Palliative Care Reduces Health Care Use, Symptom Burden in Chronic Noncancer Illness

By Will Boggs MD

October 14, 2020

NEW YORK (Reuters Health) - Palliative care interventions are associated with reduced health care use and modestly lower symptom burden, but not with improved quality of life, in adults with chronic noncancer illness, according to a systematic review and meta-analysis.

"Palliative care is an important part of a multifaceted approach to delivering high-quality care for patients with noncancer illness," Dr. Kieran L. Quinn from Sinai Health System, University of Toronto, Toronto, Ontario, Canada told Reuters Health by email. "It reduces symptom burden and potentially unwanted healthcare use near the end of life."

Most evidence for the benefits of palliative care come from studies of patients with cancer, yet there are twice as many patients with noncancer illness than there are patients with cancer who need palliative care.

Dr. Quinn and colleagues evaluated the association between palliative care and health care use, quality of life, and symptom burden for patients with noncancer illness in their systematic review of 26 randomized clinical trials that enrolled 13,664 patients.

Palliative care interventions included elements of ongoing case management to help coordinate care; ongoing interdisciplinary support for unmet palliative care needs; facilitated discussions to help define goals of care and advance care planning; and care at the end of life.

In the primary analysis, palliative care was associated with a significantly lower percentage of patients with emergency department (ED) use (20% versus 24% with usual care), according to the report in JAMA.

The association between palliative care and less ED use was not significant in analyses limited to trials that involved an interdisciplinary care team and home visits or among the subset of trials that excluded studies involving patients with a primary diagnosis of dementia and cancer.

Results were similar in the analysis of the association between palliative care and hospitalization rates, with significantly lower hospitalization rates overall (38% versus 42% with usual care), but not in the subgroup analyses.

Palliative care was significantly associated with lower symptom burden that translated into an average of 0.2-point decrease across all subdomains of the Edmonton Symptom Assessment Scale (in which the minimal clinically important difference is 5.7 points).

As with ED use and hospitalization rates, differences were not significant in the subgroup analyses.

Palliative care was not significantly associated with disease-generic or disease-specific measures of quality of life.

"We were surprised to find that palliative care was not associated with improved quality of life in patients with noncancer illness," Dr. Quinn said. "However, prior research suggests that these patients have a higher burden of palliative care needs compared to patients with cancer, which may be related to increased healthcare use, worse functional impairments, and higher levels of anxiety and depression."

The authors caution that "analyses for some outcomes were based predominantly on studies of patients with heart failure, which may limit generalizability to other chronic diseases."

"Ultimately, I believe that our study raises important questions about the design of palliative care interventions for patients with noncancer illness," Dr. Quinn said. "The majority of prior evidence for palliative care comes from studies of patient with cancer, which may explain some of the observed discrepancies in our findings. It is entirely possible that we will need to rethink how palliative care is delivered to patients with noncancer illness to achieve similar benefits."

"Like all interventions in medicine, (palliative care) also has its limits and should not be viewed as a one-size-fits-all solution," he said. "However, there are many incredible opportunities to refine and optimize palliative care programs to ensure the delivery of equitable, high-quality care for all patients with serious illness."

Dr. Alexander K. Smith from University of California, San Francisco, who wrote an editorial related to this report, told Reuters Health by email, "Doctors should refer patients with noncancer serious illness to palliative care specialty palliative care. They should do this because (1) it will likely modestly improve symptoms; (2) most people with serious illness would rather be taken care of outside the emergency department and hospital, and palliative care helps them achieve that goal; (3) through engagement in advance care planning, palliative care helps family members of people with serious illness prepare for 'in-the-moment' decision making."

"Improving access to outpatient palliative care is not only the right thing to do for patients and families; it is also the smart move for health systems financially," he said.

Dr. Arif H. Kamal from Duke University, Durham, North Carolina, who has researched various aspects of palliative care, told Reuters Health by email, "We have known for over a decade that palliative care integration in cancer care is a best practice. This manuscript reflects a building evidence base that palliative care helps patients and caregivers reach their goals of spending less time in the ED and hospital near the end of life in the non-cancer setting, and that more evidence is needed regarding the benefits of palliative care in 'evidence deserts,' such as COPD, kidney failure, stroke, and advanced liver disease."

"Importantly," he said, "the evidence continues to support that less acute care utilization and honoring patient wishes is a mutually achievable goal."

SOURCE: https://bit.ly/3dpWiuW and https://bit.ly/3729BRa JAMA, online October 13, 2020.

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