Nurse-led Telephonic Case Management versus Outpatient Palliative Care in Older Adults with Serious Illness (SAPLEN 101)

Outcomes 1. Learners will understand the impacts of two different methods of palliative care delivery among patients with serious, life-limiting illness.2. Learners will be able to identify and deploy methods of palliative care specialty based on the resources available within their health systems. Key Message An 18-site randomized, pragmatic clinical trial was conducted to compare two established palliative care models, nurse-led telephonic case management and specialty outpatient palliative care, on patient-centered outcomes, including quality of life, loneliness and symptom burden. In this study, neither model was more effective with respect to these outcomes. Importance Community-based palliative care is a limited resource that improves patient-centered outcomes, yet the comparative effectiveness of two predominant palliative care models is unknown. Objective(s) To compare the effectiveness of nurse-led telephonic case management and facilitated, outpatient specialty palliative care on patient-centered outcomes, including quality of life (QOL), symptom burden, loneliness, and healthcare utilization. Scientific Methods Utilized Emergency Medicine Palliative Care Access (EMPallA) is a patient-level randomized trial comprising persons 50+ years with advanced cancer or end-stage organ failure recruited across 18 Emergency Departments (EDs). Patients were randomized to either telephonic nurse-led case management or specialty, outpatient palliative care. Summary statistics and mixed effects models with multiple imputation with chained equations were used to assess change in QOL. Secondary analyses evaluated the change in: 1) symptom burden; 2) loneliness; and 3) healthcare utilization (ED revisits, inpatient days and hospice utilization) during 12 months of follow-up. Exploratory analyses evaluated intervention effects by disease type, functional status, and racial/ethnic subgroups. Results Based on 1,283 patients with complete data at baseline, the mean age was 67 (SD 10.4), 666 (52%) were female, 403 (32%) were Black, 460 (36%) had advanced cancer, and 280 (22%) required at least considerable assistance. After adjusting for baseline QOL, the estimated difference between the intervention groups in average QOL score six months post-enrollment was 0.71 points (95% CI: -1.19, 2.61). Additionally, there were no differences between groups in secondary outcomes or in subgroup analyses. Conclusion(s) Nurse-led telephonic case management and facilitated, outpatient specialty palliative care have similar impact on QOL, symptom burden, loneliness and healthcare utilization.Impact:: As nurse-led telephonic case management programs can be appealing to payers and medical centers that participate in alternative payment models as well as policymakers who are looking for scalable outpatient palliative care models, health systems should consider the cost of deploying brick-and-mortar outpatient specialty palliative care, and consider a centralized model staffed by nurses. Keywords Models of palliative/hospice care delivery/Interdisciplinary Teamwork/Professionalism