Effect of specialist palliative care services on quality of life in adults with advanced incurable illness in hospital, hospice, or community settings: systematic review and meta-analysisBMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j2925 (Published 04 July 2017) Cite this as: BMJ 2017;357:j2925
- Jan Gaertner, head of department1 2,
- Waldemar Siemens, researcher1,
- Joerg J Meerpohl, co-director3 4,
- Gerd Antes, director3,
- Cornelia Meffert, researcher1,
- Carola Xander, researcher1,
- Stephanie Stock, director5,
- Dirk Mueller, researcher5,
- Guido Schwarzer, statistician6,
- Gerhild Becker, director1
- 1Clinic for Palliative Care, Medical Centre, University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
- 2Palliative Care Centre Hildegard, Basel, Switzerland
- 3Cochrane Germany, Medical Centre, University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
- 4Centre de Recherche Épidémiologie et Statistique Sorbonne Paris Cité-U1153, Inserm/Université Paris Descartes, Cochrane France, Hôpital Hôtel-Dieu, 1 Place du Parvis Notre Dame, 75181 Paris Cedex 04, France
- 5Institute for Health Economics and Clinical Epidemiology, Cologne University Hospital, Cologne, Germany
- 6Institute for Medical Biometry and Statistics, Faculty of Medicine and Medical Centre, University of Freiburg, Germany
- Correspondence to: J Gaertner
- Accepted 5 June 2017
Objective To assess the effect of specialist palliative care on quality of life and additional outcomes relevant to patients in those with advanced illness.
Design Systematic review with meta-analysis.
Data sources Medline, Embase, Cochrane Central Register of Controlled Trials, PsycINFO, and trial registers searched up to July 2016.
Eligibility criteria for selecting studies Randomised controlled trials with adult inpatients or outpatients treated in hospital, hospice, or community settings with any advanced illness. Minimum requirements for specialist palliative care included the multiprofessional team approach. Two reviewers independently screened and extracted data, assessed the risk of bias (Cochrane risk of bias tool), and evaluated the quality of evidence (GRADE tool).
Data synthesis Primary outcome was quality of life with Hedges’ g as standardised mean difference (SMD) and random effects model in meta-analysis. In addition, the pooled SMDs of the analyses of quality of life were re-expressed on the global health/QoL scale (item 29 and 30, respectively) of the European Organization for Research and Treatment of Cancer QLQ-C30 (0-100, high values=good quality of life, minimal clinically important difference 8.1).
Results Of 3967 publications, 12 were included (10 randomised controlled trials with 2454 patients randomised, of whom 72% (n=1766) had cancer). In no trial was integration of specialist palliative care triggered according to patients’ needs as identified by screening. Overall, there was a small effect in favour of specialist palliative care (SMD 0.16, 95% confidence interval 0.01 to 0.31; QLQ-C30 global health/QoL 4.1, 0.3 to 8.2; n=1218, six trials). Sensitivity analysis showed an SMD of 0.57 (−0.02 to 1.15; global health/QoL 14.6, −0.5 to 29.4; n=1385, seven trials). The effect was marginally larger for patients with cancer (0.20, 0.01 to 0.38; global health/QoL 5.1, 0.3 to 9.7; n=828, five trials) and especially for those who received specialist palliative care early (0.33, 0.05 to 0.61, global health/QoL 8.5, 1.3 to 15.6; n=388, two trials). The results for pain and other secondary outcomes were inconclusive. Some methodological problems (such as lack of blinding) reduced the strength of the evidence.
Conclusions Specialist palliative care was associated with a small effect on QoL and might have most pronounced effects for patients with cancer who received such care early. It could be most effective if it is provided early and if it identifies though screening those patients with unmet needs.
Systematic review registration PROSPERO CRD42015020674.
We thank Cinzia Brunelli (statistician, palliative care, pain therapy and rehabilitation unit, Fondazione IRCCS Istituto Nazionale Tumori) for providing statistical data of the study from Jordhøy and colleagues34 35; Abbey Sidebottom (division of applied research, Allina Health, Minneapolis, Minnesota) for re-running the change score regression models and confirming their results; and Mayang Mayang, graduate assistant at the department of palliative care, University Medical Center Freiburg, for her help with data extraction and proofreading.
Contributors: JG and WS contributed equally. JG had the idea for the work, wrote the protocol, extracted data, evaluated quality of evidence (GRADE), wrote the abstract, introduction, discussion, and conclusion section of the manuscript, and critically revised the entire manuscript. WS extracted data, evaluated quality of evidence (GRADE) and economic analyses, conducted meta-analyses, wrote methods and results; and critically revised and finalised the manuscript. JJM and GA wrote and critically revised the protocol, supervised application of Cochrane standards and GRADE, and critically revised the manuscript. CX critically revised the protocol and manuscript. SS wrote the protocol and supervised the economic analysis. GS wrote the protocol, supervised meta-analysis and all other statistical analyses, and did a detailed revision of methods and results section of the manuscript. GB critically revised the protocol and manuscript. JG is guarantor.
Funding: This review was funded by the German Ministry for Education and Research (BMBF), Germany, Grant No. 01KG1408. The funder of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.
Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
Ethical approval: Not required.
Data sharing: No additional data available.
Transparency: The lead authors (JG, WS) affirm that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained.
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