Development of Prognosis in Palliative care Study (PiPS) predictor models to improve prognostication in advanced cancer: prospective cohort study

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Background The Prognosis in Palliative care Scale (PiPS) predicts survival in advanced cancer patients more accurately than a doctor's or a nurse's estimate. PiPS scores are derived using observer ratings of symptom severity and performance status. The purpose of this study was to determine whether patient-rated data would provide better prognostic estimates than clinician observer ratings. Patients and methods 1018 subjects with advanced cancer no longer undergoing tumour-directed therapy were recruited to a multi-centre study. Prognostic models were developed using observer ratings, patient ratings or a composite method that used patient ratings when available or else used observer ratings. The performance of the prognostic models was compared by determining the agreement between the models' predictions and the survival of study participants. Results All three approaches to model development resulted in prognostic scores that were able to differentiate between patients with a survival of 'days', 'weeks' or 'months+'. However, the observer-rated models were signifi cantly (p<0.05) more accurate than the patient-rated models. Conclusions A prognostic model derived using observer-rated data was more accurate at predicting survival than a similar model derived using patient selfreport measures. This is clinically important because patient-rated data can be burdensome and diffi cult to obtain in patients with terminal illnesses.

Section: Discussioncontrasting

confidence: 46%

“…A detailed report of the methods used in the PiPS study has been published elsewhere 3. Briefly, consecutive referrals to participating palliative care units were screened for inclusion.…”

Section: Methodsmentioning

confidence: 99%

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Patients' reports or clinicians' assessments: which are better for prognosticating?

Stone

Gwilliam

Keeley

et al. 2012

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“…The Prognosis in Palliative care Study (PiPS) was a large multicentre observational study to develop a novel prognostic indicator for use with patients with advanced cancer 9. As we were aware that many previous studies in palliative care populations had failed to recruit the intended sample size, we prospectively collected information on difficulties that we anticipated encountering in patient accrual.…”

Section: Introductionmentioning

confidence: 99%

Factors affecting recruitment to an observational multicentre palliative care study

Stone

Gwilliam

Keeley

et al. 2013

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ObjectivesTo identify those factors which adversely affected recruitment to a large multicentre palliative care study.MethodsPatient accrual to a multicentre, observational, palliative care study was monitored at three critical junctures in the research process. (1) Eligibility—did the patient fulfil the study entry criteria? (2) Accessibility—was it possible to access the patient to be able to inform them about the study? (3) Consent—did the patient agree to participate in the study? The reasons why patients were ineligible, inaccessible or refused consent were recorded.Results12 412 consecutive referrals to participating clinical services were screened for study inclusion of whom 5394 (43%) were deemed to be ineligible. Of the remaining patients 4617/7018 (66%) were inaccessible to the research team. The most common reasons being precipitous death, ‘gatekeeping’ by clinical staff or rapid discharge. Of the 2410 patients who were visited by the research team and asked to participate in the study 1378 (57%) declined. Overall 8.2% (1018/12 412) of patients screened participated in the study. There were significant differences in recruitment patterns between hospice inpatient units, hospital support and community palliative care teams.ConclusionsSystematic monitoring and analysis of patient flows through the clinical trial accrual process provided valuable insights about the reasons for failure to recruit patients to a clinical trial and may help to improve recruitment in future studies.

“…Understanding and communicating margins of uncertainty—the range and probability of future events including survival time and death—is the most important factual information we can give to patients who want it. Examination of survival data within our palliative care services is the richest source of information on this subject and we should use it 19. A probabilistic approach to describing the future, including estimates of survival, is the only way to convey, using hard data, the very real and unsurprising risk of sudden deterioration or death in our patients.…”

Section: Deconstructing Our Methodsmentioning

confidence: 99%

A clinical method for physicians in palliative care: the four points of agreement vital to a consultation; context, issues, story, plan

Noble

George

Vedder

2013

In palliative care, where interactions cross clinical, pathological, psychological, social and spiritual considerations, it may be useful to take a minimal approach and avoid an overcomplicated or formulaic structure for the consultation. We will concern ourselves with points in the encounter where doctor and patient with or without family or carers need to be in agreement. Whether a consultation is based on a structured interview, a cue-based assessment or a narrative approach, the points of agreement or concordance need to cover four key areas; missing any of these has grave consequences for the clinical relationship. Without concordance, patients may be right to conclude that you don't know why you're all there (context), you don't know what's the matter (issues), you don't know what's going on (story) or you don't know what you're doing (plan). These four elements may serve also as a guide to the quality and effectiveness of an encounter among a doctor, patient and carers. We consider how this clinical method might integrate the nosological practices of doctors in palliative care services better, and we argue that finding concordance is likely to establish a better doctor-patient relationship at a human and professional level through empathy and trust rather than just a technical exchange.