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Specialist palliative care may enhance effect if provided early

Stephen Padilla
07 Jul 2017
Palliative care: Why patients deserve the truth

Integrating specialist palliative care is likely to have a small effect on quality of life (QoL) and has inconclusive results for pain and other outcomes, according to the findings of a systematic review and meta-analysis. Also, its effect on QoL may be more noticeable for patients with cancer and those who receive such care early.

“We hypothesize that specialist palliative care could be most effective if it is provided early and if it identifies patients with unmet needs through screening (care as needed),” researchers said.

Medline, Embase, Cochrane Central Register of Controlled Trials, PsycINFO and trial registers were searched up to July 2016 for randomized controlled trials (RCTs) with adult patients treated in hospital, hospice or community settings with any advanced illness. One of the minimum requirement for specialist palliative care was multiprofessional team approach.

The primary outcome assessed was QoL with Hedges’ g as standardized mean difference (SMD) and random effects model in meta-analysis. The pooled SMDs were also re-expressed on the global health/QoL scale of the European Organization for Research and Treatment of Cancer QLQ-C30 (0 to 100; high values=good QoL; minimal clinically important difference, 8.1).

A total of 3,967 publications were identified, of which only 12 were included (10 RCTs with 2,454 patients, of whom 72 percent [n=1,766] had cancer). The integration of specialist palliative care was never initiated according to patients’ needs as identified by screening in any trial. [BMJ 2017;357:j2925]

Specialist palliative care only had a small effect on the QoL of patients (SMD, 0.16; 95 percent CI, 0.01 to 0.31; QLQ-C30 global health/QoL, 4.1; 0.3 to 8.2; n=1,218; six trials). Based on sensitivity analysis, the SMD was 0.57 (‒0.02 to 1.15; global health/QoL, 14.6; ‒0.5 to 29.4; n=1,385; seven trials).

There was a slightly larger effect on QoL for patients with cancer (SMD, 0.20; 0.01 to 0.38; global health/QoL, 5.1; 0.3 to 9.7; n=828; five trials) and particularly for those who received specialist palliative care early (SMD, 0.33; 0.05 to 0.61; global health/QoL, 8.5; 1.3 to 15.6; n=388; two trials).

“This effect was observed even though all trials also provided specialist palliative care to patients who did not have symptoms nor had any other needs for palliative care,” researchers said. “Instead, it was initiated according to diagnosis and stage of disease.”

The results were inconclusive for pain and other secondary outcomes. In addition, some methodological problems, such as lack of blinding, reduced the strength of the evidence.

“Because of the obvious equivocal nature of the studies included in our review, special attention must be paid to the meticulous discussion of these findings,” researchers noted, adding that this study differs from previous publications in several aspects. [J Clin Oncol 2012;357:880-7; J Clin Oncol 2017;357:96-112; JAMA 2008;357:1698-709]

Such aspects include the clear definition of inclusion criteria, clarity and extent of the provided results, a priori specified subgroup analyses (such as cancer, early specialist palliative care), and interpretability, according to researchers.

“We hope that the discussion of the importance of general palliative care and the detailed description of shortcomings of the included studies will increase the quality of further clinical research in the specialty of palliative care,” researchers said.

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