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

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.

Figure 1.. Literature Search to Identify Randomized Clinical Trials of Palliative Care Interventions

Figure 2.. Random-Effects Meta-analysis of the Association Between Palliative Care and Health Care Use Among Patients With Noncancer Illness

Data are presented as the odds ratios and 95% CIs (error bars) of at least 1 emergency department visit or hospitalization during study follow-up. The area of the shaded squares is proportional to the study weight and the shaded diamonds represent pooled odds ratios and 95% CIs. The dashed line indicates the pooled effect estimate and the dotted line depicts a null effect.

Figure 3.. Random-Effects Meta-analysis of the Association Between Palliative Care and Quality of Life (QOL) Among Patients With Noncancer Illness

Data are presented as the means and 95% CIs (error bars) of the change in QOL measures from baseline to the end of study follow-up. The area of the shaded squares is proportional to the study weight and the shaded diamonds represent pooled standardized mean differences (SMDs) and 95% CIs. The dashed line indicates the pooled effect estimate and the black vertical line depicts a null effect. CHQ-C indicates Chronic Heart Failure Questionnaire Chinese; CRQ Chronic Respiratory Questionnaire; EQ-5D, EuroQol-5D; FACIT-PAL, Functional Assessment of Chronic Illness Therapy-Palliative Care; FACIT-Sp, Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being; HRQOL, Health-Related Quality of Life; KCCQ, Kansas City Cardiomyopathy Questionnaire; MLHFQ, Minnesota Living with Heart Failure Questionnaire; and QoL-AD, Quality of Life in Alzheimer's Disease .

Figure 4.. Random-Effects Meta-analysis of the Association Between Palliative Care and Symptoms Among Patients With Noncancer Illness

Data are presented as the means and 95% CIs (error bars) of the change in symptom measures from baseline to the end of study follow-up. The area of the shaded squares is proportional to the study weight and the shaded diamonds represent pooled standardized mean difference and 95% CIs. The dashed line indicates the pooled effect estimate and the black vertical line depicts a null effect. CAD-EOLD, End-of-Life in Dementia comfort around dying scale; ESAS indicates Edmonton Symptom Assessment Scale; HADS, Hospital Anxiety and Depression Scale; MCOHPQ, Modified City of Hope Patient Questionnaire; PHQ, Patient Health Questionnaire; SMD, standardized mean difference; and VAS, visual analog scale.

Figure 5.. Random-Effects Meta-analysis of the Association Between Palliative Care and Advance Care Planning Among Patients With Noncancer Illness

Data are presented as the odds ratios and 95% CIs (error bars) of a newly documented advanced care plan during study follow-up. The area of the shaded squares is proportional to the study weight and the shaded diamonds represent pooled odds ratios and 95% CIs. The dashed line indicates the pooled effect estimate and the dotted line depicts a null effect. COPD indicates chronic obstructive pulmonary disease.