Association of Receipt of Palliative Care Interventions With Health Care Use, Quality of Life, and Symptom Burden Among Adults With Chronic Noncancer Illness: A Systematic Review and Meta-analysis

• Published in: JAMA : the journal of the American Medical Association 2020-10, Vol.324 (14), p.1439-1450
• Main Authors: Quinn, Kieran L, Shurrab, Mohammed, Gitau, Kevin, Kavalieratos, Dio, Isenberg, Sarina R, Stall, Nathan M, Stukel, Therese A, Goldman, Russell, Horn, Daphne, Cram, Peter, Detsky, Allan S, Bell, Chaim M
• Format: Article
• Language: English
• Subjects: Adults; Aged; Bias; Cancer; Chronic Disease; Chronic illnesses; Chronic obstructive pulmonary disease; Clinical trials; Congestive heart failure; Dementia - epidemiology; Dementia - therapy; Dementia disorders; Emergency medical care; Emergency medical services; Emergency Service, Hospital - statistics & numerical data; End of life; Female; Health care; Health Services Needs and Demand - statistics & numerical data; Heart failure; Heart Failure - epidemiology; Heart Failure - therapy; Hospitalization - statistics & numerical data; Humans; Illnesses; Lung diseases; Male; Meta-analysis; Obstructive lung disease; Odds Ratio; Original Investigation; Palliation; Palliative care; Palliative Care - statistics & numerical data; Patients; Pulmonary Disease, Chronic Obstructive - epidemiology; Pulmonary Disease, Chronic Obstructive - therapy; Quality of Life; Randomized Controlled Trials as Topic - statistics & numerical data; Signs and symptoms; Symptom Assessment - statistics & numerical data; Synthesis; Systematic review
• ISSN: 0098-7484; 1538-3598
• DOI: 10.1001/jama.2020.14205

IMPORTANCE: The evidence for palliative care exists predominantly for patients with cancer. The effect of palliative care on important end-of-life outcomes in patients with noncancer illness is unclear. OBJECTIVE: To measure the association between palliative care and acute health care use, quality of life (QOL), and symptom burden in adults with chronic noncancer illnesses. DATA SOURCES: MEDLINE, Embase, CINAHL, PsycINFO, and PubMed from inception to April 18, 2020. STUDY SELECTION: Randomized clinical trials of palliative care interventions in adults with chronic noncancer illness. Studies involving at least 50% of patients with cancer were excluded. DATA EXTRACTION AND SYNTHESIS: Two reviewers independently screened, selected, and extracted data from studies. Narrative synthesis was conducted for all trials. All outcomes were analyzed using random-effects meta-analysis. MAIN OUTCOMES AND MEASURES: Acute health care use (hospitalizations and emergency department use), disease-generic and disease-specific quality of life (QOL), and symptoms, with estimates of QOL translated to units of the Functional Assessment of Chronic Illness Therapy-Palliative Care scale (range, 0 [worst] to 184 [best]; minimal clinically important difference, 9 points) and symptoms translated to units of the Edmonton Symptom Assessment Scale global distress score (range, 0 [best] to 90 [worst]; minimal clinically important difference, 5.7 points). RESULTS: Twenty-eight trials provided data on 13 664 patients (mean age, 74 years; 46% were women). Ten trials were of heart failure (n = 4068 patients), 11 of mixed disease (n = 8119), 4 of dementia (n = 1036), and 3 of chronic obstructive pulmonary disease (n = 441). Palliative care, compared with usual care, was statistically significantly associated with less emergency department use (9 trials [n = 2712]; 20% vs 24%; odds ratio, 0.82 [95% CI, 0.68-1.00]; I2 = 3%), less hospitalization (14 trials [n = 3706]; 38% vs 42%; odds ratio, 0.80 [95% CI, 0.65-0.99]; I2 = 41%), and modestly lower symptom burden (11 trials [n = 2598]; pooled standardized mean difference (SMD), −0.12; [95% CI, −0.20 to −0.03]; I2 = 0%; Edmonton Symptom Assessment Scale score mean difference, −1.6 [95% CI, −2.6 to −0.4]). Palliative care was not significantly associated with disease-generic QOL (6 trials [n = 1334]; SMD, 0.18 [95% CI, −0.24 to 0.61]; I2 = 87%; Functional Assessment of Chronic Illness Therapy-Palliative Care score mean difference, 4.7 [95% CI, −6.3 t