Is a specialist breathlessness service more effective and cost-effective for patients with advanced cancer and their carers than standard care? Findings of a mixed-method randomised controlled trial

Abstract

BackgroundBreathlessness is common in advanced cancer. The Breathlessness Intervention Service (BIS) is a multi-disciplinary complex intervention theoretically underpinned by a palliative care approach, utilising evidence-based non-pharmacological and pharmacological interventions to support patients with advanced disease. We sought to establish whether BIS was more effective, and cost-effective, for patients with advanced cancer and their carers than standard care.MethodsA single-centre Phase III fast-track single-blind mixed-method randomised controlled trial (RCT) of BIS versus standard care was conducted. Participants were randomised to one of two groups (randomly permuted blocks). A total of 67 patients referred to BIS were randomised (intervention arm n = 35; control arm n = 32 received BIS after a two-week wait); 54 completed to the key outcome measurement. The primary outcome measure was a 0 to 10 numerical rating scale for patient distress due to breathlessness at two-weeks. Secondary outcomes were evaluated using the Chronic Respiratory Questionnaire, Hospital Anxiety and Depression Scale, Client Services Receipt Inventory, EQ-5D and topic-guided interviews.ResultsBIS reduced patient distress due to breathlessness (primary outcome: −1.29; 95% CI −2.57 to −0.005; P = 0.049) significantly more than the control group; 94% of respondents reported a positive impact (51/53). BIS reduced fear and worry, and increased confidence in managing breathlessness. Patients and carers consistently identified specific and repeatable aspects of the BIS model and interventions that helped. How interventions were delivered was important. BIS legitimised breathlessness and increased knowledge whilst making patients and carers feel ‘not alone’. BIS had a 66% likelihood of better outcomes in terms of reduced distress due to breathlessness at lower health/social care costs than standard care (81% with informal care costs included).ConclusionsBIS appears to be more effective and cost-effective in advanced cancer than standard care.Trial registrationRCT registration at ClinicalTrials.gov NCT00678405 (May 2008) and Current Controlled Trials ISRCTN04119516 (December 2008).Electronic supplementary materialThe online version of this article (doi:10.1186/s12916-014-0194-2) contains supplementary material, which is available to authorized users.

Managing breathlessness: a palliative care approach

“…A BIS comprises of a multidisciplinary complex intervention underpinned by a palliative care approach and uses evidence-based non-pharmacological and pharmacological interventions to support patients with advanced disease. Patients also had better outcomes for breathlessness at lower cost than standard care 25. The second RCT showed that a breathlessness support service improved breathlessness mastery in patients with a variety of advanced diseases and provided evidence to support the early integration of palliative care into respiratory services 26…”

“…Two recently published randomised controlled trials (RCTs) have emphasised the importance of multidisciplinary breathlessness support services in the management of breathlessness 25 26. The first study showed that the interventions of a Breathlessness Intervention Service (BIS) significantly reduced distress due to breathlessness and increased confidence in managing breathlessness in patients with advanced cancer 25.…”

“…The first study showed that the interventions of a Breathlessness Intervention Service (BIS) significantly reduced distress due to breathlessness and increased confidence in managing breathlessness in patients with advanced cancer 25. A BIS comprises of a multidisciplinary complex intervention underpinned by a palliative care approach and uses evidence-based non-pharmacological and pharmacological interventions to support patients with advanced disease.…”

“…Evidence suggests that how the fan is provided to patients is also important—some patients received handheld fans from clinicians, but identified that the way CBIS delivered the intervention was different as they provided explanation as to how and when to use the fan, and how it might work, legitimising what might appear to be an ineffective intervention 25. Therefore, offering a fan should include a brief scientific explanation of the mechanisms thought to underlie its effectiveness, instruction and demonstration of its optimal use.…”

Separated at birth?

“…Have things changed? Despite burgeoning signs in the literature2 3 and presentations at international palliative care conferences, little obvious progress is being made 4…”