Comparison of Integrated Outpatient Palliative Care With Standard Care in Patients With Parkinson Disease and Related Disorders: A Randomized Clinical Trial

Abstract

Importance: Parkinson disease and related disorders (PDRD) have consequences for quality of life (QoL) and are the 14th leading cause of death in the United States. Despite growing interest in palliative care (PC) for persons with PDRD, few studies are available supporting its effectiveness.

Objective: To determine if outpatient PC is associated with improvements in patient-centered outcomes compared with standard care among patients with PDRD and their caregivers.

Design, setting, and participants: This randomized clinical trial enrolled participants at 3 academic tertiary care centers between November 1, 2015, and September 30, 2017, and followed them up for 1 year. A total of 584 persons with PDRD were referred to the study. Of those, 351 persons were excluded by phone and 23 were excluded during in-person screenings. Patients were eligible to participate if they had PDRD and moderate to high PC needs. Patients were excluded if they had urgent PC needs, another diagnosis meriting PC, were already receiving PC, or were unable or unwilling to follow the study protocol. Enrolled participants were assigned to receive standard care plus outpatient integrated PC or standard care alone. Data were analyzed between November 1, 2018, and December 9, 2019.

Interventions: Outpatient integrated PC administered by a neurologist, social worker, chaplain, and nurse using PC checklists, with guidance and selective involvement from a palliative medicine specialist. Standard care was provided by a neurologist and a primary care practitioner.

Main outcomes and measures: The primary outcomes were the differences in patient quality of life (QoL; measured by the Quality of Life in Alzheimer Disease scale) and caregiver burden (measured by the Zarit Burden Interview) between the PC intervention and standard care groups at 6 months.

Results: A total of 210 patients with PDRD (135 men [64.3%]; mean [SD] age, 70.1 [8.2] years) and 175 caregivers (128 women [73.1%]; mean [SD] age, 66.1 [11.1] years) were enrolled in the study; 193 participants (91.9%) were white and non-Hispanic. Compared with participants receiving standard care alone at 6 months, participants receiving the PC intervention had better QoL (mean [SD], 0.66 [5.5] improvement vs 0.84 [4.2] worsening; treatment effect estimate, 1.87; 95% CI, 0.47-3.27; P = .009). No significant difference was observed in caregiver burden (mean [SD], 2.3 [5.0] improvement vs 1.2 [5.6] improvement in the standard care group; treatment effect estimate, -1.62; 95% CI, -3.32 to 0.09; P = .06). Other significant differences favoring the PC intervention included nonmotor symptom burden, motor symptom severity, completion of advance directives, caregiver anxiety, and caregiver burden at 12 months. No outcomes favored standard care alone. Secondary analyses suggested that benefits were greater for persons with higher PC needs.

Conclusions and relevance: Outpatient PC is associated with benefits among patients with PDRD compared with standard care alone. This study supports efforts to integrate PC into PDRD care. The lack of diversity and implementation of PC at experienced centers suggests a need for implementation research in other populations and care settings.

Trial registration: ClinicalTrials.gov Identifier: NCT02533921.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Kluger reported receiving grants from the Patient-Centered Outcomes Research Institute during the conduct of the study. Dr Miyasaki reported receiving grants from the Patient-Centered Outcomes Research Institute during the conduct of the study, and receiving grants from Allergan, Merz Pharma, and the University Hospital Foundation and serving as a consultant for GE Pharmaceuticals and Sunovion Pharmaceuticals outside the submitted work. Dr Pantilat reported receiving grants from the Archstone Foundation, the California Health Care Foundation, the Cambia Health Foundation, the Gordon and Betty Moore Foundation, the National Institute of Nursing Research, the Patient-Centered Outcomes Research Institute, the Stupski Foundation, and the UniHealth Foundation during the conduct of the study. Dr Khan reported receiving grants from the Patient-Centered Outcomes Research Institute during the conduct of the study. Dr Friedman reported receiving grants from the Patient-Centered Outcomes Research Institute during the conduct of the study. Dr Sillau reported receiving grants from the Patient-Centered Outcomes Research Institute during the conduct of the study. No other disclosures were reported.

Figures

Figure 1.. CONSORT Patient Flow Diagram

Figure 2.. Patient-Reported and Caregiver-Reported Outcomes

A, Patient-reported outcomes. QoL-AD indicates Quality of Life in Alzheimer Disease Scale. B, Caregiver-reported outcomes. ZBI-12 indicates Zarit Burden Interview 12-item scale. Error bars indicate the SE. aPoints with significant group differences in the primary adjusted model.