Evolution of Complexity of Palliative Care Needs and Patient Profiles According to the PALCOM Scale (Part Two): Pooled Analysis of the Cohorts for the Development and Validation of the PALCOM Scale in Advanced Cancer Patients
Abstract
:Simple Summary
Abstract
1. Introduction
2. Materials and Methods
2.1. Study Site and Period
2.2. PALCOM Scale of the Complexity of Palliative Care Needs
2.3. Study Objectives
2.4. Inclusion Criteria
2.5. Main Outcome Variables
2.6. Descriptive Variables
2.7. Statistical Method
3. Results
3.1. Pooled Analysis of the Two Cohorts
3.2. Evolutionary Behavior of the Levels of Complexity (Table 4)
Low | Medium | High | |||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
N (%) | Instability ratio N (cumulative %) * | Emergency. Mean ±SD ** | Hospital days Mean ±SD * | N (%) | Instability ratio N (cumulative %) * | Emergency. Mean ±SD ** | Hospital days Mean ±SD * | N (%) | Instability ratio N (cumulative %) * | Emergency. Mean ±SD ** | Hospital days Mean ±SD * | p | |
Baseline | 67 (23.7) | 167 (59.9) | 49 (17.3) | ||||||||||
Month 1 | 64 (95.5) | 3 (4.5) | 0.17 ±0.4 | 1.0 ± 3.1 | 153 (91.6) | 14 (8.4) | 0.22 ± 0.4 | 1.5 ± 4.8 | 40 (81.6) | 9 (18.4) | 0.31 ± 0.5 | 2.5 ± 6.7 | * <0.001 ** NSD |
Month 2 | 57 (85.1) | 7 (14.9) | 0.27 ±0.6 | 2.0 ± 5.5 | 118 (70.7) | 35 (29.3) | 0.24 ± 0.5 | 1.9 ± 5.6 | 26 (53.1) | 14 (46.9) | 0.25 ± 0.5 | 1.97 ± 5.8 | * <0.001 ** NSD |
Month 3 | 51 (76.1) | 6 (23.8) | 0.20 ±0.4 | 2.2 ± 5.2 | 90 (53.9) | 28 (46.1) | 0.25 ± 0.5 | 2.0 ± 5.5 | 16 (32.7) | 10 (67.3) | 0.26 ± 0.6 | 2.09 ± 6.6 | * <0.001 ** NSD |
Month 4 | 45 (67.2) | 6 (32.8) | 0.18 ±0.4 | 1.5 ± 4.1 | 71 (42.5) | 19 (57.5) | 0.22 ± 0.4 | 2.1 ± 5.4 | 12 (24.5) | 4 (75.5) | 0.23 ± 0.4 | 4.38 ± 9.5 | * <0.001 ** NSD |
Month 5 | 36 (53.7) | 9 (46.3) | 0.10 ±0.3 | 1.3 ± 5.1 | 67 (40.1) | 4 (59.9) | 0.23 ± 0.5 | 2.0 ± 5.9 | 11 (22.4) | 1 (77.6) | 0.25 ± 0.6 | 2.92 ± 7.9 | * <0.001 ** NSD |
Month 6 | 33 (49.3) | 3 (50.7) | 0.14 ±0.3 | 1.1 ± 2.8 | 53 (31.7) | 14 (68.3) | 0.24 ± 0.5 | 1.2 ± 3.1 | 11 (22.4) | 0 (77.6) | 0.17 ± 0.4 | 5.25 ± 10.6 | * <0.001 ** NSD |
Overall 6 months | 34 (50.7) | 0.2 ±0.3 | 1.5 ± 4.0 | 114 (68.3) | 0.2 ± 0.5 | 1.8 ± 5.0 | 38 (77.6) | 0.25 ± 0.5 | 3.2 ± 7.8 | * <0.001 ** NSD |
3.2.1. Instability Ratio (IR) According to the Level of PALCOM Complexity
3.2.2. Indicators of Resource Consumption according to the PALCOM Level of Complexity
3.2.3. Survival according to the PALCOM Level of Complexity
3.3. Profiles of PALCOM Complexity
3.3.1. Profile of Low Complexity
3.3.2. Profile of Medium Complexity
3.3.3. Profile of High Complexity:
4. Discussion
Study Limitations
5. Conclusions
5.1. Practical Implications
5.2. Implications for Investigation
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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First, surprise question: Would I be surprised if this patient died in the next 12 months? If the answer is no, the PALCOM scale can help you determine the level of complexity of palliative care needs and manage the intensity of specialist palliative care team intervention in a model of early shared care. | |
Second, explore PALCOM domains: The level of palliative complexity can be categorized by assessing the following five domains. | |
Domain 1: Symptom burden | Is a high symptom burden detected? Assess at least the following chronic symptoms: pain; anorexia; weakness; nausea-vomiting; constipation; dyspnoea or cough; insomnia; drowsiness; anxiety; sadness; others.A high symptom burden is considered to exist if the patient experiences ≥5 of these or other chronic symptoms with an intensity of at least moderate on a categorical scale, or ≥4 on a numerical or visual analogue scale of 10 points. |
Domain 2: Markers of difficult pain | Are there any markers of difficult pain control? Any of the following conditions can cause potentially difficult pain: neuropathic pain; mixed pain (nociceptive and neuropathic); breakthrough cancer pain; pain associated with a history of alcohol or other substance abuse, or cognitive impairment or severe emotional distress. |
Domain 3: Functional status | Is there functional impairment? Patients who require significant assistance with activities of daily living. (e.g., Barthel Index ≤60 or Karnofsky Index ≤50–60%) |
Domain 4: Socio-familial risk | Any socio-familial risk factors? Any of the following conditions may be considered a socio-family risk factor: absence of identified caregiver; caregiver limitations due to advanced age, health problems, or socio-family or economic burdens; minors or more than one member of the nuclear family who needs support; risk of severe family burnout; other complexity situations (social vulnerability, poverty, domestic violence, addiction of abuse substances, etc.) |
Domain 5: Spiritual/existential/ethic problems | Any ethical or existential conflict? Any of the following conditions may be considered: conflicts related to information (denial, conspiracy silence, ...); healthcare team disagreement; disagreement between patient/family and healthcare team; loss of meaning in life or existential distress; spiritual distress; desire to advance death, demand for euthanasia or assisted suicide; others. |
Third, scoring: Each of these five domains is scored dichotomously (0 for the absence and 1 for the presence of any variable in each domain). The sum of the scores between 0 and 5 is the total score of the PALCOM scale. | |
Fourth, determine the level of palliative complexity according to the observed score:
|
Development Cohort | Validation Cohort | PALCOM Pooled Data | |||
---|---|---|---|---|---|
N (%) | N (%) | p | N (%) | ||
Total | 324 | 283 | 607 | ||
Gender | Male | 189 (58.0) | 161 (56.9) | 0.280 | 350 (57.7) |
Age | (mean ± SD *) | 69 (SD ± 59–80) | 71 (SD ± 59–81) | 0.320 | 70 SD ± 59–80 |
Primary origin | |||||
Lung | 71 (21.9) | 64 (24.4) | 0.310 | 140 (23.1) | |
Colon | 38 (11.7) | 56 (19.8) | 0.290 | 94 (15.5) | |
Pancreas | 28 (8.6) | 18 (6.4) | 0.270 | 46 (7.6) | |
Breast | 22 (6.8) | 19 (6.7) | 0.190 | 41 (6.8) | |
Prostate | 18 (5.5) | 28 (9.9) | 0.210 | 46 (7.6) | |
Others | 146 (45.1) | 93 (32.8) | 0.300 | 239 (39.4) | |
Symptom prevalence | |||||
Asthenia | 299 (92.2) | 269 (95.1) | 0.210 | 568 (93.6) | |
Anorexia | 253 (78.1) | 226 (79.9) | 0.079 | 479 (78.9) | |
Pain | 245 (75.6) | 245 (86.6) | 0.100 | 490 (80.7) | |
Nausea | 110 (34.0) | 68 (24.0) | 0.080 | 178 (29.3) | |
Constipation | 202 (62.3) | 162 (57.2) | 0.110 | 364 (59.9) | |
Dyspnoea | 149 (45.9) | 111 (39.2) | 0.220 | 260 (42.8) | |
Insomnia | 191 (58.9) | 177 (62.5) | 0.180 | 368 (60.6) | |
Anxiety | 238 (73.4) | 184 (65.0) | 0.090 | 422 (69.5) | |
Sadness | 225 (69.4) | 196 (69.3) | 0.220 | 421 (69.4) | |
PALCOM domains | |||||
High symptom burden | 134 (41.3) | 136 (48.1) | 0.190 | 270 (44.5) | |
Refractory pain | 175 (54.0) | 166 (58.5) | 0.220 | 341 (56.2) | |
Karnoksky index ≤ 60% | 129 (39.9) | 135 (47.5) | 0.210 | 264 (43.5) | |
Socio-familial risk | 221 (68.3) | 184 (64.8) | 0.420 | 405 (66.7) | |
Existential/ethical conflicts | 59 (18.3) | 67 (23.6) | 0.080 | 126 (20.7) | |
PALCOM scale level | |||||
Low | 51 (15.8) | 67 (23.7) | 0.080 | 118 (19.5) | |
Medium | 139 (43.0) | 167 (59.9) | 0.780 | 306 (50.5) | |
High | 133 (41.2) | 49 (17.3) | 0.060 | 182 (30.0) |
Development Cohort | Validation Cohort | Pooled Data | |||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
N (%) | 324 (53.4% of polled data) | 283 (46.6% of polled data) | 607 | ||||||||||
Hospital inclusion | 180 (55.6) | 175 (61.8) | 355 (58.5) | ||||||||||
Community inclusion | 144 (44.4) | 108 (38.2) | 252 (41.5) | ||||||||||
Low | Medium | High | Low | Medium | High | Low | Medium | High | |||||
51 (15.8) | 139 (43.0) | 133 (41.2) | 67 (23.7) | 167 (59.9) | 49 (17.3) | 118 (19.5) | 306 (50.5) | 182 (30.0) | |||||
PALCOM domains | p | p | p | ||||||||||
High symptom burden | 20 (39.2) | 99 (71.2) | 115 (86.5) | <0.001 | 6 (8.9) | 83 (49.7) | 47 (95.5) | <0.001 | 26 (22.0) | 182 (59.4) | 162 (89.0) | <0.001 | |
Refractory pain | 13 (25.5) | 69 (49.6) | 93 (69.9) | <0.001 | 30 (45.7) | 93 (55.4) | 43 (87.8) | <0.001 | 43 (36.4) | 162 (52.9) | 136 (74.7) | <0.001 | |
Karnofsky index <60% | 17 (33.3) | 53 (38.1) | 59 (44.4) | <0.001 | 4 (5.9) | 90 (53.6) | 41 (83.7) | <0.001 | 21 (17.8) | 143 (46.7) | 100 (54.9) | <0.001 | |
Socio-familial risk | 33 (64.7) | 81 (58.3) | 107 (80.5) | 0.055 | 13 (19.4) | 126 (75.0) | 45 (91.8) | <0.001 | 46 (42.5) | 207 (67.6) | 152 (83.5) | <0.001 | |
Existential/ethical conflicts | 1 (2.0) | 25 (18.0) | 33 (24.8) | <0.001 | 4 (5.9) | 34 (20.2) | 29 (59.2) | <0.001 | 5 (4.2) | 59 (19.5) | 56 (30.8) | <0.001 | |
Death within 6 months | 18 (35.3) | 77 (55.4) | 99 (74.3) | <0.001 | 33 (49.2) | 114 (68.3) | 38 (77.6) | <0.001 | 51 (43.2) | 190 (62.7) | 138 (75.8) | <0.001 | |
Hospital death | 3 (5.9) | 24 (17.3) | 40 (30.1) | <0.001 | 6 (8.9) | 25 (22.1) | 12 (30.8) | <0.001 | 9 (7.6) | 49 (16.0) | 52 (28.6) | <0.001 |
Level | Characteristics |
---|---|
Low | Involvement of 0 or 1 domains on the PALCOM scale. Low likelihood of radical change in baseline conditions in the first 3 months, at least moderate in next months. Frequency of emergency department visits similar to other levels (cancer complications or treatment toxicity). Need for hospitalization significantly lower than other levelsSurvival significantly higher than other levels. |
| |
Medium | Involvement of 2–3 domains on the PALCOM scale. Low-moderate likelihood of radical change in baseline conditions in the first 3 months, at moderate-high in next months. Frequency of emergency department visits similar to other levels (cancer complications or treatment toxicity). Need for hospitalization significantly higher than low complexity level. Survival significantly lower than low complexity level. |
| |
High | Involvement of 4–5 domains on the PALCOM scale. At least moderate likelihood of radical change in baseline conditions in the first weeks, at very high since second month of follow-up. Frequency of emergency department visits similar to other levels (cancer complications or treatment toxicity). Need for hospitalization significantly higher than other levels Survival significantly lower than other levels. |
|
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© 2024 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
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Tuca, A.; Viladot, M.; Carrera, G.; Llavata, L.; Barrera, C.; Chicote, M.; Marco-Hernández, J.; Padrosa, J.; Zamora-Martínez, C.; Grafia, I.; et al. Evolution of Complexity of Palliative Care Needs and Patient Profiles According to the PALCOM Scale (Part Two): Pooled Analysis of the Cohorts for the Development and Validation of the PALCOM Scale in Advanced Cancer Patients. Cancers 2024, 16, 1744. https://doi.org/10.3390/cancers16091744
Tuca A, Viladot M, Carrera G, Llavata L, Barrera C, Chicote M, Marco-Hernández J, Padrosa J, Zamora-Martínez C, Grafia I, et al. Evolution of Complexity of Palliative Care Needs and Patient Profiles According to the PALCOM Scale (Part Two): Pooled Analysis of the Cohorts for the Development and Validation of the PALCOM Scale in Advanced Cancer Patients. Cancers. 2024; 16(9):1744. https://doi.org/10.3390/cancers16091744
Chicago/Turabian StyleTuca, Albert, Margarita Viladot, Gemma Carrera, Lucia Llavata, Carmen Barrera, Manoli Chicote, Javier Marco-Hernández, Joan Padrosa, Carles Zamora-Martínez, Ignacio Grafia, and et al. 2024. "Evolution of Complexity of Palliative Care Needs and Patient Profiles According to the PALCOM Scale (Part Two): Pooled Analysis of the Cohorts for the Development and Validation of the PALCOM Scale in Advanced Cancer Patients" Cancers 16, no. 9: 1744. https://doi.org/10.3390/cancers16091744