Thursday, April 10, 2008

Specialized Palliative Care is Not Effective...or Is It?

(Begin sarcasm)
Stop the palliative medicine fellowship accreditation! Stop the first official accredited subspecialty palliative medicine boards this year! Tell JACHO not to include palliative care in their next round of hospital reviews! Find a job in a procedure based specialty! Quick! Hurry before it is too late. In case you have not heard, palliative care doesn't do anything beneficial.
(End sarcasm)

Don't PanicNow take a deep breath. Do some self-care. Don't over-react.

ResearchBlogging.orgLet's look at the study JAMA published this week on a detailed systematic review on the "Effectiveness of Specialized Palliative Care." Dr. Camilla Zimmermann and colleagues from Toronto and Sao Paulo did an exhaustive review of the available literature on randomized control trials looking at organized palliative care interventions. Shall we start with the Conclusion as that is what most people will look at first before deciding whether to delve in deeper.
"The evidence for benefit from specialized palliative care is sparse and limited by
 methodological shortcomings. Carefully planned trials, using a standardized palliative care intervention and measures constructed specifically for this population are needed."
Do you think many people in or out of the field of palliative care would read this and have the feeling palliative care may not be effective and therefore is not worth the investment?
Well if I were trying to figure out whether to include palliative care in my health care facility/company budget, a study like this does not give administration warm fuzzies, which is why I would like to explain the real lesson from this study.

Read the conclusion again, slowly, and without my catastrophic thoughts from the beginning of this post. This is not a descriptive study about the failure to show a benefit from palliative care interventions. This is a prescriptive study. The article is designed to warn against further efforts of research bound to fail despite many work hours. The article is designed to teach palliative care researchers how to design better studies and to start making more uniform study designs. The key part of the conclusion is the "limitation of methodological shortcomings."

Many of us see that palliative care works. We see it every day in our work. We just have not done the best job studying and marketing our successes, especially in a objective, scientific paradigm. As I was walking out of the hospital today, a respiratory therapist from the ICU, stopped to tell me how much he appreciated the palliative care team, and the difference he has seen it make for patients, families and staff. I am sure many readers of this blog can share similar stories. But this demonstrates an anecdotal, subjective, and narrative method of effectiveness, one that does not resonate as well as statistical objective numbers would to the administrative/business/policy people.
Zimmerman and colleagues teach us some important things in the article for our field to design better studies to show our talents. Here are some of the key highlights:

Hire a statistician:
Sample size calculations for statistical power were rarely done. This is shooting your study down before it leaves the gate.
Define the population:
Just taking people referred to palliative care and then randomizing causes all sorts of biases to be introduced. That could be a greatly heterogeneous population which can never be replicated, reducing the possibility of pooled meta-analysis. Rather pick objective assessment criteria like all oncology patients with a Palliative Performance Status of 60 percent or less and then randomize to usual care or concurrent palliative care.

Pick a hypothesis: Many studies measured everything under the sun, and then reported the positive findings. Choose a primary outcome measure (single, one, uno, ein) and leave the rest in the secondary outcomes part of the article.

Pick your survey tools carefully:
Do not use the one you made up last week, because you wanted to ask 'interesting questions.' There are many survey tools with many pro/con arguments, and different applicability to palliative care populations. Choose wisely.

Cost-effectiveness analysis is tricky:
We need to take a global approach to cost-effective analysis as the hospital/insurance/Medicare may save money, but the palliative care team loses money. That is going to be hard to sustain, unless larger support exists from the system for palliative care team (inpatient and outpatient).

Overall this is a great study, which serves as a wonderful resource to palliative care/health systems researchers on how to do future studies. It does not condemn the field to irrelevance as a brief glance at the summary may suggest, and I commend the authors and JAMA for not making the lack of evidence part of the title which could have been grossly misinterpreted. I encourage you to scan the Results section to see how much variability existed in these studies. So to conclude...keep your job, sign up for the boards, get your CHPN, and make sure your administration understands this article is not a swan song for our field, and they better get ready cuz JACHO wants to see more palliative care.
Zimmermann, C., Riechelmann, R., Krzyzanowska, M., Rodin, G., Tannock, I. (2008). Effectiveness of Specialized Palliative Care: A Systematic Review. JAMA: The Journal of the American Medical Association, 299(14), 1698-1709. DOI: 10.1001/jama.299.14.1698

(For those who missed the LOLcat phenomenon of 2007, this is a riff on "I CAN HAS CHEEZBURGER?" I find them pointless and hilarious, my wife just laughs at me for laughing at the pictures.)

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