Results Summary

What was the research about?

Nearly one in three Americans lives in a nursing home at the end of their life. Prior studies have shown that when residents are dying, the care nursing homes give may not always match what the residents want. For example, many nursing home residents don’t get enough help with pain. Also, nursing homes may send patients to the hospital for treatment when they would prefer to stay where they are.

In this study, the research team wanted to learn if giving nursing homes support to set up and train palliative care teams would improve care quality for dying residents. Palliative care aims to prevent and treat suffering. The palliative care teams included nursing home staff such as doctors, nurses, and social workers. These teams worked with experts for several months to learn how to care for patients using a palliative approach.

The research team compared two groups of nursing homes: those that had the team training and those that didn’t. The team looked at

  • Residents’ pain and depression symptoms in the last 90 days of life
  • How often residents went to the hospital in the last 90 days of life
  • Whether residents died in the hospital or nursing home

What were the results?

There was no difference in these three areas between nursing homes that had and didn’t have team training. But of the 14 nursing homes that had the training, 6 had palliative care teams that worked together well, based on staff interviews. The other 8 homes didn’t have consistently working teams.

The research team compared the six nursing homes with working palliative care teams and the eight other nursing homes. In nursing homes with working palliative care teams, fewer residents who died did so in the hospital. Residents of nursing homes with working teams had fewer symptoms of depression in the last 90 days of life than residents of nursing homes without working teams. Residents’ pain severity and the number of hospital admissions in the last 90 days of life were about the same at nursing homes with and without working palliative care teams.

Who was in the study?

The study used Medicare data for 5,830 deceased residents from 25 nursing homes in New York. These residents were at least 65 years old. More than 90 percent of residents were white, and 65 percent were women.

What did the research team do?

The research team assigned 14 nursing homes by chance to receive staff training in palliative care and 11 nursing homes to not receive training. The team helped set up and train the palliative care teams. After training, a palliative care nurse practitioner worked with nursing home staff for two months to guide patient care. The nurse practitioner then consulted with nursing home staff as needed for another 8 to 10 months.

The research team looked at Medicare records for the location of residents’ deaths and their hospital admissions, pain, and depression in the last 90 days of life.

Patient advocates, palliative care experts, and nursing home managers helped the research team design the study.

What were the limits of the study?

Some nursing homes were better able to support the new palliative care teams than other nursing homes. Results may have been different if all nursing homes were able to form and maintain working palliative care teams.

Future research could look at ways to create palliative care teams that work well in more nursing homes.

How can people use the results?

Palliative care may help improve end-of-life care for nursing home residents. But nursing homes may need more or different types of support to provide this type of care.

Final Research Report

View this project's final research report.

Peer-Review Summary

Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.

The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments. 

The following are strengths and limitations noted in peer review, and the researchers’ responses:

  • The reviewers applauded the researchers for providing a clear presentation not only of the research but also of their difficulties in implementing the palliative care intervention in nursing homes and in collecting data from staff.
  • The reviewers requested clarification regarding the nature of this study, which the report described as testing efficacy (i.e., whether the intervention works when compared with no intervention). The researchers revised the report to indicate that the study looked at the intervention’s effectiveness (i.e., how well the intervention works in a real-world context). 
  • The reviewers asked the researchers to provide results from tests of the study’s main hypotheses in the final report’s abstract. The researchers responded that the report did provide results for the first hypothesis, but they were unable to test the second and third hypotheses because of problems collecting data.
  • The final report emphasized the results of a sensitivity analysis showing that nursing home teams that were more functional, or working, had better implementation of the intervention than teams that were less functional, or nonworking. The reviewers noted that while the idea for this analysis came from preplanned in-depth interviews with nursing home staff, the analysis comparing working and nonworking nursing home teams was not preplanned and therefore should not be presented as key findings. The researchers responded that the report clearly presents these findings as sensitivity analyses and not as main findings.
  • The reviewers asked the researchers to soften the conclusion that the intervention was effective, pointing out that the prespecified analysis across all nursing home teams, the main result, did not show the intervention to be effective. The researchers declined to revise their conclusions to downplay the importance of the analysis of working versus nonworking teams’ outcomes. The final report retains a focus on this post-hoc result, which reviewers described as hypothesis generating and not a confirmation of the intervention’s effectiveness.

Conflict of Interest Disclosures

Project Information

Helena Temkin-Greener, PhD
University of Rochester
$2,002,336
10.25302/7.2019.CER.641
Improving Palliative and End-of-Life Care in Nursing Homes

Key Dates

December 2012
July 2018
2012
2018

Study Registration Information

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Last updated: January 25, 2023