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Original Investigation
October 13, 2020

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

Author Affiliations
  • 1Department of Medicine, University of Toronto, Toronto, Ontario, Canada
  • 2ICES, Toronto, Ottawa and North, Ontario, Canada
  • 3Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
  • 4Department of Medicine, Sinai Health System, Toronto, Ontario, Canada
  • 5Health Sciences North Research Institute, Sudbury, Ontario, Canada
  • 6Northern Ontario School of Medicine, Laurentian University, Sudbury, Ontario, Canada
  • 7Division of Palliative Medicine, Department of Family and Preventive Medicine, Emory University, Atlanta, Georgia
  • 8Temmy Latner Centre for Palliative Care and Lunenfeld-Tanenbaum Research Institute, Toronto, Ontario, Canada
  • 9Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
  • 10Women’s College Research Institute, Women’s College Hospital, Toronto, Ontario, Canada
  • 11Division of Geriatric Medicine, University of Toronto, Toronto, Ontario, Canada
JAMA. 2020;324(14):1439-1450. doi:10.1001/jama.2020.14205
Key Points

Question  Is receipt of palliative care interventions associated with lower acute health care use and better patient-centered outcomes in adults with noncancer illness?

Findings  In this systematic review and meta-analysis of 28 randomized clinical trials of patients with primarily noncancer illness, receipt of palliative care interventions, compared with usual care, was statistically significantly associated with less acute health care use and modestly lower symptom burden, but there was no significant difference in quality of life.

Meaning  Among patients with primarily noncancer illness, receipt of palliative care interventions was associated with lower acute health care use and modestly lower symptom burden, although analyses for some outcomes were based predominantly on studies of patients with heart failure, which may limit the generalizability of these findings to other chronic illnesses.

Abstract

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 to 15.9]) or disease-specific measures of QOL (11 trials [n = 2204]; SMD, 0.07 [95% CI, −0.09 to 0.23]; I2 = 68%).

Conclusions and Relevance  In this systematic review and meta-analysis of randomized clinical trials of patients with primarily noncancer illness, palliative care, compared with usual care, was statistically significantly associated with less acute health care use and modestly lower symptom burden, but there was no significant difference in quality of life. Analyses for some outcomes were based predominantly on studies of patients with heart failure, which may limit generalizability to other chronic illnesses.

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