Original Study| Volume 21, ISSUE 12, P1973-1978.e2, December 2020

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Lack of Effect of a Multicomponent Palliative Care Program for Nursing Home Residents on Hospital Use in the Last Month of Life and on Place of Death: A Secondary Analysis of a Multicountry Cluster Randomized Control Trial



      PACE Steps to Success is a 1-year train-the-trainer program aiming to integrate nonspecialist palliative care into nursing homes via staff education and organizational support. In this study, we aimed to explore whether this program resulted in changes in residents' hospital use and place of death.


      Secondary analysis of the PACE cluster randomized controlled trial (ISRCTN14741671). Data were collected on deaths over the previous 4 months via questionnaires at baseline and postintervention.

      Setting and Participants

      Questionnaires were completed by the nurse/care-assistant most involved from 78 nursing homes in 7 European Union countries.


      We measured number of emergency department visits, hospital admissions, length of hospital stay, and place of death. Baseline and postintervention scores between intervention and control groups were compared, and we conducted exploratory mixed-model analyses. We collected 551 out of 610 questionnaires at baseline and 984 out of 1178 at postintervention in 37 intervention and 36 control homes.


      We found no statistical significant effects of the program on emergency department visits [odds ratio (OR) = 1.38, P = .32], hospital admissions (OR = 0.98, P = .93), length of hospital stay (geometric mean difference = 0.85, P = .44), or place of death (OR = 1.08, P = .80).

      Conclusions and Implications

      We found no effect of the PACE program on either hospital use in the last month of life or place of death. Although this may be related to implementation problems in some homes, the program might also require a more specific focus on managing acute end-of-life situations and a closer involvement of general practitioners or specialist palliative care services to influence hospital use or place of death.


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        • Payne S.
        • Froggatt K.
        • Hockley J.
        • et al.
        PACE Steps to Success Programme: Information Pack.
        (Available at:)
        • Smets T.
        • Onwuteaka-Philipsen B.B.D.
        • Miranda R.
        • et al.
        Integrating palliative care in long-term care facilities across Europe (PACE): Protocol of a cluster randomized controlled trial of the “PACE Steps to Success” intervention in seven countries.
        BMC Palliat Care. 2018; 17: 47
        • Van den Block L.
        • Honinx E.
        • Pivodic L.
        • et al.
        Evaluation of a palliative care program for nursing homes in 7 countries: The PACE cluster-randomized clinical trial.
        JAMA Intern Med. 2019; 180: 1-10
        • Munn J.C.
        • Zimmerman S.
        • Hanson L.C.
        • et al.
        Measuring the quality of dying in long-term care.
        J Am Geriatr Soc. 2007; 55: 1371-1379
        • Oosterveld-Vlug M.
        • Onwuteaka-Philipsen B.
        • Ten Koppel M.
        • et al.
        Evaluating the implementation of the PACE Steps to Success Programme in long-term care facilities in seven countries according to the RE-AIM framework.
        Implement Sci. 2019; 14: 107
        • Pivodic L.
        • Pardon K.
        • Morin L.
        • et al.
        Place of death in the population dying from diseases indicative of palliative care need: A cross-national population-level study in 14 countries.
        J Epidemiol Community Health. 2016; 70: 17-24
        • Verhofstede R.
        • Smets T.
        • Cohen J.
        • et al.
        Implementing the care programme for the last days of life in an acute geriatric hospital ward: A phase 2 mixed method study.
        BMC Palliat Care. 2016; 15: 27
        • Pivodic L.
        • Pardon K.
        • Miccinesi G.
        • et al.
        Hospitalisations at the end of life in four European countries: A population-based study via epidemiological surveillance networks.
        J Epidemiol Community Health. 2016; 70: 430-436
        • Van den Block L.
        • Ko W.
        • Miccinesi G.
        • et al.
        Final transitions to place of death: Patients and families wishes.
        J Public Health. 2017; 39: e302-e311
        • Hockley J.
        • Froggatt K.
        • Van den Block L.
        • et al.
        A framework for cross-cultural development and implementation of complex interventions to improve palliative care in nursing homes: The PACE steps to success programme.
        BMC Health Serv Res. 2019; 19: 745
        • Badger F.
        • Plumridge G.
        • Hewison A.
        • et al.
        An evaluation of the impact of the Gold Standards Framework on collaboration in end-of-life care in nursing homes. A qualitative and quantitative evaluation.
        Int J Nurs Stud. 2012; 49: 586-595
        • Steel K.
        • Ljunggren G.
        • Topinková E.
        • et al.
        The RAI-PC: An assessment instrument for palliative care in all settings.
        Am J Hosp Palliat Care. 2003; 20: 211-219
        • Dewolf L.
        • Koller M.
        • Velikova G.
        • et al.
        EORTC Quality of Life Group translation procedure.
        (Available at:)
        • RStudio Team
        RStudio: Integrated Development for R.
        RStudio Inc, Boston, MA2015
        • Low L.-F.
        • Fletcher J.
        • Goodenough B.
        • et al.
        A systematic review of interventions to change staff care practices in order to improve resident outcomes in nursing homes.
        PLoS One. 2015; 10: e0140711
        • Graverholt B.
        • Forsetlund L.
        • Jamtvedt G.
        Reducing hospital admissions from nursing homes: A systematic review.
        BMC Health Serv Res. 2014; 14: 36
        • Wolters A.
        Emergency admissions to hospital from care homes: How often and what for? The Health Foundation.
        (Available at:)
        • Tejwani V.
        • Wu Y.
        • Serrano S.
        • et al.
        Issues surrounding end-of-life decision-making.
        Patient Prefer Adherence. 2013; 7: 771-775
        • Temkin-Greener H.
        • Mukamel D.
        • Ladd H.
        • et al.
        Impact of nursing home palliative care teams on end-of-life outcomes: A randomized controlled trial.
        Med Care. 2018; 56: 11-18
        • Cohen A.B.
        • Knobf M.T.
        • Fried T.
        Avoiding hospitalizations from nursing homes for potentially burdensome care: What helps facilities succeed?.
        JAMA Intern Med. 2017; 177: 137-139
        • Reyniers T.
        • Houttekier D.
        • Cohen J.
        • et al.
        What justifies a hospital admission at the end of life? A focus group study on perspectives of family physicians and nurses.
        Palliat Med. 2014; 28: 941-948
        • Keeley M.P.
        Family communication at the end of life.
        Behav Sci. 2017; 7: 45