Health Services Research & Development

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2006 HSR&D National Meeting Abstract


3066 — Case Finding in Palliative Care: Development and Evaluation of a Resident Prognostication Tool

Author List:
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))

Objectives:
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.

Methods:
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.

Results:
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.

Implications:
Resident prognostication is a reasonable method to identify patients at risk of dying in the intermediate term.

Impacts:
Resident prognostication can be a valuable tool to identify patients for additional supportive care services to improve the quality of end-of-life care.