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Temas

Study flow diagram.
Figuras y tablas -
Figure 1

Study flow diagram.

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Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Figuras y tablas -
Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Figuras y tablas -
Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Comparison 1 Place of death, Outcome 1 Dying at home.
Figuras y tablas -
Analysis 1.1

Comparison 1 Place of death, Outcome 1 Dying at home.

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Study

Grande 2000

T= 152/186 (82%), C= 34/44 (77%), P = 0.46

Figuras y tablas -
Analysis 1.2

Comparison 1 Place of death, Outcome 2 Time spent at home in the last 2 weeks of life.

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Comparison 1 Place of death, Outcome 3 Dying in hospital.
Figuras y tablas -
Analysis 1.3

Comparison 1 Place of death, Outcome 3 Dying in hospital.

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Study

Jordhøy 2000

T= 19/235 (9%), C= 36/199 (21%), P = 0.01

Figuras y tablas -
Analysis 1.4

Comparison 1 Place of death, Outcome 4 Dying in a nursing home.

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Comparison 1 Place of death, Outcome 5 Dying in a nursing home.
Figuras y tablas -
Analysis 1.5

Comparison 1 Place of death, Outcome 5 Dying in a nursing home.

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Comparison 2 Unplanned admissions, Outcome 1 Admitted to hospital.
Figuras y tablas -
Analysis 2.1

Comparison 2 Unplanned admissions, Outcome 1 Admitted to hospital.

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Study

Outcomes

Notes

Grande 2000

Pain, mean SD

T= 2.49 (0.92), C= 3.12 (1.05), P = 0.02

Nausea/vomiting, mean SD

T= 1.91 (0.87), C= 2.47 (1.07), P = 0.06

Constipation, mean SD

T= 2.32 (1.09), C= 2.50 (0.97), P = 0.51

Diarrhoea, mean SD

T= 1.49 (0.88), C= 1.60 (0.98), P = 0.69

Breathlessness, mean SD

T= 2.39 (1.17), C= 2.21 (1.19), P = 0.70

Anxiety, mean SD

T= 2.45 (1.05), C= 2.50 (1.10), P = 0.10

Depression, mean SD

T= 2.08 (0.97), C= 1.93 (1.14), P = 0.65

4‐point scale completed by the care giver.

Lower score indicates less of a problem.

Figuras y tablas -
Analysis 3.1

Comparison 3 Control of symptoms, Outcome 1 Caregivers' ratings of symptoms.

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Study

Outcomes

Notes

Grande 2000

Pain, mean SD

T= 2.03 (0.73), C= 2.35 (0.95), P = 0.09

Nausea/vomiting, mean SD

T= 1.78 (0.82), C= 2.00 (1.02), P = 0.28

Constipation, mean SD

T= 1.81 (0.78), C= 1.97 (0.94), P = 0.45

Diarrhoea, mean SD

T= 1.17 (0.49), C= 1.36 (0.73), P = 0.20

Breathlessness, mean SD

T= 1.82 (1.01), C= 1.66 (0.93), P = 0.42

Anxiety, mean SD

T= 2.10 (0.95), C= 2.50 (0.97), P = 0.05

Depression, mean SD

T= 1.62 (0.76), C= 2.19 (1.08), P = 0.01

Intention to treat

4‐point scale completed by the GP

Lower score indicates less of a problem.

No difference was detected for the ratings reported

by district nurses and informal care givers

Figuras y tablas -
Analysis 3.2

Comparison 3 Control of symptoms, Outcome 2 GPs' ratings of symptoms.

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Study

Outcomes

Notes

Hughes 1992

At 6 months, mean
T= 72 (n=18)
C= 69.31 (n=16)

High attrition in both groups due to death.

The Barthel Self‐Care Index with modified scoring system was used.

No P value given, insufficient data to calculate CI

Figuras y tablas -
Analysis 4.1

Comparison 4 Participant health outcomes, Outcome 1 Functional status.

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Study

Outcomes

Notes

Hughes 1992

At 6 months, mean
T= 1.54 (n=17)
C= 1.57 (n=14)

High attrition in both groups due to death.

Philadelphia Geriatric Morale Scale used (shortened version).

No P value given, insufficient data to calculate CI

Figuras y tablas -
Analysis 4.2

Comparison 4 Participant health outcomes, Outcome 2 Psychological well‐being.

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Study

Outcomes

Notes

Hughes 1992

At 6 months, mean
T= 8.33 (n=18)
C= 8.86 (n=14)

High attrition in both groups due to death.

Short Portable Mental Status Questionnaire used (10 items).

No P value given, insufficient data to calculate CI

Figuras y tablas -
Analysis 4.3

Comparison 4 Participant health outcomes, Outcome 3 Cognitive status.

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Study

Outcomes

Notes

Brumley 2007

At 30 days

OR = 3.37, 95% CI = 1.42‐8.10 (n=216)

At 60 days

OR= 1.79, 95% CI 0.65 to 4.96 (n=168)

Satisfaction measured by the Reid‐Gundlack Satisfaction with Service instrument

Hughes 1992

At one month: P = .02
At 6 months, mean
T= 2.72 (n=17), C= 2.45 (n=14)

17 item questionnaire derived from the National Hospice Study

No P value reported, insufficient data to calculate CI.

Figuras y tablas -
Analysis 4.4

Comparison 4 Participant health outcomes, Outcome 4 Patient satisfaction.

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Study

Hughes 1992

At 6 month, proportion (percentage)
T= 68/86 (79.1%), C= 66/85 (77.6%), difference 1.4, 95% CI ‐10.9 to 13.7

Figuras y tablas -
Analysis 4.5

Comparison 4 Participant health outcomes, Outcome 5 Mortality.

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Study

Brumley 2007

Days, mean (SD)

T= 196 (164), C= 242 (200), P = 0.03

Grande 2000

Treatment group (allocated and admitted to hospital at home): median 16 days
Allocated and not admitted to hospital at home: median 8 days
Z = 3.005, P = 0.003

Jordhøy 2000

Days, median (95% CI)

T= 99 (79 to 119), C= 127 (88 to 166)

Figuras y tablas -
Analysis 4.6

Comparison 4 Participant health outcomes, Outcome 6 Survival time from referral to death.

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Study

Outcomes

Notes

Hughes 1992

At 1 month: Carers in the treatment group reported a greater level of satisfaction
At 6 months: NS

Figuras y tablas -
Analysis 5.1

Comparison 5 Caregiver‐reported outcomes, Outcome 1 Caregiver satisfaction.

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Study

Outcomes

Notes

Brumley 2007

Controlling for survival, age, severity of illness and primary disease, adjusted mean cost (SD)

T= $12,670 ($12,523)

C= $20,222 ($30,026)

Average cost per day incurred by those on intervention arm ($95.30) was significantly lower than that of comparator group ($212.80) (t = ‐2.417; P = 0.02)

Service costs were calculated using actual costs for contracted medical services in Colorado and proxy cost estimates for all services provided within the HMO as services within the HMO are not billed separately.

Costs were based on figures from 2002

Hospitalisation and emergency department cost estimates were calculated using aggregated data from more than 500,000 HMO patient records and include ancillary services such as laboratory and radiology.

Costs of physician office visits included nurse and clerk expenses.

Home health and palliative care visits were calculated using average time spent on each visit and multiplying that by the cost for each discipline’s reimbursement rate.

Proxy costs generated for hospital days and emergency department visits were significantly lower than the actual costs received from contracted providers.

Total cost variable was constructed by aggregating costs for physician visits, emergency department visits, hospital days, skilled nursing facility days and home health or palliative days accumulated from the point of study enrolment until the end of the study period or death

Hughes 1992

1986 prices (average costs)

Home care
T= $1,001, C=, P = 0.001

VA hospital
T= $1,795, C= $3,434, P = 0.02

Cost of all institutional care
T= 2341.79, C= $3757.37, P = 0.05

Total costs (VA hospital, private hospital, nursing home, outpatient clinic, home care, community nursing)
T= $3,479.36, C= $4,248.68

Figuras y tablas -
Analysis 6.1

Comparison 6 Resource use and cost, Outcome 1 Cost.

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Study

Outcomes

Notes

Grande 2000

GP workload in penultimate week of life

Evening home visits, mean (SD)
T= 0.17 (0.46), C= 0.61 (1.42), Z = 2.295, P = 0.022

Night visits, mean (SD)
T= 0.04 (0.20), C= 0.26 (0.55), Z = 3.61, P = 0.0003

GP workload in last week of life

Evening home visits, mean (SD)
T= 0.17 (0.46), C= 0.61 (1.42)

Night time visits, mean (SD)
T= 0.04 (0.2), C= 0.26 (0.55)

Primary and secondary care services in last 2 weeks of life: failed to detect a difference

Hughes 1992

VA services at 6 months
Outpatient visits mean (SD)
T= 0.73 (1.9), C= 2.59 (6.1), difference: 1.86, P = 0.01

95% CI not calculated as equal variances can not be assumed

Comparisons were made with 13 other types of service, not reported.

Figuras y tablas -
Analysis 6.2

Comparison 6 Resource use and cost, Outcome 2 Health service use.

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Study

Hughes 1992

At 6 months
General bed days, mean (SD)

T= 5.63 (10), C= 12.06 (15.2), mean difference 6.43 days (95% CI 2.55 to 10.3), P = 0.002

All VA hospital days, mean (SD)
T= 9.94 (13.3), C= 15.86 (20.1), mean difference 5.92 (95% CI 0.78 to 11), P = 0.03

Jordhøy 2000

Nmber of inpatient days, mean (SD)

T= 5.0 (17.3), C= 9.3 (31.4)

Figuras y tablas -
Analysis 6.3

Comparison 6 Resource use and cost, Outcome 3 Inpatient days.

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Comparison 6 Resource use and cost, Outcome 4 Number of inpatient days.
Figuras y tablas -
Analysis 6.4

Comparison 6 Resource use and cost, Outcome 4 Number of inpatient days.

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Study

Outcomes

Notes

Grande 2000

District nurse thought there should be additional help for the care giver, mean (SD)

T= 1.81 (0.87) (n = 141), C= 1.36 (0.60) (n = 31), P = 0.005

District nurse thought there should be more help with night nursing

T= 1.43 (0.64) (n = 143), C= 2.03 (0.84) (n = 33); P < 0.0001

3 point scale with lower scores indicating less of a problem
No difference was detected for the ratings reported by GPs and informal care givers.

A 3 point scale with lower scores indicating less of a problem
No difference was detected for the ratings reported by GPs and informal care givers.

Figuras y tablas -
Analysis 7.1

Comparison 7 Staff views, Outcome 1 District nurse views.

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Summary of findings for the main comparison. Summary of findings table for main outcomes

Participant outcomes for home‐based end‐of‐life care

Patient or population: terminally ill people
Settings: Norway, UK, USA
Intervention: home‐based end‐of‐life care

Comparison: a combination of services that could include routine (not specialised) home care, acute inpatient care, primary care services, and hospice care

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Certainty of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

Home‐based end‐of‐life care

Place of death (home)
Follow‐up: 6 to 24 months

Study population

RR 1.33
(1.14 to 1.55)

652
(3 studies)

⊕⊕⊕⊕
high

In 1 trial, eligible participants were assigned treatment according to the district (cluster) in which they lived

444 per 1000

591 per 1000
(506 to 688)

Difference: 147 more

(62 to 244 more)

Medium‐risk population

510 per 1000

678 per 1000
(581 to 790)

Difference: 168 more

(71 to 280 more)

Admission to hospital

Follow‐up: 6 to 24 months

Estimates ranged from a relative increase in risk of admission to hospital of 2.61 to a relative reduction in risk of 0.62

823

(4 studies)

⊕⊕⊕⊝

moderate1

Data were not pooled due to the high degree of statistical heterogeneity for this outcome

Patient satisfaction

Follow‐up: 1 to 6 months

A small increase in satisfaction for those receiving end‐of‐life care at home reported at 1 month, and reduced at 6 months

199

(2 studies)

⊕⊕⊝⊝2

low

Satisfaction measured using questions derived from the US National Hospice Study and the Reid‐Gundlach Satisfaction with Services instrument (minimum low score 1, high score 5)

Caregiver burden

Follow‐up 6 months

One study demonstrated a reduction in psychological well‐being for caregivers of participants who had survived more than 30 days, and a second study reported little or no difference in caregiver response to bereavement

155

(2 studies)

⊕⊕⊝⊝2

low

Measured by the Philadelphia Geriatric Center Morale Scale and the Texas Revised Inventory of Grief

Health service cost

A reduction in total health service cost was reported for those participants receiving end‐of‐life care at home (range from a 18% to 30% reduction)

2 studies

⊕⊕⊝⊝3

low

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; RR: risk ratio

GRADE Working Group grades of evidence
High certainty: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate certainty: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low certainty: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low certainty: We are very uncertain about the estimate.

1We downgraded the certainty of the evidence due to inconsistency of findings among studies.

2We downgraded the certainty of the evidence as different measures were used, and only two out of the four included studies reported data for these outcomes.

3We downgraded the certainty of evidence due to inconsistency of findings among studies, studies reporting different healthcare resources, and only two out of four included studies reporting data for this outcome.

Figuras y tablas -
Summary of findings for the main comparison. Summary of findings table for main outcomes
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Comparison 1. Place of death

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Dying at home Show forest plot

3

652

Risk Ratio (M‐H, Fixed, 95% CI)

1.33 [1.14, 1.55]

2 Time spent at home in the last 2 weeks of life Show forest plot

Other data

No numeric data

3 Dying in hospital Show forest plot

1

113

Risk Ratio (M‐H, Fixed, 95% CI)

1.12 [0.82, 1.52]

4 Dying in a nursing home Show forest plot

Other data

No numeric data

5 Dying in a nursing home Show forest plot

1

113

Risk Ratio (M‐H, Fixed, 95% CI)

0.47 [0.17, 1.32]
Figuras y tablas -
Comparison 1. Place of death
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Comparison 2. Unplanned admissions

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Admitted to hospital Show forest plot

4

823

Risk Ratio (M‐H, Fixed, 95% CI)

0.93 [0.82, 1.05]
Figuras y tablas -
Comparison 2. Unplanned admissions
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Comparison 3. Control of symptoms

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Caregivers' ratings of symptoms Show forest plot

Other data

No numeric data

2 GPs' ratings of symptoms Show forest plot

Other data

No numeric data
Figuras y tablas -
Comparison 3. Control of symptoms
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Comparison 4. Participant health outcomes

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Functional status Show forest plot

Other data

No numeric data

2 Psychological well‐being Show forest plot

Other data

No numeric data

3 Cognitive status Show forest plot

Other data

No numeric data

4 Patient satisfaction Show forest plot

Other data

No numeric data

5 Mortality Show forest plot

Other data

No numeric data

6 Survival time from referral to death Show forest plot

Other data

No numeric data
Figuras y tablas -
Comparison 4. Participant health outcomes
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Comparison 5. Caregiver‐reported outcomes

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Caregiver satisfaction Show forest plot

Other data

No numeric data
Figuras y tablas -
Comparison 5. Caregiver‐reported outcomes
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Comparison 6. Resource use and cost

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Cost Show forest plot

Other data

No numeric data

2 Health service use Show forest plot

Other data

No numeric data

3 Inpatient days Show forest plot

Other data

No numeric data

4 Number of inpatient days Show forest plot

1

113

Mean Difference (IV, Fixed, 95% CI)

‐4.30 [‐13.88, 5.28]
Figuras y tablas -
Comparison 6. Resource use and cost
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Comparison 7. Staff views

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 District nurse views Show forest plot

Other data

No numeric data
Figuras y tablas -
Comparison 7. Staff views
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