Leonard Davis School of Gerontology, University of Southern California, Los Angeles, California, USA.
J Palliat Med. 2022 Dec;25(12):1767-1773. doi: 10.1089/jpm.2022.0065. Epub 2022 Jun 8.
In 2007 we published a trial of home-based palliative care (HBPC) conducted in a managed care organization (MCO) that found significant improvements in patient satisfaction with health care, rates of home deaths, and reductions in health care use and costs. A decade later, we undertook a similar trial of HBPC within accountable care organizations (ACOs) funded by the Patient-Centered Outcomes Research Institute. This trial tested the same model using similar eligibility criteria and recruitment strategies as the earlier trial, yet it failed to achieve its enrollment targets. To understand key differences in the trials that contributed to the success of one and failure of the other. We conducted a comparative case study of the original MCO HBPC trial and the subsequent ACO HBPC trial. Two researchers familiar with both trials reviewed both quantitative and qualitative data obtained from previous analyses and publications to develop a rich, in-depth understanding of each study. We identified four differences that explain in large part why the ACO trial failed while the MCO trial succeeded. These differences center on the trials' setting, target populations, outreach strategies, and providers' understanding of palliative care. Our findings demonstrate the challenges in conducting research in complex health care systems and how physician and setting structures along with target population and lack of general palliative care knowledge can influence the success of research. Future HBPC trials must consider the strengths and weaknesses of trial design factors when partnering with multiple health care organizations. ClinicalTrials.gov Identifier: NCT03128060.
2007 年，我们在一家管理式医疗组织（MCO）中开展了一项居家姑息治疗（HBPC）试验，结果发现患者对医疗保健的满意度、居家死亡比例、医疗保健使用和成本均有显著改善。十年后，我们在患者导向医疗成果研究所（PCORI）资助的问责制医疗组织（ACO）中开展了一项类似的 HBPC 试验。该试验采用与早期试验相同的模式和招募策略，检验了相同的模型，但未能达到预期的入组目标。为了了解导致一项试验成功而另一项试验失败的关键差异，我们对最初的 MCO HBPC 试验和随后的 ACO HBPC 试验进行了对比案例研究。两名熟悉这两项试验的研究人员对之前分析和出版物中获得的定量和定性数据进行了回顾，以深入了解每项研究。我们确定了四项差异，这些差异在很大程度上解释了为什么 ACO 试验失败而 MCO 试验成功。这些差异集中在试验的设置、目标人群、外展策略以及医疗保健提供者对姑息治疗的理解上。我们的研究结果表明，在复杂的医疗保健系统中开展研究存在挑战，以及医生和设置结构、目标人群以及缺乏普遍的姑息治疗知识如何影响研究的成功。未来的 HBPC 试验在与多个医疗保健组织合作时，必须考虑试验设计因素的优缺点。临床试验.gov 标识符：NCT03128060。
