|
Does palliative care improve outcomes for patients with HIV/AIDS: a systematic review of the evidence |
Harding R, Karus D, Easterbrook P, Raveis V H, Higginson I J, Marconi K |
|
|
CRD summary The review assessed the effectiveness of palliative care in patients with the human immunodeficiency virus/acquired immune deficiency syndrome. The authors found improvements across a number of domains. However, further studies are needed because of a lack of experimental methods and standardised measures. The authors' cautious conclusion seems to reflect the limited evidence available. Authors' objectives To determine the effectiveness of palliative care in improving outcomes for patients with the human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS). Searching MEDLINE (1980 to 2003), CINAHL (1982 to 2003), PsycINFO (1980 to 2003), EMBASE (1980 to 2003), ASSIA (1987 to 2003) and the Social Sciences Citation Index (1981 to 2003) were searched; the search terms were reported. Only English language publications were included. Study selection Study designs included a randomised controlled trial (RCT), observational studies, longitudinal studies (retrospective, prospective and single group), a retrospective cohort study, a cross-sectional study and qualitative studies. Studies that provided a basic service description and/or evaluation of patient outcomes or patient satisfaction with care were eligible for inclusion, as were studies that incorporated elements of palliative care (e.g. pain and symptom control, psychosocial support, and terminal care) regardless of whether they explicitly used the term. A number of different palliative care services were described, the different service models included: home-based care, home palliative care/hospice at home, hospice in-patient, hospital in-patient palliative care, specialist AIDS in-patient unit, and hospital in-patient and out-patient care with most services including various combinations of care disciplines. The clinical outcomes used in the evaluation of palliative care services varied across the studies. Studies with a minimum of 50% of the study population infected with HIV, or an HIV-infected sub-sample analysed and reported separately, were eligible for inclusion. Where reported, patient eligibility ranged from any stage of HIV disease to only those with an AIDS diagnosis, or advanced or terminal AIDS.
The studies were conducted in the USA, UK, sub-Saharan Africa, Canada, Australia, France, Italy, the Netherlands and Norway. Of the countries that adopted widespread use of highly active antiretroviral therapy (HAART), i.e. all but the sub-Saharan African studies, 18 studies were published pre-HAART and 9 studies published post-HAART.
The authors did not state how the papers were selected for the review, or how many reviewers performed the selection. Assessment of study quality The authors did not assess the validity of the included studies, although the studies were ranked according to a hierarchy of evidence: grade I was the highest level of evidence (RCTs) and grade IV the lowest (cross-sectional study, Delphi exercise or consensus of experts). Data extraction The data were extracted using a standard proforma. The authors did not state how the data were extracted for the review, or how many reviewers performed the data extraction. Methods of synthesis The studies were combined in a narrative, grouped by level of evidence. Differences between the individual studies were described in the table of study characteristics and in the body of the text. A formal meta-analysis was not performed, owing to the absence of both appropriate study designs and standardised outcomes. Results of the review Grade 1 (strong evidence): 1 RCT (n=57) was found. This study of integrated multi-professional home care in AIDS patients found a trend for improvement in quality of well-being and survival over standard home care, although this did not reach statistical significance.
Grade 2 (fairly strong evidence): 2 observational studies were found. One study, which assessed home palliative care in addition to hospital care, found no difference in quality of well-being, although hospital admissions and mean duration of each admission, as well as overall cost, were lower for those receiving home care compared with hospital care alone. The other study, which compared standard hospital in-patient care with hospital in-patient palliative care, found that the latter group were prescribed fewer antiretrovirals and antimicrobial agents, were more likely to have ceased treatment for curable infections, were more likely to have been prescribed 3-step analgesics and had less depression, although a similar level of pain.
Grade 3 (weaker evidence): 7 retrospective/observational studies were found. These studies largely demonstrated that home palliative and in-patient hospice care significantly improved patient outcomes in the domains of pain and symptom control, anxiety, insight and spiritual well-being. A need for improvements in pain and symptom management was indicated even among specialist services.
Grade 4 (weak evidence): 1 cross-sectional study was found. This study, which evaluated HIV home care, found high patient satisfaction with care and personal control over care, and regularity of contact with staff, using a Likert rating scale.
Qualitative (6 studies: focus group data and interviews): the studies reported that patients valued information-giving, support, welfare assistance and specialist clinical referrals, as well as greater dignity, less disturbance of daily routine and fewer hospital visits for home-based care. A small number of patients reported anxiety and fear of being cared for at home, in addition to poor weekend/out-of-hours and primary care communication. For the majority of studies, the number of interviews these results were based upon was not specified in the original studies. Authors' conclusions Although improvements were found across domains, there is a lack of experimental methods and standardised measures. Further studies are needed, particularly in the post-HAART era. CRD commentary The review question was supported by rather broad inclusion criteria, which is reflected in the diversity of studies included in the review in terms of study design, clinical setting, disease stage, outcomes and service/management strategies. Given such differences between the included studies, a narrative synthesis was appropriate. Several sources were searched, but language restrictions applied to the search mean that relevant material might have been missed. The authors did not report review methodology for the study selection or data extraction, thus the possibility of reviewer error or bias at these stages cannot be assessed. In addition, the validity of the included studies was not assessed. The authors' cautious conclusion seems to reflect the limited evidence available. Implications of the review for practice and research Practice: The authors indicated that palliative care should become part of the shift towards earlier intervention and not simply be associated with terminal care. They also stated that palliative care expertise should be part of the multi-professional care team, throughout the disease trajectory.
Research: The authors stated that further studies, using experimental study designs and standardised measures, are needed to identify methods and evaluate the effect of palliative care on patient outcomes in the post-HAART era. The authors also stated that few studies have looked at palliative care throughout the disease trajectory and suggest that longitudinal studies evaluating the benefit of integrated palliative care should be a priority in future research. Bibliographic details Harding R, Karus D, Easterbrook P, Raveis V H, Higginson I J, Marconi K. Does palliative care improve outcomes for patients with HIV/AIDS: a systematic review of the evidence. Sexually Transmitted Infections 2005; 81: 5-14 Indexing Status Subject indexing assigned by NLM MeSH Antiretroviral Therapy, Highly Active; Evidence-Based Medicine; HIV Infections /therapy; Humans; Palliative Care /methods; Treatment Outcome AccessionNumber 12006008401 Date bibliographic record published 14/12/2006 Date abstract record published 03/11/2008 Record Status This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn. |
|
|
|