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End of Life

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

Educational Objective
To review the benefits of palliative care for patients with noncancer illnesses.

1 Credit CME

JAMA

Published Online: October 13, 2020

Original Investigation

Article Information and Disclosures

Kieran L. Quinn, MD, MSc^1,2,3,4;

Mohammed Shurrab, MD, MSc^2,3,5,6;

Kevin Gitau, MD¹;

Dio Kavalieratos, PhD⁷;

Sarina R. Isenberg, PhD^8,9;

Nathan M. Stall, MD^3,10,11;

Therese A. Stukel, PhD^2,3;

Russell Goldman, MD^8,9;

Daphne Horn, MI⁴;

Peter Cram, MD, MBA^1,2,3,4;

Allan S. Detsky, MD, PhD^1,3,4;

Chaim M. Bell, MD, PhD^1,2,3,4

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

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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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Article Information

Corresponding Author: Kieran L. Quinn, MD, MSc, Sinai Health System, 60 Murray St, Second Floor, Room 404, Toronto, ON M5T 3L9, Canada (kieran.quinn@mail.utoronto.ca).

Accepted for Publication: July 16, 2020.

Author Contributions: Dr Quinn had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Quinn, Kavalieratos, Isenberg, Stukel, Goldman, Cram, Detsky, Bell.

Acquisition, analysis, or interpretation of data: Quinn, Shurrab, Gitau, Kavalieratos, Stall, Horn, Bell.

Drafting of the manuscript: Quinn, Kavalieratos, Horn, Cram.

Critical revision of the manuscript for important intellectual content: Quinn, Shurrab, Gitau, Kavalieratos, Isenberg, Stall, Stukel, Goldman, Detsky, Bell.

Statistical analysis: Quinn, Shurrab, Stall, Stukel.

Obtained funding: Quinn.

Administrative, technical, or material support: Quinn, Gitau, Kavalieratos, Isenberg, Stall, Horn.

Supervision: Kavalieratos, Goldman, Cram, Detsky, Bell.

Conflict of Interest Disclosures: Dr Kavalieratos reported receiving grants from the National Heart, Lung, and Blood Institute during the conduct of the study. Dr Cram reported receiving grants from the National Institutes of Health outside the submitted work. No other disclosures were reported.

Funding/Support: This study was supported by the Sinai Health System Research Foundation. Drs Quinn and Stall receive funding from the Canadian Institutes of Health Research Vanier Scholarship Program, the Eliot Phillipson Clinician-Scientist Training Program, and the Clinician Investigator Program at the University of Toronto. Dr Kavalieratos receives research funding from the National Institutes of Health (K01HL133466), the Cystic Fibrosis Foundation, and the Milbank Foundation.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We thank Juan Diaz Martinez, MSc (Biostatistics Research Unit, University Health Network, University of Toronto), for his assistance with the statistical analyses and creation of the figures. He was not compensated for his contribution.

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.