Effect of Inpatient Palliative Care on Quality of Life 2 Weeks After Hematopoietic Stem Cell Transplantation
Authors: Areej El-Jawahri, Thomas LeBlanc, Harry VanDusen, Lara Traeger, Joseph A. Greer, William F. Pirl, Vicki A. Jackson, Jason Telles, Alison Rhodes, Thomas R. Spitzer, Steven McAfee, Yi-Bin A. Chen, Stephanie S. Lee, Jennifer S. Temel
Journal: JAMA (2016)

<h3>Importance</h3> During hospitalization for hematopoietic stem cell transplantation (HCT), patients receive high-dose chemotherapy before transplantation and experience significant physical and psychological symptoms and poor quality of life (QOL). <h3>Objective</h3> To assess the effect of inpatient palliative care on patient- and caregiver-reported outcomes during hospitalization for HCT and 3 months after transplantation. <h3>Design, Setting, and Participants</h3> Nonblinded randomized clinical trial among 160 adults with hematologic malignancies undergoing autologous/allogeneic HCT and their caregivers (n = 94). The study was conducted from August 2014 to January 2016 in a Boston hospital; follow-up was completed in May 2016. <h3>Interventions</h3> Patients assigned to the intervention (n=81) were seen by palliative care clinicians at least twice a week during HCT hospitalization; the palliative intervention was focused on management of physical and psychological symptoms. Patients assigned to standard transplant care (n=79) could be seen by palliative care clinicians on request. <h3>Main Outcomes and Measures</h3> Primary: change in patient QOL from baseline to week 2; secondary: patient-assessed mood, fatigue, and symptom burden scores at baseline, 2 weeks, and 3 months after HCT and caregiver-assessed QOL and mood at baseline and 2 weeks after HCT. <h3>Results</h3> Among 160 enrolled patients (mean age, 60 [SD, 13.3] years; 91 women [56.9%]; median hospital stay, 21 days) and 94 caregivers, 157 (98.1%) and 89 (94.7%), respectively, completed 2-week follow-up, and 149 patients (93.1%) completed 3-month follow-up. Patients in the intervention group reported a smaller decrease in QOL from baseline to week 2 (mean baseline score, 110.26; week 2 score, 95.46; mean change, −14.72) compared with patients in the control group (mean baseline score, 106.83; week 2 score, 85.42; mean change, −21.54; difference between groups, −6.82; 95% CI, −13.48 to −0.16;<i>P</i> = .045). Among the secondary outcomes, from baseline to week 2, patients in the intervention group vs those in the control group had less increase in depression (mean, 2.43 vs 3.94; mean difference, 1.52; 95% CI, 0.23-2.81;<i>P</i> = .02), lower anxiety (mean, −0.80 vs 1.12; mean difference, 1.92; 95% CI, 0.83-3.01;<i>P</i> &lt; .001), no difference in fatigue (mean, −10.30 vs −13.65; mean difference, −3.34; 95% CI, −7.25 to 0.56;<i>P</i> = .09), and less increase in symptom burden (mean, 17.35 vs 23.14; mean difference, 5.80; 95% CI, 0.49-11.10;<i>P</i> = .03). At 3 months after HCT, intervention patients vs control patients had higher QOL scores (mean, 112.00 vs 106.66; mean difference, 5.34; 95% CI, 0.04-10.65;<i>P</i> = .048) and less depression symptoms (mean, 3.49 vs 5.19; mean difference, −1.70; 95% CI, −2.75 to −0.65;<i>P</i> = .002) but no significant differences in anxiety, fatigue, or symptom burden. From baseline to week 2 after HCT, caregivers of patients in the intervention group vs caregivers of patients in the control group reported no significant differences in QOL or anxiety but had a smaller increase in depression (mean, 0.25 vs 1.80; mean difference, 1.55; 95% CI, 0.14-2.96;<i>P</i> = .03). <h3>Conclusions and Relevance</h3> Among adults at a single institution undergoing HCT for hematologic malignancy, the use of inpatient palliative care compared with standard transplant care resulted in a smaller decrease in QOL 2 weeks after transplantation. Further research is needed for replication and to assess longer-term outcomes and cost implications. <h3>Trial Registration</h3> clinicaltrials.gov Identifier:NCT02207322