Effectiveness palliative home care for

patients with HIV/AIDS: a systematic review

Linlin
Ical

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 Background

End of Life Care (EOL)

Broader than

• Purpose : Improve Quality of life (QOL)

• Domain: Bio-psycho-social-spiritual
• Continuum care /alongside disease prognosis

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 symptom control

• Accepted worldwide & reducing anxiety

recommended by WHO
(Huang, 2013; WHO, 2005)
↑ Survival time

Improves QOL
(Huang, 2013; R. Harding & Higginson, 2005 )

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Models • Hospital-based 11% wanted to
palliative care die in hospital

• Home-based 56% wanted to die

palliative care at home

• Hospice model of 24% wanted to die

palliative care in a hospice

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 Palliative care in Indonesia

• Began : 2007 for cancer patients

• 2011 : policy palliative care for HIV/AIDS
patients
• 2013 : 5 hospital: Cancer palliative care
0 hospital : HIV/AIDS palliative care

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 Epidemiology HIV in Indonesia

• 65% total patients with HIV/AIDS get ARV

• ARV provide in province and city hospital (262
Hospital)
• 5 hospital provide specialist HIV/AIDS clinic
• bed occupied at hospital for patients with HIV is
limited
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 PICO question

In patients with HIV/AIDS, How does palliative home care

compare to hospital palliative care affect to patients outcomes?

Population (P) Patients with HIV/AIDS

Intervention (I) Palliative home care

Compare (C) Hospital palliative care

Outcomes (O) Patients outcomes

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 Inclusion Criteria

• Type of Study • Type of outcome

1. Systematic review /Meta analyses  Primary outcome: Death
2. Randomized controlled trial
 Secondary outcome:
3. Prospective studies
4. Cohort studies
1. QOL
5. Case control studies 2. Pain & other symptoms
3.Satisfaction of care
• Type of participant
1. Aged ≥18 y.0
2. HIV/AIDS patients
• Type of intervention
Delivering home palliative care

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 Search methods for identification of studies

Electronic searches Searching other resources

Years : 2000-2013 Hand searching
1. PubMed 1. Oxford Textbook of
2. Cochrane Library Palliative Medicine (Hanks
3. Ebscohost
4. Ovids 2009)
5. AIDS care 2. Oxford Textbook of
6. Journal of palliative care Palliative Nursing (Ferrell
7. Journal of palliative 2010).
medicine

Language:
English

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 Searching Strategies

Keyword

(P) HIV, AIDS, Terminal illness, advance diseases

(I) home care, Home-Based, palliative care

(C) Hospital, inpatients, hospital-based, palliative care

(O) Patients outcomes, QOL, pain, symptoms, cost effective,

satisfaction

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Keyword combination

1. Palliative AND Home care AND HIV/AIDS

2. Home-based AND palliative care AND HIV/AIDS

3. Home-based AND palliative care AND advance diseases

4. palliative care AND home care AND HIV/AIDS

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 Results of the search

Electronic search
(n=906)
Exclude duplicate records
(n=191)

Record screened Exclude with reason:

(n=715) • No patients with HIV/AIDS (n=245)
• No home palliative care intervention
(n=231)
• Not meet type of study (n=205)
34 Fully assess for
eligibility
Exclude with reason (n=30):
• Not meet type of study (n=28 )
• Pilot study (n=2)

4 include :
• 1 RCT
• 4 prospective
study

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 Included studies

1 1 RCT
1. A palliative-care intervention and death at home: a cluster
randomized trial
4 Prospectively controlled study
1.Nurse Practitioner-Based Models of Specialist Palliative Care at
Home: Sustainability and Evaluation of Feasibility
2.Effectiveness of Palliative Day Care in Improving Pain, Symptom
Control, and Quality of Life
3.Clinical Impact of a Home-Based Palliative Care Program: A
Hospice-Private Payer Partnership

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 A palliative-care intervention and death at home: a cluster randomized trial

Authors level year Number of Method Intervention Outcome Risk of bias

s participant
Jordhøy,M IC 2000 Included RCT  Cooperation with the  the rate of home  Adequate sequence
patients with  Allocation community service, the deaths 25 % vs. generation? Yes
.,S.et al
HIV/AIDS generation: team at the Palliative control group 15% Random number charts
 Interventio Random number Medicine Unit served (p value=0.02) were used
n n=235 charts were used as a link to the  Median survival  Allocation concealment?
 Control  Allocation community. was 127 days in No C – Inadequate
n=199 concealment:  Provide palliative home the intervention  Blinding? Unclear not
numbers on the care. group and days 99 reported
charts were in the control group  Incomplete outcome
designated as (p=0·1, adjusted for data addressed?
either experimental diagnostic groups Unclear not reported
or control group A–C).  Type of randomization;
 Blinding: not  34 (14%) details of any restriction
reported intervention patients (such as blocking and
 Loss to follow-up: and 35 (18%) block size) : unreported
not reported controls died within
1 month of
enrolment

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 Critical appraisal

• Critical appraisal : Exclude

• Reason: risk of bias can be produce
1. Allocation concealment Inadequate
2. Blinding Unclear and not reported
3. Unclear not reported Incomplete outcome data addressed
4. unreported type of randomization; details of any restriction (such
as blocking and block size) 15
 Clinical Impact of a Home-Based Palliative Care Program: A Hospice-Private
Payer Partnership

Authors level years Number of Method Intervention Outcome

participant

Kerr,W.,E, 2t 2C 2014 Included  A prospective study Intervention Included:  The site of death was home for 47% of
patients with  Secondary data :  pain and symptom those who died during or after
al
HIV/AIDS database study of HC management directed by participation in the program.
499 Home program participants the palliative care  Six of eight symptom domains (anxiety,
Connections physician appetite, dyspnea, wellbeing, depression
participants  patient education and nausea) showed improvement.
enrolled  supportive discussions  Patients, caregivers and physicians gave
between July 1, about health care high program satisfaction scores (93%-
2008 and May decision making and goals 96%).
31, 2013  social work visit to  Home Connections participants who
facilitate access to subsequently enrolled in hospice care had a
community support longer average length of stay of 77.9 days
services, respite care as compared to all other hospice referrals
through volunteers (average length of stay 56.5 days).
 24/7 on call palliative
care nurse support.

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 Critical appraisal
Using CEBM
•

Included & Grade A

Reason:
follow-up sufficiently long and complete, outcome criteria either objective
or applied in a ‘blind’ fashion

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 Nurse Practitioner-Based Models of Specialist Palliative Care at Home:
Sustainability and Evaluation of Feasibility

Authors level years Number of Method Intervention Outcome

participant

Bookbinder 3e 2011 Included Observational • NP was linked with  significant decline in symptom distress
patients prospective study a social worker (SW) during the initial two weeks after
, M, et.al to create a new
with The new palliative referral (P = 0.003)
palliative home care
HIV/AIDS home care team  100% compliance with advance care
team (PHCT-NP-
499 Home included an NP and SW), which would planning
an SW (PCHT-NP- provide consultation
SW), both of whom and direct care to
had advanced referred homebound
training in palliative patients with
care. advanced illnesses.
• In a second model,
an NP was assigned
to a hospice
program (Hospice-
NP) for the purpose
of enhancing the
reach and impact of
a home care team.

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 Critical appraisal

(CEBM,2009)

Included & Grade A

Reason:
follow-up sufficiently long and complete, outcome criteria either• objective
or applied in a ‘blind’ fashion

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 Effectiveness of Palliative Day Care in Improving Pain, Symptom Control,
and Quality of Life

Authors level years Number of Method Intervention Outcome

participant

Goodwin, 2C 2003 Included Prospectively Palliative day care  At baseline, the day care group were (non-
patients with controlled study including home significantly) worse than the comparison
D.W., et al
HIV/AIDS To evaluate the palliative care group in the MQOL support domain
 Interventio effectiveness of (P=0.065).
n n=120 palliative day care for  The comparison group had marginally more
 Control a group of new severe pain at baseline (P=0.053) and more
n=120 referrals attending severe symptoms at second assessment
five centers. Day care (P=0.025).
patients were  Both patient groups maintained overall
compared over time health-related quality of life during the three
with a comparison months of the study
group.
Measuring the
domains of palliative
day care is
highly complex and a
non-randomized trial
a

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 Critical appraisal
Using CEBM
•

Included & Grade A

Reason:
follow-up sufficiently long and complete, outcome criteria either objective
or applied in a ‘blind’ fashion

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 Conclusion

• Primary outcome
1.↑ site of death at home
2.↑ survival time
• Secondary outcome
1.Effective to control and reduce symptoms: pain,
anxiety, appetite, dyspnea, wellbeing, depression and
nausea
2.Satisfaction of care
3.The model a Home-Based Palliative Care Program,
have given satisfaction among Patients, caregivers
and physicians

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 Clinical implication

• Design effective palliative care based on the resource,

capability and condition of patients with HIV/AIDS.
• Preparation: Training for nurses (palliative home care)

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THANK YOU

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