Jordhøy 2000.
| Methods | Cluster‐RCT (3 pairs of clusters stratified into pairs according to the number of inhabitants older than 60 years, and if area was urban or rural) Originally 8 clusters, 2 urban districts with the smallest number of inhabitants > 60 years were merged with larger ones |
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| Participants | People with incurable malignant disease, life expectancy of 2 to 9 months (estimated at referral) and age older than 18 years. People with haematological malignant disorders other than lymphomas were excluded from the trial Median age (range): T = 70 years (38 to 90), C = 69 years (37 to 93) Sex (percentage male): T = 132/235 (56%), C = 98/199 (49%) Living alone: T = 70/235 (30%), C = 71/199 (36%) Relatives in the same neighbourhood: T = 214/235 (91%), C = 179/199 (90%) Receiving home help at the time of recruitment: T = 26/235 (11%), C = 45/199 (23%) Number recruited from March 1995 to November 1997: 434/707 referred patients were included; T = 235, C = 199 Numbers of participants per cluster: cluster 1: T = 134, C = 116; cluster 2: T = 77, C = 65; cluster 3: T = 24, C = 18 |
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| Interventions | A hospital‐based intervention co‐ordinated by the Palliative Medicine Unit with community outreach. The intervention had been operational for 2 years and 8 months. The Palliative Medicine Unit provided supervision and advice and joined visits at home. The community nursing office determined the type and amount of home care and nursing home care offered. Multidisciplinary, involving palliative‐care team, community team, participants, and families Specialist palliative‐care nurses provided care in the home with a family physician and palliative‐care consultants (n = 3). Physiotherapy, nutrition and social care available. Access to a priest. 24‐hour care was limited, with the smallest urban district not having access to 24‐hour care Educational programme for community staff including bedside teaching and 6 to 12 hours of lectures every 6 months Access to informal help (T = 187/235 (80%), C = 140/199 (70%); Control group: conventional care is shared among the hospital departments and the community) |
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| Outcomes | Time at home, place of death, admissions to hospital, health‐related quality of life, admission to nursing home, survival Follow‐up of maximum 2 years |
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| Notes | Healthcare system: the Norwegian Public Health Service, which provides hospital and community care. The intervention was linked to the Trondheim University Hospital. The Norwegian Public Health Service provides hospital and community care. 8 community healthcare districts participated: 6 districts of Trondheim city (population 141,000) and 2 neighbouring rural communities (Malvik: population 10,000, and Melhus: population 13,000) Community services in all the districts are similar, including family physicians, home care nursing, and nursing homes. 1 family physician manpower‐year serves around 1500 inhabitants. A mean of 30 manpower‐years of home care nurses’ or nurse assistants’ time are available per 1000 inhabitants older than 67 years. All except the smallest urban district provides 24‐hour home care service. However, night service is limited to short visits or telephone consultations. Number of nursing home beds (short and long term) is restricted to 20 beds per 100 inhabitants older than 80 years. In each district, home care and nursing home services are co‐ordinated at a common community nursing office, which decides the type and amount of service that a referred patient will be offered Hospital services for all 8 districts are provided by Trondheim University Hospital. Palliative Medicine Unit has 12 inpatient beds, an outpatient clinic, and a consultant team that works in and out of the hospital, including 2 palliative‐care nurses, a social worker, a priest, a nutritionist, and a part‐time physiotherapist. 3 full‐time physicians were employed during the study. The team only worked daytime hours |
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| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | High risk | Eligible patients were assigned treatment according to the district (cluster) in which they lived |
| Allocation concealment (selection bias) | High risk | Cluster‐RCT of 8 local community healthcare districts stratified into pairs according to the number of inhabitants older than 60 years and whether the areas were rural or urban. 2 small urban districts were merged with larger ones, for a total of 3 clusters |
| Blinding (performance bias and detection bias) All outcomes | High risk | Blinding not possible, reliable measures of outcome used |
| Incomplete outcome data (attrition bias) All outcomes | Unclear risk | Alive at follow‐up: 10/229 in the intervention group and 13/189 in the control group |
| Selective reporting (reporting bias) | Low risk | Wide range of outcomes reported |
| Baseline measures | Low risk | No differences in key baseline characteristics |
| Protection against contamination | Low risk | Intervention was not available to control groups |
C = control CHF = congestive heart failure COPD = chronic obstructive pulmonary disease GP = general practitioner HAH = hospital at home HMO = health maintenance organisation RCT = randomised controlled trial RGN = registered general nurse SD = standard deviation T = treatment