Gaertner Jan, Siemens Waldemar, Meerpohl Joerg J, Antes Gerd, Meffert Cornelia, Xander Carola, Stock Stephanie, Mueller Dirk, Schwarzer Guido, Becker Gerhild
Clinic for Palliative Care, Medical Centre, University of Freiburg, Faculty of Medicine, University of Freiburg, Germany.
Palliative Care Centre Hildegard, Basel, Switzerland.
BMJ. 2017 Jul 4;357:j2925. doi: 10.1136/bmj.j2925.
To assess the effect of specialist palliative care on quality of life and additional outcomes relevant to patients in those with advanced illness. Systematic review with meta-analysis. Medline, Embase, Cochrane Central Register of Controlled Trials, PsycINFO, and trial registers searched up to July 2016. 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). 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). 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. 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. PROSPERO CRD42015020674.
评估专科姑息治疗对晚期疾病患者生活质量及其他相关结局的影响。系统评价与荟萃分析。检索截至2016年7月的Medline、Embase、Cochrane对照试验中央注册库、PsycINFO及试验注册库。纳入在医院、临终关怀机构或社区环境中接受治疗的患有任何晚期疾病的成年住院或门诊患者的随机对照试验。专科姑息治疗的最低要求包括多专业团队方法。两名研究者独立筛选和提取数据，评估偏倚风险（Cochrane偏倚风险工具），并评价证据质量（GRADE工具）。主要结局为生活质量，荟萃分析中以Hedges' g作为标准化均数差（SMD）并采用随机效应模型。此外，生活质量分析的合并SMD在欧洲癌症研究与治疗组织QLQ-C30的总体健康/生活质量量表（分别为第29项和第30项）上重新表达（0-100，分值越高=生活质量越好，最小临床重要差异为8.1）。在3967篇出版物中，纳入12篇（10项随机对照试验，2454例患者随机分组，其中72%（n = 1766）患有癌症）。在任何试验中，均未根据筛查确定的患者需求启动专科姑息治疗的整合。总体而言，专科姑息治疗有小的益处（SMD 0.16，95%置信区间0.01至0.31；QLQ-C30总体健康/生活质量4.1，0.3至8.2；n = 1218，6项试验）。敏感性分析显示SMD为0.57（-0.02至1.15；总体健康/生活质量14.6，-0.5至29.4；n = 1385，7项试验）。对癌症患者的影响略大（0.20，0.01至0.38；总体健康/生活质量5.1，0.3至9.7；n = 828，5项试验），尤其是对那些早期接受专科姑息治疗的患者（0.33，0.05至0.61，总体健康/生活质量8.5，1.3至15.6；n = 388，2项试验）。疼痛及其他次要结局的结果尚无定论。一些方法学问题（如缺乏盲法）降低了证据的强度。专科姑息治疗与生活质量有小的关联，可能对早期接受此类治疗的癌症患者影响最为显著。如果早期提供并通过筛查识别出那些有未满足需求的患者，可能最为有效。国际前瞻性系统评价注册库编号CRD42015020674。
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