2006 HSR&D National Meeting Abstract
3066 — Case Finding in Palliative Care: Development and Evaluation of a Resident Prognostication Tool
Steckart MJ (Palliative Care Program, Veterans Administration Greater Los Angeles Healthcare System (VA-GLAHS))
Sverdlik AF (Palliative Care Program, Veterans Administration Greater Los Angeles Healthcare System (VA-GLAHS))
Riopelle DD (Research & Development Service, VA Greater Los Angeles Healthcare System)
Wagner GJ (Health, RAND Corporation)
Rosenfeld KE (Palliative Care Program, Veterans Administration Greater Los Angeles Healthcare System (VA-GLAHS))
Improving end-of-life care is of critical importance to the VA as it faces an increasingly aging and dying veteran population. Currently only a minority of patients with palliative needs receive palliative services,
partly due to the difficulty of identifying patients appropriately early in the course of an ultimately-fatal illness. Although various methods for patient identification have been proposed, none has been rigorously, prospectively tested for accuracy. The purpose of this study was to evaluate a tool utilizing medical resident prognostication to identify patients at high risk of dying, who might benefit from additional palliative services.
A prognosis rating scale was implemented to assign one-year mortality risk for patients admitted to the General Medicine inpatient service. Residents estimated one-year mortality on a 6-point scale ranging from 0 (“minimal” / < 5 percent) to 5 (“terminal” / > 75 percent). Primary diagnoses were also collected for those patients with a greater than 25 percent mortality risk. One-year survival data was tabulated and an accuracy scoring system applied to measure resident accuracy based on prognostic category and diagnosis.
Prognostic data was collected on 1055 of 1120 admissions (94%) over 158 admission days. At one year follow-up, overall survival was 71%. Actual one-year mortality based on prognostic category showed that 9% (n=173) of patients rated as having a minimal risk of death (ROD) were deceased; 18% (n=329) of patients with low ROD were deceased; 29% (n=194) of patients with moderate ROD were deceased; 39% (n=139) of patients with high ROD were deceased; 44% of patients rated as having a very high ROD were deceased; and 61% (n=98) of patients rated as terminal were dead at one year follow-up. Prognostic estimates for cancer diagnoses were found to be more accurate than for non-cancer diagnostic categories.
Resident prognostication is a reasonable method to identify patients at risk of dying in the intermediate term.
Resident prognostication can be a valuable tool to identify patients for additional supportive care services to improve the quality of end-of-life care.