Effectiveness of Integrated Palliative and Oncology Care for Patients With Acute Myeloid Leukemia: A Randomized Clinical Trial.

IMPORTANCE: Patients with acute myeloid leukemia (AML) receiving intensive chemotherapy experience substantial decline in their quality of life (QOL) and mood during their hospitalization for induction chemotherapy and often receive aggressive care at the end of life (EOL). However, the role of specialty palliative care for improving the QOL and care for this population is currently unknown. OBJECTIVE: To assess the effect of integrated palliative and oncology care (IPC) on patient-reported and EOL outcomes in patients with AML. DESIGN, SETTING, AND PARTICIPANTS: We conducted a multisite randomized clinical trial of IPC (n = 86) vs usual care (UC) (n = 74) for patients with AML undergoing intensive chemotherapy. Data were collected from January 2017 through July 2019 at 4 tertiary care academic hospitals in the United States. INTERVENTIONS: Patients assigned to IPC were seen by palliative care clinicians at least twice per week during their initial and subsequent hospitalizations. MAIN OUTCOMES AND MEASURES: Patients completed the 44-item Functional Assessment of Cancer Therapy-Leukemia scale (score range, 0-176) to assess QOL; the 14-item Hospital Anxiety and Depression Scale (HADS), with subscales assessing symptoms of anxiety and depression (score range, 0-21); and the PTSD Checklist-Civilian version to assess posttraumatic stress disorder (PTSD) symptoms (score range, 17-85) at baseline and weeks 2, 4, 12, and 24. The primary end point was QOL at week 2. We used analysis of covariance adjusting and mixed linear effect models to evaluate patient-reported outcomes. We used Fisher exact test to compare patient-reported discussion of EOL care preferences and receipt of chemotherapy in the last 30 days of life. RESULTS: Of 235 eligible patients, 160 (68.1%) were enrolled; of the 160 participants, the median (range) age was 64.4 (19.7-80.1) years, and 64 (40.0%) were women. Compared with those receiving UC, IPC participants reported better QOL (adjusted mean score, 107.59 vs 116.45; P = .04), and lower depression (adjusted mean score, 7.20 vs 5.68; P = .02), anxiety (adjusted mean score, 5.94 vs 4.53; P = .02), and PTSD symptoms (adjusted mean score, 31.69 vs 27.79; P = .01) at week 2. Intervention effects were sustained to week 24 for QOL (ß, 2.35; 95% CI, 0.02-4.68; P = .048), depression (ß, -0.42; 95% CI, -0.82 to -0.02; P = .04), anxiety (ß, -0.38; 95% CI, -0.75 to -0.01; P = .04), and PTSD symptoms (ß, -1.43; 95% CI, -2.34 to -0.54; P = .002). Among patients who died, those receiving IPC were more likely than those receiving UC to report discussing EOL care preferences (21 of 28 [75.0%] vs 12 of 30 [40.0%]; P = .01) and less likely to receive chemotherapy near EOL (15 of 43 [34.9%] vs 27 of 41 [65.9%]; P = .01). CONCLUSIONS AND RELEVANCE: In this randomized clinical trial of patients with AML, IPC led to substantial improvements in QOL, psychological distress, and EOL care. Palliative care should be considered a new standard of care for patients with AML. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02975869.

What matters to patients? A timely question for value-based care.

BACKGROUND: Our healthcare system is moving towards patient-centered and value-based care models that prioritize health outcomes that matter to patients. However, little is known about what aspects of care patients would prioritize when presented with choices of desirable attributes and whether these patient priorities differ based on certain demographics. OBJECTIVE: To assess patients' priorities for a range of attributes in ambulatory care consultations across five key health service delivery domains and determine potential associations between patient priorities and certain demographic profiles. METHODS: Using a What Matters to You survey patients ranked in order of importance various choices related to five health service domains (patient-physician relationship, personal responsibility, test/procedures, medications, and cost). Subjects were selected from two Johns Hopkins affiliated primary care clinics and a third gastroenterology subspecialty clinic over a period of 11 months. We calculated the percentage of respondents who selected each quality as their top 1-3 choice. Univariate and multivariate analyses determined demographic characteristics associated with patient priorities. RESULTS: Humanistic qualities of physicians, leading a healthy lifestyle, shared decision making (SDM) for medications and tests/procedures as well as knowledge about insurance coverage were the most frequently ranked choices. Privately insured and more educated patients were less likely to rank humanistic qualities highly. Those with younger age, higher educational attainment and private insurance had higher odds of ranking healthy lifestyle as a top choice. Those with more education had higher odds of ranking SDM as a top choice. CONCLUSIONS: Identifying what matters most to patients is useful as we move towards patient-centered and Value Based Care Models. Our findings suggest that patients have priorities on qualities they value across key health service domains. Multiple factors including patient demographics can be predictors of these priorities. Elucidating these preferences is a challenging but a valuable step in the right direction.