Evaluation of palliative care: steps to quality assurance?

Abstract

We have reviewed the UK and North American evaluations of hospice and palliative care and consider the future needs for evaluation and quality assurance. Nonrandomized studies on single sites in the UK suggested that inpatient hospice care is more effective than hospital care, however, comparisons of hospital care with outpatient or home hospice care were equivocal. In North America the converse was found: one randomized controlled trial showed few advantages of inpatient hospice care compared with conventional care, while in another study, patients randomly allocated to a home care team reported greater satisfaction and spent more time at home than the controls. Multicentre studies in the UK have described only the process of care, whereas North American studies (especially the National Hospice Study) have included outcome measures. Their general conclusion, that hospice care was not worse than conventional care and in some special centres was better, is not likely to satisfy most health service managers and planners nor many hospice staff. Hospice care is now well established and it will be difficult to set up further randomized trials in the future. Yet many aspects of the services remain to be evaluated. Studies in progress in the UK are developing methods for clinical audit of care; these may prove useful guides to quality assurance in palliative medicine.