Community palliative care

National Guideline Centre (UK)

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National Guideline Centre (UK). Emergency and acute medical care in over 16s: service delivery and organisation. London: National Institute for Health and Care Excellence (NICE); 2018 Mar. (NICE Guideline, No. 94.)

Emergency and acute medical care in over 16s: service delivery and organisation.

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Chapter 14Community palliative care

14. Community palliative care

14.1. Introduction

Acute medical illness can present at the end of life and contribute to significant distress in patients, their families and their carers. Care models should be able to assess, treat and support patients with an acute medical illness at the end of life in the setting chosen by patients, which could include home, care home, hospice or hospital.

There is some uncertainty over the clinical and cost-effectiveness of different models of community based palliative care, which can support management of acute medical illnesses at the end of life outside hospices and hospitals. This is important to determine as it offers choice to patients and carers at a crucial time of life.

14.2. Review question: Does community-based palliative care improve outcomes compared with hospital care?

For full details see review protocol in Appendix A.

Table 1

PICO characteristics of review question.

14.3. Clinical evidence

Nineteen studies were included in the review: 3 Cochrane reviews¹⁰⁶^,²⁴²^,²⁷⁹ and 16 individual RCTs;⁵^,¹⁸^–²⁰^,³⁵^,⁴⁰^,¹¹⁰^,¹¹¹^,¹³²^,¹³⁶^,¹⁴⁷^,¹⁷⁷^,²¹⁰^,²⁶³^,²⁸⁰^,²⁹⁰^,²⁹¹ these are summarised in Table 2 below. One study (out of 9) from the Cochrane review ²⁷⁸, all 4 studies from the Cochrane review ²⁴² and 8 studies (out of 23) from the Cochrane review¹⁰⁶ were included in our evidence review. Other studies from the Cochrane reviews were not included as they did not fit in our protocol criteria for study design, population, or interventions. Evidence from these studies is summarised in the GRADE clinical evidence profile below (Table 3 and Table 4). See also the study selection flow chart in Appendix B, study evidence tables in Appendix D, forest plots in Appendix C, GRADE tables in Appendix F and excluded studies list in Appendix G.

Table 2

Summary of studies included in the review.

Table 3

Clinical evidence profile: Community palliative care versus hospital palliative care.

Table 4

Clinical evidence summary: Enhanced community palliative care versus standard community palliative care.

We searched for randomised controlled trials comparing the effectiveness of the interventions listed in the protocol. Fifteen randomised controlled trials were identified:

Seven studies evaluated community based palliative care with hospital based palliative care.¹⁹^,³⁵^,⁴⁰^,¹¹¹^,¹³⁵^,¹⁴⁷^,²⁹⁰
Five studies looked at enhanced community based palliative care versus standard community based palliative care.⁵^,¹⁸^,¹³²^,¹⁷⁷^,²¹⁰
Four studies compared community based palliative care with usual care.²⁰^,²⁶³^,²⁸⁰^,²⁹¹
Life expectancy of patients included varied among the included studies from a few months, to as much as 2 years.
Cancer, chronic heart failure and chronic obstructive pulmonary disease were the main diagnoses among those included.

Narrative findings

One study Hughes, 1992¹³⁵ reported that roughly 50% of patients in each group died in hospital. The same study also reported that at 1 month, carers in the treatment group had a greater level of satisfaction compared to carers in the control group (p=0.005). At 6 month follow-up there was no difference in satisfaction anymore.

Table 5

Clinical evidence summary: Community based palliative care versus usual care.

14.4. Economic evidence

Published literature

Two economic evaluations were identified with the relevant comparison and have been included in this review.¹³⁰^,²²⁷ These are summarised in the economic evidence profile below (Table 6) and the economic evidence tables in Appendix E.

Table 6

Economic evidence profile: community-based palliative care versus usual care.

Four economic evaluations relating to this review question were excluded on the grounds of applicability, quality and the availability of more relevant evidence. The reasons summarised in Appendix H.

The economic article selection protocol and flow chart for the whole guideline can found in the guideline’s Appendix 41A and Appendix 41B.

14.5. Evidence statements

Clinical

Seven studies comprising 1493 people evaluated the role of community based palliative care versus hospital based palliative care for improving outcomes in adults and young people at risk of an AME, or with a suspected or confirmed AME. The evidence suggested that community based palliative care may provide benefit in increased number of people in which home was the place of death (5 studies, low quality), decreased number of people in which hospital was the place of death (3 studies, very low quality), decreased the number of presentations to the ED (1 study, low quality) and improved patient and/or carer satisfaction (3 studies reported separately, low quality). However, the evidence suggested no difference on the number of hospital admissions (5 studies, very low quality), length of hospital stay (4 studies, low quality), mean number of ED visits (1 study, moderate quality) or quality of life (2 studies reporting different scores, low quality).

Five studies comprising 1404 people evaluated the role of enhanced community based palliative care versus standard community based palliative care for improving outcomes in adults and young people at risk of an AME, or with a suspected or confirmed AME. The evidence suggested that enhanced community based palliative care has no effect on number of hospital admissions (1 study, low quality), number of presentations to ED (1 study, low quality), length of hospital stay (1 study, very low quality) or quality of life (1 study, low quality). One study suggested there was no difference in place of death (1 study, moderate quality) while another study suggested an increase in the number of people achieving their preferred place of death (1 study, low quality).

Four studies comprising 890 people evaluated the role of community based palliative care versus usual care for improving outcomes in adults and young people at risk of an AME, or with a suspected or confirmed AME. The evidence suggested that community based palliative care may provide benefit in increased number of people in which home was the place of death (1 study, very low quality), decreased the number of presentations to the ED (1 study, very low quality), improved patient and/or carer satisfaction (3 studies reporting different scores, very low to moderate quality), reduced length of hospital stay (1 study, very low quality) and reduced number of admissions (1 study, moderate quality) and readmissions to hospital (1 study, low quality). One study suggested there was a possible improvement in quality of life (low quality) while 2 other studies looking at different scores suggested no difference (moderate quality).

Economic

One cost-utility analysis found community-based specialist palliative care to dominate usual care, reducing costs and improving health outcomes. This evidence was assessed as partially applicable with potentially serious limitations.

One cost-effectiveness analysis found community-based specialist palliative care to reduce costs, however to also reduce quality of life, measured on the POS-8 scale. This evidence was assessed as partially applicable with minor limitations.

14.6. Recommendations and link to evidence

Recommendations	8. Provide specialist multidisciplinary community-based palliative care as an option for people in the terminal phase of an illness.
Research recommendation	-
Relative values of different outcomes	The guideline committee considered the following outcomes as critical: place of death, avoidable adverse events, quality of life, and patient and/or carer satisfaction. The following outcomes were identified as important to decision making: readmission, number of admissions to hospital, number of presentations to ED, number of presentations to GP and length of hospital stay.
Trade-off between benefits and harms	The review was split into a comparison of community based palliative care versus hospital based palliative care, enhanced community based palliative care versus standard community based palliative care and community based palliative care versus usual care as defined by the studies (for example, comparators that included elements of both hospital and community care or comparators which were not well defined). A total of 16 randomised controlled trials were included in the review. Community palliative care versus hospital palliative care Seven studies comprising 1493 people evaluated the role of community based palliative care versus hospital based palliative care. The evidence suggested that community palliative care may provide benefit in increased number of people in which home was the place of death, decreased number of people in which hospital was the place of death, decreased number of presentations to ED and improved patient and/or carer satisfaction. The evidence suggested that there was no difference for the outcomes of number of hospital admissions, length of hospital stay, mean number of ED visits or quality of life. No evidence was found for the outcomes of avoidable adverse events, number of presentations to the GP and readmission. Enhanced versus standard community palliative care Five studies comprising 1404 people evaluated the role of enhanced community based palliative care versus standard community based palliative care. Enhanced palliative care is the provision of additional palliative care support care over and above the usual provision of community palliative care in the patient’s local healthcare system. The evidence suggested that enhanced community based palliative care has no effect on number of hospital admissions, number of presentations to ED, length of hospital stay or quality of life. One study suggested there was no difference in place of death while another study suggested an increase in the number of people achieving their preferred place of death. No evidence was found for the outcomes patient and/or carer satisfaction, readmission, number of presentations to GP and avoidable adverse events. Community based palliative care versus usual care Four studies comprising 890 people evaluated the role of community based palliative care versus usual as defined by the studies (for example, comparators that included elements of both hospital and community care or comparators which were not well defined). Usual care usually consisted of telephone or outpatient clinic follow up or a combination of both. The evidence suggested that community based palliative care may provide a benefit in increased number of people for whom home was the place of death, decreased number of presentations to the ED, improved patient and/or carer satisfaction, reduced length of hospital stay and reduced number of admissions and readmissions to hospital. One study suggested there was a possible improvement in quality of life while 2 other studies looking at different scores suggested no difference. No evidence was found for the outcomes avoidable adverse events or number of presentations to the GP. The committee emphasised that as far as possible the health system should respect patients’ wishes when planning palliative care at home or in a healthcare setting. Surveys of the public have consistently shown that home is the preferred place of death, and the provision of community palliative care would facilitate this. The committee also noted, however, that there would be occasions when managing the process of dying at home could be very difficult, and therefore alternative options should be retained. The committee agreed that community palliative care should be an option for all patients as an alternative to hospital admission. The service provided should incorporate staff with appropriate competencies to allow patients to be cared for in line with their preferences (for example, symptom management). No benefit was found for enhanced community based palliative over standard community palliative care and so this was not included in the recommendation. The reasons for this lack of benefit are unclear. It could be surmised that the interventions in both groups were very similar in terms of support at home except for intensity of support. Therefore, it is possible that more intensive input would only offer marginal gains, or none.
Trade-off between net effects and costs	Two economic evaluations found community palliative care to be cost saving compared with usual care. One cost-effectiveness study found community palliative care to have a slightly poorer result on the palliative outcome-8 scale compared to usual care. However, the difference was small and not statistically significant whereas the evidence on the ‘Trade-off between benefits and harms’ above showed improvements in patient and/or carer satisfaction without evidence of adverse events. One cost-utility analysis found community palliative care improves health outcomes and reduces costs. The committee acknowledged the limitations, given it was conducted in a Swedish cohort and patient numbers were rather small. However, the committee noted the outcome of the study was largely in line with what was seen in other clinical studies presented in the clinical review. The evidence for patient and carer satisfaction evidence was in favour of community palliative care Although the economic evidence was not substantial it was based on data that largely coincided with the clinical evidence meaning it is unlikely that more economic evidence on this topic would change conclusions concerning cost effectiveness. The economic evidence identified would suggest there is a good chance community palliative care could reduce costs to the health service. The clinical evidence would suggest quality of life would remain unchanged or potentially improve therefore supporting the conclusion that it would be an effective use of NHS resources.
Quality of evidence	For the comparison of community palliative care versus hospital palliative care the evidence for the outcome of number of presentations to ED (mean number of presentations) was of moderate quality due to risk of bias. The evidence for place of death, number of presentations to ED (number of visits), length of stay, quality of life and patient and/or carer satisfaction was low due to risk of bias, and inconsistency or imprecision. The evidence for number of hospital admissions was of very low quality due to risk of bias and inconsistency. For the comparison of enhanced versus standard community based palliative care, the evidence for the outcome of place of death (OR) was of moderate quality due to risk of bias. The evidence for the outcome of admissions, number of ED presentations, quality of life and place of death was of low quality due to risk of bias and imprecision. The quality of the evidence for length of stay was very low due to risk of bias and imprecision. For the comparison between community based palliative care and usual care, the evidence for quality of life and patient and/or carer satisfaction (FAMCARE scale) was of moderate quality due to inconsistency and imprecision. The evidence for patient and/or carer satisfaction (overall satisfaction) was of low quality due to risk of bias. The evidence for the outcomes of relatives’ satisfaction, place of death, length of stay and ED presentations was of very low quality due to risk of bias and imprecision. One cost-effectiveness analysis was assessed as partially applicable (no QALYs) with minor limitations. The other three economic evaluations were assessed as partially applicable (not UK and/or no QALYs) but with potentially serious limitations.
Other considerations	Patient choice should always be considered in decision making, such as patient preference in terms of where they wish to die. Family and/or carer satisfaction and burden is also important when providing holistic palliative care. Ideally the service should follow the patient’s wishes if possible without increasing the burden on the family or carers. It is also important that the family or carers are supported and satisfied with the care provided. Healthcare professionals who are in contact with patients in the terminal phase of their life (for example, GPs, district nurses, hospital doctors and nurses) should be trained in the early identification of patients that might benefit from community based palliative care (see Linking Evidence to recommendation [LETR] in the Advanced Care Planning chapter [15]). Many people in the terminal phase of illness will have 1 or more AMEs at some point and are also likely to have more than 1 chronic long-term condition, which therefore gives the healthcare system ample opportunity to identify these patients to ensure that the focus is on managing the patient’s overall health status as well as optimising individual conditions (or their symptom management) independently. The committee noted that in the current service, the provision of community palliative care is variable and often not comprehensive. The service provided should be responsive to the patients’ needs and preferences, for example, provided 24 hours a day, 7 days a week (although no evidence was identified in relation to the timing of services). However, it is likely that a significant proportion of these patients’ deterioration will be out of the normal 9-5, Monday to Friday working hours. Healthcare professionals, particularly in secondary care, may be unaware of the availability of palliative care and other forms of support in the community. This could result in avoidable admission to, or delay in discharge from hospital. Early involvement of palliative care in hospital will ensure that patients receive the best balance between active treatment of underlying diseases and comorbidities while also ensuring effective symptom relief. Staff should be better trained in palliative care as current demographic changes will contribute to an increased demand for these specialised services. Pharmacists are a key component of the multidisciplinary community based palliative care service. As well as providing timely access to medicines they can advise on doses and combination of medicines. Recommendations on the management of people who are near the end of life can be found in the NICE clinical guideline on End of Life Care, currently in development (https://www.nice.org.uk/guidance/indevelopment/gid-cgwave0799).

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Appendices

Appendix A. Review protocol

Table 7Review protocol: Community base palliative care

Review question	Does community based palliative care improve outcomes compared with hospital care?
Guideline condition and its definition	Acute Medical Emergencies. Definition: a medical emergency can arise in anyone, for example, in people without a previously diagnosed medical condition, with an acute exacerbation of underlying chronic illness, after surgery or after trauma.
Objectives	To determine if wider provision of community-based intermediate care prevents people from staying in hospitals longer than necessary while not impacting on patient and carer outcomes.
Review population	Adults and young people (16 years and over) with a suspected or confirmed AME or patients at risk of AME.
	Adults (17 years and above). Young people (aged 16-17 years).
	Line of therapy not an inclusion criterion.
Interventions and comparators: generic/class; specific/drug (All interventions will be compared with each other, unless otherwise stated)	Usual Care. Community based palliative care; enhanced palliative care in community. Community based palliative care; standard palliative care in community. Hospital based palliative care.
Outcomes	- Quality of life (Continuous) CRITICAL - Length of hospital stay (Continuous) IMPORTANT - Place of death at during study period (Dichotomous) IMPORTANT - Avoidable adverse events (Dichotomous) CRITICAL - Patient and/or carer satisfaction (Dichotomous) CRITICAL - Number of presentations to Emergency Department (Dichotomous) IMPORTANT - Number of admissions to hospital (Dichotomous) CRITICAL - Number of GP presentations (Dichotomous) IMPORTANT - Readmission up to 30 days (Dichotomous) IMPORTANT
Study design	Systematic reviews (SRs) of RCTs, RCTs, observational studies only to be included if no relevant SRs or RCTs are identified.
Unit of randomisation	Patient.
Crossover study	Permitted.
Minimum duration of study	Not defined.
Population stratification	Early discharge. Admission avoidance.
Reasons for stratification	Each of them targets a separate outcome: early discharge would be primarily aimed at reducing length of stay, while admission avoidance would be primarily aimed at reducing hospital admission. Also, the population would be different as the admission avoidance group could be managed at home for the whole episode of care (they could be cared for at home from the start) while the early discharge group needs to be “stabilised” at hospital first then discharged.
Subgroup analyses if there is heterogeneity	- Frail elderly (frail elderly; not frail elderly); different from younger population.
Search criteria	Databases: Medline, Embase, the Cochrane Library, CINAHL. Date limits for search: 2010 (update of the search for a Cochrane review¹⁰⁶). Language: English language only.

Appendix B. Clinical article selection

Figure 1Flow chart of clinical article selection for the review of community palliative care

Appendix C. Forest plots

C.1. Community palliative care versus hospital care

Figure 1Place of death (deaths at home)

Figure 2Admissions to hospital

Figure 3Number of presentations to ED

Figure 4Number of presentations to ED (continuous)

Source: SDs are the same for each group because they were calculated from the p-value, mean and n in each group.

Figure 5Length of stay

Figure 6Length of stay (SD calculated)

Source: SDs are the same for each group because they were calculated from the p-value, mean and n in each group.

Figure 7Quality of Life

Figure 8Patient satisfaction (continuous)

Source: SDs are the same for each group because they were calculated from the p-value, mean and n in each group.

Figure 9Patient satisfaction

Figure 10Carer satisfaction

Source: SDs are the same for each group because they were calculated from the p-value, mean and n in each group.

Figure 11Place of death (in-hospital mortality)

C.2. Enhanced palliative care versus standard palliative care

Figure 12Admissions

Figure 13Number of presentations to ED

Figure 14Length of stay

Figure 15Quality of life (QUAL-E end of life scale)

Figure 16Preferred place of death achieved

Figure 17Preferred place of death achieved

C.3. Community palliative care versus usual care

Figure 18Quality of life (QUAL-E end of life scale)

Figure 19Quality of life (functional assessment of chronic illness therapy spiritual wellbeing scale)

Figure 20Patient satisfaction (overall satisfaction 1-10)

Figure 21Patient satisfaction (FAMCARE patient satisfaction with care scale)

Figure 22Relatives satisfaction (overall satisfaction 1-10)

Figure 23Death at home

Figure 24Length of stay (rate of hospital days)

Figure 25ED visits (rate of ED visits)

Figure 26Readmissions (28 days)

Figure 27Admissions (84 days)

Figure 28Quality of life (chronic heart failure questionnaire; higher score is better)

Appendix D. Clinical evidence tables

Download PDF (816K)

Appendix E. Economic evidence tables

Download PDF (434K)

Appendix F. GRADE tables

Table 8Clinical evidence profile: Community palliative versus hospital care

Quality assessment							No of patients		Effect		Quality	Importance
No of studies	Design	Risk of bias	Inconsistency	Indirectness	Imprecision	Other considerations	Community Palliative care	Hospital care	Relative (95% CI)	Absolute	Quality	Importance
Place of death (assessed with: deaths at home)
5	randomised trials	serious¹	no serious inconsistency	no serious indirectness	serious²	none	316/532 (59.4%)	50%	RR 1.27 (1.11 to 1.45)	135 more per 1000 (from 55 more to 225 more)	⨁⨁◯◯ LOW	CRITICAL
Admissions to hospital (follow-up median 6 months; assessed with: number of admissions)
5	randomised trials	very serious¹	serious³	no serious indirectness	no serious imprecision	none	368/593 (62.1%)	58.7%	RR 0.87 (0.8 to 0.93)	76 fewer per 1000 (from 41 fewer to 117 fewer)	⨁◯◯◯ VERY LOW	IMPORTANT
Number of presentations to ED (follow-up 12 months; assessed with: ED visits)
1	randomised trials	serious¹	no serious inconsistency	no serious indirectness	serious²	none	29/145 (20%)	32.9%	RR 0.61 (0.41 to 0.9)	128 fewer per 1000 (from 33 fewer to 194 fewer)	⨁⨁◯◯ LOW	IMPORTANT
Number of presentations to ED (continuous) (measured with: ED visits; Better indicated by lower values)
1	randomised trials	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	none	145	134	-	MD 0.23 higher (0.49 lower to 0.95 higher)	⨁⨁⨁◯ MODERATE	IMPORTANT
Length of stay (follow-up 6 months; measured with: length of hospital stay; Better indicated by lower values)
3	randomised trials	serious¹	serious³	no serious indirectness	no serious imprecision	none	357	320	-	MD 1.77 lower (3.19 to 0.35 lower)	⨁⨁◯◯ LOW	IMPORTANT
Length of stay (measured with: length of hospital stay; Better indicated by lower values)
1	randomised trials	very serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	none	145	134	-	MD 0.1 higher (0.03 lower to 0.23 higher)	⨁⨁◯◯ LOW	IMPORTANT
Quality of life (follow-up 6 months; measured with: QoL-EQ5D (0-100 scale); Better indicated by higher values)
1	randomised trials	serious¹	no serious inconsistency	no serious indirectness	serious²	none	36	36	-	MD 8.1 higher (2.03 lower to 18.23 higher)	⨁⨁◯◯ LOW	CRITICAL
Quality of life (follow-up 12 months; measured with: QoL- Functional assessment of chronic illness therapy (0-184 scale); Better indicated by higher values)
1	randomised trials	serious¹	no serious inconsistency	no serious indirectness	serious²	none	27	31	-	MD 3 higher (3.91 lower to 9.91 higher)	⨁⨁◯◯ LOW	CRITICAL
Patient Satisfaction (follow-up 6 months; Better indicated by higher values)
1	randomised trials	serious¹	no serious inconsistency	no serious indirectness	serious²	none	17	14	-	MD 0.27 higher (0 to 0.54 higher)	⨁⨁◯◯ LOW	CRITICAL
Patient satisfaction (follow-up 3 months)
1	randomised trials	serious¹	no serious inconsistency	no serious indirectness	serious²	none	135/145 (93.1%)	80.9%	RR 1.15 (1.05 to 1.26)	121 more per 1000 (from 40 more to 210 more)	⨁⨁◯◯ LOW	CRITICAL
Carer satisfaction (follow-up 6 months; measured with: scale 26-130; Better indicated by higher values)
1	randomised trials	serious¹	no serious inconsistency	no serious indirectness	serious²	none	31	33	-	MD 11 higher (4.32 to 17.68 higher)	⨁⨁◯◯ LOW	CRITICAL
In-hospital mortality (follow up mean 18 months)
3	randomised trials	serious¹	serious inconsistency³	no serious indirectness	serious²	none	170/403 (42.2%)	53.3%	RR 0.77 (0.67 to 0.88)	123 fewer per 1000 (from 64 fewer to 176 fewer)	⨁◯◯◯ VERY LOW	CRITICAL

1: Downgraded by 1 increment if the majority of the evidence was at high risk of bias, and downgraded by 2 increments if the majority of the evidence was at very high risk of bias.
2: Downgraded by 1 increment if the confidence interval crossed 1 MID or by 2 increments if the confidence interval crossed both MIDs.
3: Heterogeneity, I²=50%, p=0.04, unexplained by subgroup analysis.

Table 9Clinical evidence profile: Enhanced community palliative versus standard community palliative care

Quality assessment							No of patients		Effect		Quality	Importance
No of studies	Design	Risk of bias	Inconsistency	Indirectness	Imprecision	Other considerations	Enhanced palliative care	standard palliative care	Relative (95% CI)	Absolute	Quality	Importance
Admissions (Better indicated by lower values)
1	randomised trials	serious¹	no serious inconsistency	no serious indirectness	serious²	none	24	27	-	MD 0.2 lower (1.63 lower to 1.23 higher)	⨁⨁◯◯ LOW	IMPORTANT
Number of presentations to ED (follow-up 12 months)
1	randomised trials	no serious risk of bias	no serious inconsistency	no serious indirectness	very serious²	none	10/40 (25%)	25%	RR 1 (0.47 to 2.14)	0 fewer per 1000 (from 132 fewer to 285 more)	⨁⨁◯◯ LOW	IMPORTANT
Length of stay (follow-up 6 months; Better indicated by lower values)
1	randomised trials	serious¹	no serious inconsistency	no serious indirectness	very serious²	none	14	18	-	MD 0.82 higher (12.36 lower to 14 higher)	⨁◯◯◯ VERY LOW	IMPORTANT
Quality of life (measured with: QUAL-E End of life Scale; Better indicated by higher values)
1	randomised trials	serious¹	no serious inconsistency	no serious indirectness	serious²	none	0	-	-	MD 4.05 lower (11.49 lower to 3.38 higher)	⨁⨁◯◯ LOW	CRITICAL
Preferred place of death achieved
1	randomised trials	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	none	429/688 (62.4%)	61.90%	OR 0.95 (0.78 to 1.15)	12 fewer per 1000 (from 60 fewer to 32 more)	⨁⨁⨁◯ MODERATE	CRITICAL
Preferred place of death achieved
1	randomised trials	serious¹	no serious inconsistency	no serious indirectness	serious²	none	7/8 (87.5%)	76.9%	RR 1.14 (0.77 to 1.69)	108 more per 1000 (from 177 fewer to 531 more)	⨁⨁◯◯ LOW	CRITICAL

1: Downgraded by 1 increment if the majority of the evidence was at high risk of bias, and downgraded by 2 increments if the majority of the evidence was at very high risk of bias.
2: Downgraded by 1 increment if the confidence interval crossed 1 MID or by 2 increments if the confidence interval crossed both MIDs.

Table 10Clinical evidence profile: Community palliative care versus usual care

Quality assessment							No of patients		Effect		Quality	Importance
No of studies	Design	Risk of bias	Inconsistency	Indirectness	Imprecision	Other considerations	Community palliative care	usual care	Relative (95% CI)	Absolute	Quality	Importance
Quality of life (follow-up 3-4 months; measured with: Quality of life at end of life scale; range of scores: 21-105; Better indicated by higher values)
2	randomised trials	no serious risk of bias	serious¹	no serious indirectness	no serious imprecision	none	183	231	-	MD 025 lower (1.03 lower to 0.53 higher)	⨁⨁⨁◯ MODERATE	CRITICAL
Quality of life (follow-up 3-4 months; measured with: functional assessment of chronic illness therapy spiritual well-being scale; range of scores: 0-184; Better indicated by higher values)
2	randomised trials	no serious risk of bias	no serious inconsistency	no serious indirectness	serious²	none	194	232	-	MD 4.63 higher (1.53 to 7.73 higher)	⨁⨁⨁◯ MODERATE	CRITICAL
Patient satisfaction (follow-up 4 months; measured with: overall satisfaction rating; range of scores: 1-10; Better indicated by higher values)
1	randomised trials	very serious³	no serious inconsistency	no serious indirectness	no serious imprecision	none	21	17	-	MD 1.4 higher (0.69 to 2.11 higher)	⨁⨁◯◯ LOW	CRITICAL
Patient satisfaction (follow-up 4 months; measured with: FAMCARE patient satisfaction with care scale; range of scores: 16-80; Better indicated by higher values)
1	randomised trials	no serious risk of bias	no serious inconsistency	no serious indirectness	serious²	none	121	153	-	MD 6 higher (3.94 to 8.06 higher)	⨁⨁⨁◯ MODERATE	CRITICAL
Relatives satisfaction (follow-up 4 months; measured with: overall satisfaction rating; range of scores: 1-10; Better indicated by lower values)
1	randomised trials	very serious³	no serious inconsistency	no serious indirectness	serious²	none	21	12	-	MD 1.6 higher (0.19 to 3.01 higher)	⨁◯◯◯ VERY LOW	CRITICAL
Death at home
1	randomised trials	very serious³	no serious inconsistency	no serious indirectness	serious²	none	27/50 (54%)	47.5%	RR 1.14 (0.79 to 1.65)	66 more per 1000 (from 100 fewer to 309 more)	⨁◯◯◯ VERY LOW	CRITICAL
Length of stay (assessed with: rate of hospital days)
1	randomised trials	very serious³	no serious inconsistency	no serious indirectness	very serious²	none	0/50 (0%)	0%	RR 0.73 (0.41 to 1.3)	-	⨁◯◯◯ VERY LOW	IMPORTANT
ED visits
1	randomised trials	very serious³	no serious inconsistency	no serious indirectness	serious²	none	0/50 (0%)	0%	RR 0.73 (0.45 to 1.19)	-	⨁◯◯◯ VERY LOW	IMPORTANT
Readmissions (28 days)
1	randomised trials	no serious risk of bias	no serious inconsistency	no serious indirectness	very serious²	none	9/43 (20.9%)	29.3%	RR 0.72 (0.34 to 1.52)	82 fewer per 1000 (from 193 fewer to 152 more)	⨁⨁◯◯ LOW	IMPORTANT
Admissions (84 days)
1	randomised trials	no serious risk of bias	no serious inconsistency	no serious indirectness	serious²	none	14/43 (32.6%)	61%	RR 0.53 (0.33 to 0.88)	287 fewer per 1000 (from 73 fewer to 409 fewer)	⨁⨁⨁◯ MODERATE	IMPORTANT
Quality of life (28 days) (Chronic heart failure questionnaire; higher score is better)
1	randomised trials	serious³	no serious inconsistency	no serious indirectness	serious²	none	43	41	-	MD 0.79 higher (0.23 to 1.35 higher)	⨁⨁◯◯ LOW	CRITICAL

1: Heterogeneity, I2=50%, p=0.04, unexplained by subgroup analysis.
2: Downgraded by 1 increment if the confidence interval crossed 1 MID or by 2 increments if the confidence interval crossed both MIDs.
3: Downgraded by 1 increment if the majority of the evidence was at high risk of bias, and downgraded by 2 increments if the majority of the evidence was at very high risk of bias.

Appendix G. Excluded clinical studies

Table 11Studies excluded from the clinical review (all excluded for alternative to hospital care)

Reference	Reason for exclusion
Abernethy 2013²	Data presented ‘per patient’ and not overall
Addington-Hall 1992³	Incorrect intervention (co-ordinators did not provide “practical nursing care” or “specialist palliative care advice”; co-ordination only)
Adler 1978⁴	Not relevant: patients following elective surgery
Aimonino 2000⁷	Conference abstract; later published as Ricauda 2004²¹³
Aimonino 2001⁶	Patients not treated for acute medical emergency (advanced dementia patients) – please note not linked to Tibaldi 2004²⁵⁹
Alcide 2015⁸	Systematic review is not relevant to review question or unclear PICO
Allen 1999⁹	Not RCT; description of a website
Anderson 2000A¹⁰	Conference abstract of protocol only
Anderson 2002B¹¹	Not RCT; Systematic review
Anderson 2002A¹²	No clinical outcomes; Costs only
Anonymous 1982B¹	Not relevant comparison
Aoun 2015¹³	Incorrect intervention (caregiver assessment tool intervention)
Armstrong 2008B¹⁴	Not RCT; Retrospective single arm study
Aujesky 2011¹⁵	RCT but no community care (self- administered injections)
Bai 2013¹⁶	Not RCT; systematic review
Baidoobonso 2014¹⁷	Systematic review is not relevant to review question or unclear PICO
Bakken 2012²¹	No RCT; not relevant
Barnes 2003²²	Not RCT; review
Beech 2004²³	Not RCT; service evaluation
Bernhaut 2002²⁴	Not RCT, service evaluation
Bethell 1990²⁵	No substitute for usual care; control group received no intervention, only advice what exercises they could do by themselves
Beynon 2009²⁶	Not RCT; literature review
Blackburn 2000²⁷	Not RCT; not relevant; costs only
Blair 2011²⁸	Not RCT; systematic review
Board 2000²⁹	Not relevant; costs only
Booth 2004³⁰	Not relevant; patients following bypass surgery
Boston 2001³¹	Not RCT; prospective non-randomised comparative study
Bove 2016³²	Incorrect intervention (psychoeducative intervention)
Bowman 1998³³	Not RCT; review
Brandt 2016³⁴	Study protocol
Brooks 2002³⁶	Not RCT; retrospective case study
Brooks 2003³⁷	Not RCT; retrospective documentary analysis
Brown 2015³⁸	Systematic review is not relevant to review question or unclear PICO
Brunner 2008⁴¹	Not RCT; other experimental design
Bryan 2010⁴²	Not RCT; literature review
Bryant-lukosius 2015⁴³	Systematic review is not relevant to review question or unclear PICO
Buus 2013⁴⁴	Protocol only; no study data
Campbell 2001⁴⁵	No clinical outcomes; costs only
Caplan 2006⁴⁶	Not RCT; service evaluation
Caplan 2012⁴⁷	Not RCT; systematic review
Caplan 2004⁴⁸	Comparison is not hospital-based care
Carroll 2005⁴⁹	Not RCT; review
Cassel 2010⁵⁰	Not RCT; review
Chan 2011⁵¹	Not RCT; Cochrane review, but NO included studies as none met the criteria
Chan 2013⁵²	Not RCT; Cochrane review, but NO included studies as none met the criteria
Chang 2016⁵³	Incorrect study design
Chappell 1993⁵⁴	Not relevant; retrospective cost analysis
Chard 2006⁵⁵	Not RCT; review
Chen 2012A⁵⁶	Not relevant; costs associated with acquired brain injury
Chen 2015⁵⁷	Incorrect study design
Chiang 2015⁵⁸	Incorrect study design
Clark 2006⁵⁹	Incorrect interventions (advanced cancer intervention, participants did not meet qualification for hospice or palliative services)
Coast ⁶⁰	Not relevant; majority of patients with trauma and elective surgery
Cobelli 1996⁶¹	Not RCT; review
Coburn 1989⁶²	Not RCT; quasi-experimental; cost
Cohen 1994⁶³	Not RCT; review
Colprim 2012⁶⁵	Not RCT; quasi-experimental study
Colprim 2014⁶⁴	Not RCT; prospective cohort study
Cowie 2014⁶⁶	Not RCT; economic analysis
Craig 2014⁶⁷	Not RCT; review
Crawford-Faucher 2010⁶⁸	Not RCT; systematic review
Crotty 2002⁷²	RCT but not relevant as trauma patients only (hip fracture)
Crotty 2000⁷⁰	Not RCT; audit of trauma patients
Crotty 2000A⁶⁹	RCT but not relevant as trauma patients only (hip fracture)
Crotty 2003⁷¹	RCT but not relevant as trauma patients only
Cummings 1990⁷³	Incorrect interventions (home care intervention; <50% patients were terminally ill)
Cunliffe 2002⁷⁴	Not RCT; qualitative study; abstract only
Dalal 2003⁷⁵	Not RCT; non-randomised prospective study
Daly 2013⁷⁶	Intervention incorrect. Set in outpatient setting
Davis 2015⁷⁷	Systematic review is not relevant to review question or unclear PICO
Deutsch 2006⁷⁸	Not RCT; retrospective study
Dey⁷⁹	RCT; but unpublished data only. We have no access to paper and information in Cochrane review (Hospital at home early discharge) is insufficient to categorise the intervention
Dias 2013 ⁸⁰	RCT but not relevant (does not compare to inpatient rehabilitation)
DiMartino ⁸¹ 2014	Not RCT; systematic review
Dolansky 2010⁸²	Not RCT
Dombi 2009⁸³	Not RCT; commentary on costs
Donaldson 1982⁸⁴	Not RCT; retrospective study
Donath 2001⁸⁵	Not RCT; Commentary
Donlevy 1996A⁸⁶	Not relevant; article is on cross-training to provide care at home on discharge
Donnelly 2002⁸⁷	Not RCT; not relevant; questionnaire survey
Dorney-Smith 2011⁸⁸	Not RCT; case study of the cost of nurse-led hostels for the homeless
Dow 2004⁸⁹	Not RCT; case study
Dow 2007⁹⁰	Not RCT; qualitative study
Duffy 2010⁹¹	RCT but wrong comparison (control group not in hospital)
Dyar 2012⁹²	Incorrect intervention. Only discussions of end of life
Eldar 2000A⁹³	Not RCT; review
Elder 2001⁹⁴	Not RCT; literature review
Emme 2014⁹⁵	RCT; but no relevant outcomes
Emme 2014A⁹⁶	RCT; but no relevant outcomes
Engelhardt 2006⁹⁷	No extractable outcomes
Eron 2004⁹⁸	Not RCT; no data
Feltner 2014⁹⁹	Not RCT; systematic review
Ferrell 2015¹⁰⁰	Incorrect study design
Fischer 2015¹⁰¹	No relevant outcomes
Gaspoz 1994¹⁰²	Not RCT; prospective cohort study
Glasby 2008¹⁰³	Not RCT; qualitative study
Glick 1998¹⁰⁴	Not relevant – observing outcome of aneurysmal subarachnoid haemorrhage
Gobbi 2004¹⁰⁵	Not RCT; and not relevant
Gracey 1992¹⁰⁷	Not RCT; case studies
Graham 2013¹⁰⁸	Not RCT; description of organisation of rehabilitation services
Grande 2004¹⁰⁹	RCT on bereavement. Not relevant.
Graverholt 2014 ¹¹²	Not RCT; review
Greer 2012¹¹³	Intervention incorrect and no outcomes that match protocol
Gregory 2010¹¹⁴	Not RCT; Cross-sectional study
Gregory 2009¹¹⁵	Not RCT; retrospective study
Griffiths 2000¹¹⁸	Not RCT; exploratory analyses
Griffiths 2005¹²¹	Not RCT; systematic review
Griffiths 2001¹¹⁷	RCT but not relevant comparison; both arms in-patient care (nurse led versus consultant managed)
Griffiths 2006A¹¹⁶	Not RCT; review
Griffiths 2006¹²⁰	Not RCT; review
Griffiths 2000A¹¹⁹	RCT but not relevant comparison (in-patients only)
Gunnell 2000¹²²	Not relevant; majority of patients with trauma and elective surgery
Hamlet 2010¹²³	Not RCT; uses secondary data. Focus is telemedicine
Hannan 2003¹²⁴	Not RCT
Hardy 2001¹²⁶	Not RCT; description of a service; and mainly trauma patients
Hansen 1992¹²⁵	Cochrane excluded list: Hospital at home early discharge (study did not evaluate hospital at home, but a model for follow-up visits at home after discharge from hospital)
Hauser 1991¹²⁷	Not RCT; retrospective study
Herr 2012¹²⁸	Not RCT; retrospective study
Heseltine 2001¹²⁹	Not RCT; review on cost
Hill 1978¹³¹	RCT but not relevant to today’s approach of managing MI as thrombolytic therapy made admission necessary (Cochrane)
Hudson 2013¹³³	Incorrect intervention; preparation of caregivers for home palliative acre with education and discussion
Hudson 2013¹³⁴	Incorrect intervention; preparation of caregivers for home palliative acre with education and discussion
Hughes 1990¹³⁶	RCT but has wrong comparison (not in hospital)
Hughes 2000¹³⁷	Incorrect interventions (home based primary care intervention; only 20% of patients were terminally ill)
Huo 2014¹³⁸	Not RCT; retrospective study. No outcomes of interest
Hwang 2013¹³⁹	Not RCT; observational study. Large sample, but set in Taiwan
Indredavik 1999¹⁴⁰	No RCT and compares stroke unit rehabilitation with general medical ward treatment
Indredavik 2008¹⁴¹	RCT but no relevant outcomes
Jakobsen 2013¹⁴²	Methodology of RCT only
Johnston 2015¹⁴³	Systematic review is not relevant to review question or unclear PICO
Jolly 2005¹⁴⁴	RCT but study aborted prematurely due to language barriers with participants. No data
Jones 1999¹⁴⁵	Costs only
Jones 2014¹⁴⁶	Not RCT; case study with little data
Kane 1984¹⁴⁸	Incorrect intervention (intensive hospice care delivered by a hospice unit of a hospital versus usual hospital care)
Kenny 2002¹⁴⁹	Not RCT and not relevant
Kinley 2014¹⁵⁰	Not RCT; retrospective observational study
Konrad 2012¹⁵¹	Not RCT; retrospective study
Koopman 1996¹⁵²	RCT but excluded as home care was self-administered
Kornowski 1995¹⁵³	Not RCT; observational study
Kortke 2006¹⁵⁴	Not RCT; open clinical study (non-randomised)
Korzeniowska-Kubacka 2014¹⁵⁵	Not RCT; prospective observational study
Langhorne 2000¹⁵⁶	Cochrane systematic review withdrawn from publication and superseded by Shepperd 2008²⁴⁰
Langhorne 2005¹⁵⁷	Not RCT; review
Lappegard 2012¹⁵⁸	Not RCT; retrospective study
Last 2000¹⁵⁹	Not RCT, service description
Leon 2011¹⁶⁰	RCT, but patient group and outcomes not relevant (stable HIV patients)
Leppert 2014¹⁶¹	Not RCT
Lewis 2007¹⁶²	Not RCT; commentary
Lewis 2011¹⁶³	Not RCT; research protocol only
Lewis 2012¹⁶⁵	Not RCT; commentary/conceptual paper
Lewis 2013¹⁶⁴	Not RCT; case studies without data
Lewis 2013¹⁶⁶	Not RCT; propensity matched controls study based on observational study data
Lim 2003¹⁶⁷	RCT but not relevant comparison
Linertova 2011¹⁶⁸	Not RCT; Systematic review
Luckett 2013¹⁶⁹	Systematic review: study designs inappropriate
Martin 1994¹⁷⁰	RCT but wrong comparison (control group received ‘appropriate conventional community services) – Cochrane (early discharge) says it is in-hospital but I checked paper -to be included into district nurse section –
Mason 2003¹⁷¹	Not RCT; description of a service
Mather 1976¹⁷²	No description of the type of service patients at home received (excluded by Cochrane too)
Matukaitis 2005¹⁷³	Not RCT. Pilot study and no comparison study
Mayhew 2006¹⁷⁴	Not RCT; health economics only
Mayo 1998¹⁷⁵	Conference abstract of study protocol only; duplicate of full paper Mayo 2000¹⁷⁶
McKegney 1981¹⁷⁸	No outcomes of interest
Mcloughlin 2015¹⁷⁹	Study protocol
Mcmillan 2006¹⁸¹	Incorrect interventions (caregiver intervention); no relevant outcomes (caregiver outcomes)
Mcmillan 2007¹⁸⁰	Incorrect interventions and comparison (caregiver intervention versus usual care in the same setting (hospice))
McNamee 1998¹⁸²	Health economic evaluation
McWhinney 1994¹⁸³	No outcome data reported. Authors describe the challenges of conducting a trail in this area
Melin 1992¹⁸⁴	Not relevant: patients with long-term care needs were recruited. Hospital at Home was substitute for long-term care and not necessarily in-hospital
Meyer 2009¹⁸⁵	Not RCT; case studies
Meyers 2011¹⁸⁶	Incorrect intervention (education)
Miller 2005¹⁸⁷	No relevant outcomes
Molassiotis 2009¹⁸⁸	Incorrect interventions (home care nursing intervention for symptom management in patients receiving oral chemotherapy)
Muijen 1992¹⁸⁹	RCT but patients treated for acute, severe mental illness (psychiatric ward versus home); not relevant to AME guideline
Nicholson 2001¹⁹⁰	Health economics only
Nissen 2007¹⁹¹	Not in English (Danish)
Nordly 2014¹⁹²	Protocol only; no study data
Nordly 2016¹⁹³	Systematic review (included incorrect study design)
Nyatanga 2014¹⁹⁴	Not RCT; commentary/conceptual paper
Palmer Hill 2000¹⁹⁷	Not relevant: patients recovering from knee replacement
Pandian 2013¹⁹⁸	Trial register only; no data
Patel 2004¹⁹⁹	Health economic evaluation
Penque 1999²⁰⁰	Not RCT; retrospective study
Pergolotti 2015²⁰¹	Study protocol
Pirl 2012²⁰²	No relevant outcomes
Pittiglio 2011²⁰³	Not RCT; not relevant
Plant 2015²⁰⁴	Incorrect interventions (coordination of care intervention for patients with chronic conditions)
Plochg 2005²⁰⁵	Not RCT; process evaluation
Pozzilli 2002²⁰⁶	RCT BUT not relevant (Multiple Sclerosis patients)
Prior 2012 ²⁰⁷	Not RCT
Puig-Junoy 2007²⁰⁸	Health economic evaluation
Rabow 2004²⁰⁹	Incorrect study design
Raftery 1996²¹¹	Incorrect intervention (co-ordinators did not provide “practical nursing care” or “specialist palliative care advice”; co-ordination only)
Raphael 2015²¹²	Inappropriate comparison (no comparator)
Richards 1998 ²¹⁵	Not relevant; majority of patients with trauma and elective surgery
Richards 1998A²¹⁴	Not relevant; correction to excluded trial with majority of patients with trauma and elective surgery
Richardson 2001 ²¹⁶	Health economic evaluation
Robinson 2009²¹⁷	Not RCT; description of new model of acute care
Rodriguez-Cerrillo 2010²¹⁹	Not RCT; Non-randomised prospective study
Rodriguez-Cerrillo 2012A²¹⁸	Not RCT; no comparison group to home treatment
Round 2004²²¹	Not RCT; prospective cohort study
Rosbotham-Williams 2002²²⁰	Not RCT; review
Rout 2011²²²	Not RCT; review
Rowley 1984²²³	Not RCT. No comparison group
Ruckley 1978²²⁴	Not relevant: patients following elective surgery
Rudkin 1997²²⁵	No service provided in community
Rummans 2006²²⁶	Incorrect interventions (advanced cancer intervention, participants did not meet qualification for hospice or palliative services)
Sahlen 2016²²⁷	No relevant outcomes
Sartain 2002²²⁸	Paediatric patient population
Saysell 2004²²⁹	Not RCT; pilot study of intermediate palliative care in care home
Schachter 2014²³⁰	Not RCT; study protocol only
Scheinberg 1986²³¹	RCT but does not state what the control group intervention is
Schneller 2012²³²	Not RCT; case study
Schou 2014²³³	RCT; but no relevant outcomes
Scott 2010²³⁴	Not RCT; literature review
Senaratne 1999²³⁵	Cost evaluation
Seow 2016²³⁶	Non-RCT; cohort study
Subirana Serrate 2001²⁵⁰	Not RCT; health economics evaluation
Shepperd 1998²³⁹	Not RCT; systematic review
Shepperd 2005A²³⁷	Not RCT; editorial
Shepperd 2009A²⁴¹	Not RCT; systematic review
Shepperd 1998A²³⁸	Costs only; no clinical outcomes
Sidebottom 2015²⁴⁴	In-patient care only considered. No alternative.
Singh 2015²⁴⁵	Systematic review is not relevant to review question or unclear PICO
Stephenson 1984²⁴⁶	Not RCT; conceptual paper
Steventon 2012²⁴⁷	Not RCT; retrospective analysis
Stewart 1999²⁴⁸	RCT but control group not in hospital.
Stromberg 2003²⁴⁹	RCT but only nurse-led follow up appointments in hospital. No actual community care given
Suijker 2012²⁵¹	Protocol only; incorrect intervention
Suwanwela 2002²⁵²	RCT but not comparable to UK setting as home treatment was managed by Red Cross Volunteers and family members (Thailand)
Temel 2010²⁵⁴	Incorrect intervention (outpatient meetings with patients at a large academic medical centre; not specifically aimed to support patients or caregivers at home)
Teng 2003²⁵⁵	Health economic evaluation
Tibaldi 2004²⁵⁹	RCT but no relevant outcomes (carer stress data incomplete)
Thorne 2001²⁵⁶	Not RCT; service description
Toseland 1995²⁶⁰	Incorrect interventions (intervention for caregivers of patients prior to the terminal stage of illness)
Trappes-Lomax 2006²⁶¹	RCT but comparison group not appropriate; did not receive ‘usual’ hospital care.
Upton 2014²⁶⁴	No RCT; not relevant
Utens 2010²⁶⁵	Study protocol of RCT only
Van hout 2005²⁶⁶	Incorrect interventions (frail elderly care, not palliative care)
Ventura 2016²⁶⁷	Abstract (Cochrane review already included)
Walshe 2010 ²⁷¹	Not RCT; review of qualitative papers
Wakefield 2008²⁷⁰	RCT but all self-care; wrong comparison
Weber 2014²⁷²	Study protocol
Widen Holmqvist 1996²⁷⁴	Health economic evaluation
Widen Holmqvist 1995²⁷³	Not RCT; observational study
Widen-Holmqvist 1998²⁷⁵	Superseded by Thorsen 2005 ²⁵⁷, 2006²⁵⁸ and Von Koch 2000²⁶⁹,2001²⁶⁸
Winkel 2008²⁷⁶	Not RCT; systematic review
Wolfe 2000²⁷⁷	RCT but excluded from Cochrane because intervention does not substitute for inpatient care; not valid comparison
Woodend 2008²⁸²	RCT but wrong control group; both at home with no actual care provided.
Woodhams 2012²⁸³	Not RCT; literature review
Yoshida 2015²⁸⁴	Incorrect study design
Young 2003B²⁸⁶	Not RCT; audit
Young 2005B²⁸⁷	Not RCT; quasi-experimental study
Young 2010B²⁸⁵	RCT but not relevant outcomes
Young 2010²⁸⁸	Incorrect intervention; not palliative
Yuan 2015²⁸⁹	Incorrect interventions (early prevention and management of COPD)

Appendix H. Excluded economic studies

Table 12Studies excluded from the economic review

Reference	Reason for exclusion
Pace 2014¹⁹⁶	This study was selectively excluded as it was conducted in a non-UK setting and does not report any health outcomes. It only looks at costs related re-hospitalisation and is based on observational evidence.
Shnoor 2007²⁴³	This study was excluded as it was conducted in a non-UK setting using costs from 2003 and does not report any health outcomes. It was also based on observational evidence. Given a UK RCT cost effectiveness study was included it was felt more appropriate and relevant evidence was available for this review question.
Tamir 2007²⁵³	This study was excluded as it was conducted in a non-UK setting using costs from the year 2000 and does not report any health outcomes.
Tzala 2005²⁶²	This study was assessed as partially applicable with potentially serious limitations. However, the committee judged that the treatment included in the intervention and comparators was for a specific population, and therefore this study was selectively excluded.

Appendix I

This appendix is not available from the publisher at this time.

Bookshelf ID: NBK564922

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National Guideline Centre (UK). Emergency and acute medical care in over 16s: service delivery and organisation. London: National Institute for Health and Care Excellence (NICE); 2018 Mar. (NICE Guideline, No. 94.) Chapter 14, Community palliative care.
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Emergency and acute medical care in over 16s: service delivery and organisation.

Chapter 14Community palliative care

14. Community palliative care

14.1. Introduction

14.2. Review question: Does community-based palliative care improve outcomes compared with hospital care?

Table 1

14.3. Clinical evidence

Table 2

Table 3

Table 4

Narrative findings

Table 5

14.4. Economic evidence

Published literature

Table 6

14.5. Evidence statements

Clinical

Economic

14.6. Recommendations and link to evidence

References

Appendices

Appendix A. Review protocol

Table 7Review protocol: Community base palliative care

Appendix B. Clinical article selection

Figure 1Flow chart of clinical article selection for the review of community palliative care

Appendix C. Forest plots

C.1. Community palliative care versus hospital care

Figure 1Place of death (deaths at home)

Figure 2Admissions to hospital

Figure 3Number of presentations to ED

Figure 4Number of presentations to ED (continuous)

Figure 5Length of stay

Figure 6Length of stay (SD calculated)

Figure 7Quality of Life

Figure 8Patient satisfaction (continuous)

Figure 9Patient satisfaction

Figure 10Carer satisfaction

Figure 11Place of death (in-hospital mortality)

C.2. Enhanced palliative care versus standard palliative care

Figure 12Admissions

Figure 13Number of presentations to ED

Figure 14Length of stay

Figure 15Quality of life (QUAL-E end of life scale)

Figure 16Preferred place of death achieved

Figure 17Preferred place of death achieved

C.3. Community palliative care versus usual care

Figure 18Quality of life (QUAL-E end of life scale)

Figure 19Quality of life (functional assessment of chronic illness therapy spiritual wellbeing scale)

Figure 20Patient satisfaction (overall satisfaction 1-10)

Figure 21Patient satisfaction (FAMCARE patient satisfaction with care scale)

Figure 22Relatives satisfaction (overall satisfaction 1-10)

Figure 23Death at home

Figure 24Length of stay (rate of hospital days)

Figure 25ED visits (rate of ED visits)

Figure 26Readmissions (28 days)

Figure 27Admissions (84 days)

Figure 28Quality of life (chronic heart failure questionnaire; higher score is better)

Appendix D. Clinical evidence tables

Appendix E. Economic evidence tables

Appendix F. GRADE tables

Table 8Clinical evidence profile: Community palliative versus hospital care

Table 9Clinical evidence profile: Enhanced community palliative versus standard community palliative care

Table 10Clinical evidence profile: Community palliative care versus usual care

Appendix G. Excluded clinical studies

Table 11Studies excluded from the clinical review (all excluded for alternative to hospital care)

Appendix H. Excluded economic studies

Table 12Studies excluded from the economic review

Appendix I

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