Efficacy of models of palliative care delivered beyond the traditional physician-led, subspecialty consultation service model: a systematic review and meta-analysis

Abstract

ObjectiveThis meta-analysis aimed to determine the effectiveness of non-physician provider-led palliative care (PC) interventions in the management of adults with advanced illnesses on patient-reported outcomes and advance care planning (ACP).MethodsWe included randomised trials and cluster trials published in MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane Register of Controlled Trials and ClinicalTrials.gov searched until July 2021 that examined individuals ≥18 years with a diagnosis of advanced, life-limiting illness and received a PC intervention led by a non-physician (nurse, advance practitioner or social worker). Our primary outcome was quality of life (QOL), which was extracted as unadjusted or adjusted estimates and measures of variability. Secondary outcomes included anxiety, depression and ACP.ResultsAmong the 21 studies (2370 subjects), 13 included patients with cancer, 3 with heart failure, 4 with chronic respiratory disease and 1 with chronic kidney disease. The interventions were diverse and varied with respect to team composition and services offered. For QOL, the standardised mean differences suggested null effects of PC interventions compared with usual care at 1–2 months (0.04; 95% CI=−0.14 to 0.23, n=10 randomised controlled trials (RCTs)) and 6–7 months (0.10; 95% CI=−0.15 to 0.34, n=6 RCTs). The results for anxiety and depression were not significant also. For the ACP, there was a strong benefit for the PC intervention (absolute increase of 0.32% (95% CI=0.06 to 0.57).ConclusionsIn this meta-analysis, PC interventions delivered by non-physician were not associated with improvement in QOL, anxiety or depression but demonstrated an impact on the ACP discussion and documentation.

Effects of advance care planning in care dependent community-dwelling older persons (STADPLAN): A cluster-randomised controlled trial

“…A recent systematic review with meta-analysis including 21 randomised controlled trials on different non-physician led palliative care interventions including ACP in patients with advanced, life-limiting illness also did not find effects on quality of life, anxiety and depression, both shortly after the intervention and later. 6 No effect on quality of life was also found in the large multinational European ACTION trial conducted in more than 1100 patients with advanced cancer. 30 Earlier studies often did not assess these outcomes.…”

“…The Dutch study found large differences regarding this outcome. 12 The same is true for a recently published randomised controlled trial in older multimorbid outpatients conducted in primary care practices in North Carolina 10 and for the meta-analysis of palliative care interventions in patients with advanced, life-limiting illnesses 6 as well as for a recent scoping review on randomised controlled trials on ACP in adults. 32 However, one has to keep in mind that most interventions evaluated also include the completion of advance directives, 6,9,31 which was explicitly not part of our program.…”

“…12 The same is true for a recently published randomised controlled trial in older multimorbid outpatients conducted in primary care practices in North Carolina 10 and for the meta-analysis of palliative care interventions in patients with advanced, life-limiting illnesses 6 as well as for a recent scoping review on randomised controlled trials on ACP in adults. 32 However, one has to keep in mind that most interventions evaluated also include the completion of advance directives, 6,9,31 which was explicitly not part of our program. Although providing advance directives obviously results in more persons completing them, successful implementation of ACP requires training of health care staff and raising awareness of all persons involved.…”

“…4 Since then, the effectiveness of ACP has mostly been studied for people with advanced, life-limiting diseases like patients with cancer or heart failure. 5,6 However, with ageing of Western populations leading to a further increase in care dependent, chronically ill as well as functionally and cognitively impaired older people, 7,8 expanding and adopting ACP to all older people is of major importance. 1,9 Most studies focusing on its effects in older people were conducted in institutional settings such as hospitals or nursing homes, while only few studies were performed in the community, 9 which is the most important setting where older care dependent people live.…”