Populations and Interventions for Palliative and End-of-Life Care: A Systematic Review.

IMPORTANCE: Evidence supports palliative care effectiveness. Given workforce constraints and the costs of new services, payers and providers need help to prioritize their investments. They need to know which patients to target, which personnel to hire, and which services best improve outcomes. OBJECTIVE: To inform how payers and providers should identify patients with "advanced illness" and the specific interventions they should implement, we reviewed the evidence to identify (1) individuals appropriate for palliative care and (2) elements of health service interventions (personnel involved, use of multidisciplinary teams, and settings of care) effective in achieving better outcomes for patients, caregivers, and the healthcare system. EVIDENCE REVIEW: Systematic searches of MEDLINE, EMBASE, PsycINFO, Web of Science, and Cochrane Database of Systematic Reviews databases (1/1/2001-1/8/2015). RESULTS: Randomized controlled trials (124) met inclusion criteria. The majority of studies in cancer (49%, 38 of 77 studies) demonstrated statistically significant patient or caregiver outcomes (e.g., p < 0.05), as did those in congestive heart failure (CHF) (62%, 13 of 21), chronic obstructive pulmonary disease (COPD; 58%, 11 of 19), and dementia (60%, 15 of 25). Most prognostic criteria used clinicians' judgment (73%, 22 of 30). Most interventions included a nurse (70%, 69 of 98), and many were nurse-only (39%, 27 of 69). Social workers were well represented, and home-based approaches were common (56%, 70 of 124). Home interventions with visits were more effective than those without (64%, 28 of 44; vs. 46%, 12 of 26). Interventions improved communication and care planning (70%, 12 of 18), psychosocial health (36%, 12 of 33, for depressive symptoms; 41%, 9 of 22, for anxiety), and patient (40%, 8 of 20) and caregiver experiences (63%, 5 of 8). Many interventions reduced hospital use (65%, 11 of 17), but most other economic outcomes, including costs, were poorly characterized. Palliative care teams did not reliably lower healthcare costs (20%, 2 of 10). CONCLUSIONS: Palliative care improves cancer, CHF, COPD, and dementia outcomes. Effective models include nurses, social workers, and home-based components, and a focus on communication, psychosocial support, and the patient or caregiver experience. High-quality research on intervention costs and cost outcomes in palliative care is limited.

Leaf hydraulic conductivity and photosynthesis are genetically correlated in an annual grass.

Comparative studies suggest that a positive correlation between xylem water transport and photosynthesis is adaptive. A requirement for the adaptive evolution of coordination between xylem and photosynthetic functions is the presence of genetic variation and covariation for these traits within populations. Here it was determined whether there was genetic variation and covariation for leaf blade hydraulic conductivity (K(W)), photosynthetic rate (A), stomatal conductance (g(s)), and time to flowering in a population of recombinant inbred lines of Avena barbata, a Mediterranean annual grass. Significant (P < 0.05) broad-sense heritabilities (H(2)) were detected for K(W) (H(2) = 0.33), A (H(2) = 0.23) and flowering time (H(2) = 0.62), but not for g(s). Significant positive genetic covariation between A and K(W) was also observed. There was no other genetic covariation among traits. The first evidence of genetic variation for K(W) within a species was obtained. These results also indicate that there is a genetic basis for the positive association between xylem water transport and photosynthesis. The presence of significant genetic variation and covariation for these traits in natural populations would facilitate correlated evolution between xylem and leaf functions.