What is the value of attendance at palliative day care? A mixed systematic review

Transcription

1 What is the value of attendance at palliative day care? A mixed systematic review George Kernohan, Ulster Kevin Brazil, Queens Felicity Hasson, Ulster Mary Rose Holman, Ulster Joanne Jordan, Ulster Sonja McIlfatrick, Ulster Joanna Coast, Bristol Louise Jones, University College London Kathy Armour, Marie Curie West Midlands Anne Finucane, Marie Curie Edinburgh Lisa Graham, Marie Curie Belfast

2 Background Demographic change Increasing numbers needing palliative care Policy shift Increased reliance on day services Wide variety of interventions Little evidence to guide practice

3 Study Aims We aim to provide evidence on effectiveness and costeffectiveness of palliative care day services in improving quality of life Our study is guided by the Donabedian (1988) model - this will be used to examine day hospice services in three categories: structure, process and outcomes

4 Overall design Systematic review on the effectiveness of day care services* Mapping of three regional palliative care day services in terms of structure and processes of care - provided by Marie Curie in Belfast, Edinburgh and West Midlands Prospective study on patient quality of life outcomes

5 Systematic Review - Objectives To assess the evidence of effectiveness of interventions offered to adults attending UK palliative day care services on quality of life To explore the barriers and facilitators of effectiveness*

6 How to explore the barriers and facilitators of effectiveness? Meta-synthesis Integrate the findings from reviews of qualitative research with those from reviews of effectiveness Provides insight into why interventions work (or not), for whom, and in what circumstances

7 Synthesising the evidence relating to the effectiveness of day care 1. From outcome (e.g. trial) studies on the effectiveness of interventions delivered in palliative day care services to improve patients quality of life 2. From both sibling and unrelated qualitative studies to identify contextual factors impacting on the effectiveness of these interventions 3. Integrating 1. and 2. into an overarching narrative synthesis*

8 Methods: synthesis of evidence in the three reviews Expert advice will be used to synthesise outcome data 1 Framework approach 2 will be used to synthesise qualitative data* Overarching narrative synthesis 3 will be used to bring together the outcome and qualitative syntheses

9 The end product a logic model Qualitative synthesis findings are condensed into a series of summary statements Statements used to develop chains of reasoning these link specific features of the context of interest to the outcome of interest

10 Core properties of a logic model COMPONENT FACILITATOR BARRIER POSITIVE MODERATOR NEGATIVE MODERATOR OUTCOME AUTHOR HYPOTHESIS POSITIVE INTERMEDIATE OUTCOME NEGATIVE INTERMEDIATE OUTCOME LONGER TERM OUTCOME

11 Example of Day Care logic model The example pulls together evidence from four studies: Outcome study: Leppert W et al. Quality of life assessment in advanced cancer patients treated at home, an inpatient unit, and a day care center. OncoTargets and Therapy 2014:7, Outcome study: Goodwin D et al. Effectiveness of Palliative Day Care in Improving Pain, Symptom Control, and Quality of Life. Journal of Pain and Symptom Management 2003; 25(3), Outcome study: Kilonzo et al. Implementing Outcomes Measures Within an Enhanced Palliative Care Day Care Model. Journal of Pain and Symptom Management 2015; 50(3), Qualitative study: Orme J & Still D. The experiences of patients undergoing blood transfusion in a day hospice. International Journal of Palliative Nursing 2013: 19,4*

12 COMPONENT BARRIERS AND FACILITATORS MODERATORS INTERMEDIATE OUTCOMES LONGER TERM OUTCOME Adequate staff:patient ratio Staff able to undertake clinical duties as required Staff able to spend time with patients beyond clinical care Patients receive timely care Patients receive additional psycho-social care (Patient perceived) high levels of clinical / other care Patient enhanced psychosocial & emotional well being Leppert et al 2014 Specified clinical interventions provided Kilonzo et al 2015 No hierarchy of patient clinical need Patients aware of the importance accorded to their needs Patients receive intervention in a timely manner Kilonzo et al 2015 (Patient perceived) high quality clinical care Improved quality of life Patient population with varying clinical needs Goodwin et al 2003 Patients aware of their physical symptoms Patients do not experience physical symptoms Goodwin et al 2003 Patients perceive benefit of clinical intervention Patients do not perceive benefit of clinical intervention (Patient perceived) enhanced patient health Patients do not experience any changes to health status

13 COMPONENT BARRIERS AND FACILITATORS MODERATORS INTERMEDIATE OUTCOMES LONGER TERM OUTCOME Patient negative understandings of hospice Patient attendance dispels negative understandings Patient continues to attend for care Patient reluctance to attend hospice Transport to and from day care Comprehensive system of volunteer drivers Ready availability of car parking Patients (are able to) access care Patients less likely to be tired / irritable because of problems with transport Improved quality of life

14 Assessing the quality of evidence Two-stage process being used to arrive at a final assessment of the overall confidence of the qualitative evidence: Stage 1: using CQIMG* guidance (Noyes 2008) to assess quality of the evidence, taking into account: quality of reporting of the study* methodological rigour of the study* overall conceptual integrity of the study* Stage 2: using CERQual* (Glenton 2013) to assess confidence in the evidence, taking into account: methodological quality (assessed in Stage 1) coherence of the findings (summary statements)* two aspects of the evidence combined to produce overall confidence rating*

15 Conclusions The logic model is an effective and readily accessible means of bringing together disparate bodies of evidence Limitation of the logic model is that it encourages a reductionist approach, whereby complex phenomena can become overly simplified* Against a backdrop of inconsistent evidence on the effectiveness of palliative care day services, it provides a rigorous, systematically derived evidence base concerning the circumstances in which palliative care day services are delivered and received in ways most likely to promote effectiveness

16 Finally Protocol available on Prospero (International prospective register of systematic reviews): Thank you