A Tale of Two Trials: A Comparative Case Study of Successful versus Terminated Home-Based Palliative Care Trials

In 2007 we published a trial of home-based palliative care (HBPC) conducted in a managed care organization (MCO) that found significant improvements in patient satisfaction with health care, rates of home deaths, and reductions in health care use and costs. A decade later, we undertook a similar trial of HBPC within accountable care organizations (ACOs) funded by the Patient-Centered Outcomes Research Institute. This trial tested the same model using similar eligibility criteria and recruitment strategies as the earlier trial, yet it failed to achieve its enrollment targets. To understand key differences in the trials that contributed to the success of one and failure of the other. We conducted a comparative case study of the original MCO HBPC trial and the subsequent ACO HBPC trial. Two researchers familiar with both trials reviewed both quantitative and qualitative data obtained from previous analyses and publications to develop a rich, in-depth understanding of each study. We identified four differences that explain in large part why the ACO trial failed while the MCO trial succeeded. These differences center on the trials' setting, target populations, outreach strategies, and providers' understanding of palliative care. Our findings demonstrate the challenges in conducting research in complex health care systems and how physician and setting structures along with target population and lack of general palliative care knowledge can influence the success of research. Future HBPC trials must consider the strengths and weaknesses of trial design factors when partnering with multiple health care organizations. ClinicalTrials.gov Identifier: NCT03128060.