Comparative Effectiveness of Generalist versus Specialist Palliative Care for Inpatients

What is the research about? 
Palliative care seeks to reduce suffering and improve quality of life for patients with serious illnesses and their families. National guidelines recommend that clinicians either provide palliative care themselves (generalist palliative care) or consult experts (specialist palliative care) as a standard part of serious illness care. Because evidence shows that both approaches to palliative care delivery improve outcomes for seriously ill hospitalized patients, health systems across the United States are highly motivated to increase palliative care for patients admitted to their hospitals. Yet health systems lack knowledge of how best to maximize the overall benefits of palliative care for all hospitalized patients. Even less is known about how best to deliver palliative care among patients who differ by race, gender, age, socioeconomic status, social determinants of health, disease type, mortality risk and other characteristics, or about what factors related to patients, caregivers, clinicians or hospitals help promote or hinder palliative care delivery. 

Who can this research help? 
Hospitals and health system leaders can use findings from this study to identify the best ways to help patients at high risk of dying to receive the best possible palliative care in the hospital and to assess how delivering this care translates into longer-term patient-centered outcomes after these patients leave the hospital. As such, the work holds considerable potential for guiding payers on the importance of supporting palliative care delivery, and for improving well-being among the nation’s sickest patients and their family caregivers. 

What is the research team doing? 
The research team is conducting the largest and most diverse study to date comparing generalist and specialist palliative care for hospitalized patients. Guided by a 10-person Patient and Caregiver Advisory Committee, a 14-person Stakeholder Advisory Committee, and two experienced engagement leads who will join both Committees, the investigators are working with 48 hospitals within two of the largest U.S. health systems to enroll 43,248 patients with at least a 50% chance of dying within one year. They are comparing generalist palliative care versus specialist palliative care delivery and measuring the benefits of each of these approaches relative to how hospitals usually deliver palliative care. The goals of the trial are to understand whether generalist and specialist palliative care delivery similarly maximize patients’ hospital-free days—the proportion of their remaining days they spend outside of an acute-care hospital—from the time of trial enrollment through six months of follow-up, and which strategies best promote other patient-centered outcomes such as patient quality of life, patient perceptions of the patient-centeredness of care, documentation of goals of care, hospice use and other outcomes. This study will also be large enough and conducted among a sufficiently diverse population of patients to determine which type of palliative care works best for specific patient groups—for example for people with different races, ethnicities, ages, diagnoses and social determinants of health. 

Research methods at a glance
Design Elements Description

• Design: Parallel cluster-randomized trial. 
• Population: Adults admitted to 48 hospitals in two of the largest U.S. health systems with moderate or greater risk of dying within one year. 
• Comparators: 
  1. Standardized Usual Care (specialist palliative care delivered by default only among very-high-risk patients). 
  2. Specialist Palliative Care (specialist palliative care delivered by default among all hospitalized patients with moderate or higher risk). 
  3. Generalist Palliative Care (generalist palliative care motivated by training and accountable justification among hospitalized patients with moderate or higher risk, still with specialist palliative care delivered by default among very-high-risk patients). 
• Outcomes: 
  • Primary: hospital-free days. 
  • Secondary: patient quality of life, patient and caregiver satisfaction, hospital readmissions, hospice use, goals of care documentation, change in code status. 
• Timeframe: six-month follow-up for the primary outcome