In this large outpatient cancer population, trajectories of mean ESAS scores followed two patterns: increasing versus generally flat. The latter was perhaps due to available treatment (eg, prescriptions) for those symptoms. Future research should prioritize addressing symptoms that worsen over time.

Objective To determine the pooled effect of exposure to one of 11 specialist palliative care teams providing services in patients' homes.Design Pooled analysis of a retrospective cohort study.Setting Ontario, Canada.Participants 3109 patients who received care from specialist palliative care teams in 2009-11 (exposed) matched by propensity score to 3109 patients who received usual care (unexposed). InterventionThe palliative care teams studied served different geographies and varied in team composition and size but had the same core team members and role: a core group of palliative care physicians, nurses, and family physicians who provide integrated palliative care to patients in their homes. The teams' role was to manage symptoms, provide education and care, coordinate services, and be available without interruption regardless of time or day.Main outcome measures Patients (a) being in hospital in the last two weeks of life; (b) having an emergency department visit in the last two weeks of life; or (c) dying in hospital.Results In both exposed and unexposed groups, about 80% had cancer and 78% received end of life homecare services for the same average duration. Across all palliative care teams, 970 (31.2%) of the exposed group were in hospital and 896 (28.9%) had an emergency department visit in the last two weeks of life respectively, compared with 1219 (39.3%) and 1070 (34.5%) of the unexposed group (P<0.001). The pooled relative risks of being in hospital and having an emergency department visit in late life comparing exposed versus unexposed were 0.68 (95% confidence interval 0.61 to 0.76) and 0.77 (0.69 to 0.86) respectively. Fewer exposed than unexposed patients died in hospital (503 (16.2%) v 887 (28.6%), P<0.001), and the pooled relative risk of dying in hospital was 0.46 (0.40 to 0.52).Conclusions Community based specialist palliative care teams, despite variation in team composition and geographies, were effective at reducing acute care use and hospital deaths at the end of life. IntroductionHome based palliative care teams are meant to help patients manage symptoms, improve quality of life, and prevent avoidable hospitalisations, which are documented issues at end of life.1-3 Moreover, policy makers internationally want to deliver integrated palliative care in the home and community, since many patients prefer to be cared for at home, community care is often less expensive than hospital care, and acute care hospitals are overwhelmed.4 5 However, policy makers are unsure of optimal models of care delivery based on interdisciplinary teams. Although studies have evaluated specialist palliative care teams in hospitals, 6-8 only nine randomised controlled trials specifically investigated specialist teams in the community. [9][10][11][12][13][14][15][16][17] The community based teams studied in these trials involved a core group of interdisciplinary team members, specifically palliative care physicians, nurses, and family physicians who provide integrated palliative care to patients in their homes...