Wednesday, September 9, 2009

PC Trial in JAMA

Well, summer's over, Congress is back in session, the President is talking health care reform tonight, and I feel like some mundane posts on journal articles. I have developed an impressive backlog of things to blog about during my real-life and then blog-only vacation the last few weeks, and it may soon be time for the fall Mag Citrate session, we'll see.

JAMA recently published a trial of a palliative care intervention for advanced cancer patients. It was called the Project Enable II and was a RCT of advanced cancer patients (n=330 which was a 47% participation rate, mean age 65 years and mean Karnofsky 77%, all patients were at two academic centers in Vermont, all within 12 weeks of diagnosis of an advanced solid tumor malignancy - they said with a diagnosis of approximately 1 year although it's unclear how this was determined). They were randomized to either usual care (including ad hoc palliative care referrals, etc.) or a palliative care case management/patient education package, and were followed over time.

The intervention is complex and tough to summarize: it involved telephone symptom assessment, education, counseling, and care coordination (e.g. organizating appropriate referrals) for these patients by a nurse practitioner. There was a heavy self-problem solving element as well (see here - the Charting Your Course handbook halfway down for more details). Phone calls were monthly and lasted 30-40 minutes.

Health related quality of life (via FACIT-Pal) and mood were modestly improved in the intervention group compared to control. Survival (14 vs 8.5 months) and global symptom burden were improved in the treatment group as well - not-statistically significantly however despite the marked difference in median survival. They reported no differences in resource use (days in hospital, ED visits etc.) between groups; rates of enrollment and length of stay in hospice weren't reported.

A few things of note:

  • The trial is important as it represents a trial of early palliative care involvement (from the time of diagnosis, or nearly) - it tries to exemplify the 'concurrent care' model most of us have been trying to move towards a long time now (as opposed to the 'I've got nothing left to offer you' hand-off to palliative care model). And it's gratifying to note that this model provided some modest benefits, and while it will surprise no one who practices palliative care that survival was similar, if not improved with the palliative care intervention, it's been the sort of month in which any non-threatening news about palliative care is welcome (and this is about as non-threatening as it comes; 'we' make people feel better with no impact on anything else including resource utilization). These are the sort of findings which kind of make you want to be a wee bit threatening.
  • But is this palliative care? On the one hand, sure, and it sounds like a worthwhile project which improved the lives of those patients who received it. But this is very different from 'palliative care' as it's actually practiced, in the US, in cancer centers and hospitals (which involves, you know, clinicians seeing patients). The intervention package, as described, is complex and comprehensive enough to make generalization of it (other than if one were to enact the project wholesale) impossible. One also wonders if this falls into the grand, and rapidly expanding category of 'studies which show people feel better if you call them frequently and talk with them about what they're struggling with' (cf here).
  • And so - why JAMA? This is not to denigrate the importance of the paper and study - certainly any well done randomized controlled trial that has anything to do with palliative care is of note for those in the field, but for a general audience? I've been puzzling over this one for a while, as it's been a long time since JAMA published some original palliative-centric research (CWCS is the last I can recall), and certainly a lot of the palliative research that's been put out in Archives the last year would be of equal interest to a general audience (here, here)? And while my lack of imagination should never be assumed to be anything more than that, it's tough for me to see the interest of this for a general audience? PC doesn't do much? PC improves QOL? PC doesn't affect survival? PC doesn't effect resource utilization? An abiding interest amongst the JAMA editors in patient problem solving/self-empowerment interventions?

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