application together. A patient and carer will be part of our project steering group and they will be involved in all stages and advising us on the best way to publicise our results. How will we publicise our results? Final results will be published through a final report, submissions to medical journals and through presentation at relevant medical conferences. In addition, we will produce a policy summary for policy makers within the NHS.

Research activity codes: 7.2 END OF LIFE CARE
Health categories: GENERIC HEALTH RELEVANCE