El valor del Instrumento Diagnóstico de la Complejidad en Cuidados Paliativos para identificar la complejidad en pacientes tributarios de cuidados paliativos / The value of the Diagnostic Tool for Complexity in Palliative Care for the assessment of palliative patients

INTRODUCCIÓN: Actualmente no existe una definición unánime en cuidados paliativos (CP) del término complejidad. Su correcta y objetiva valoración ayudaría a clasificar al paciente, permitiendo a los profesionales saber si se requieren recursos avanzados o convencionales de CP. OBJETIVOS: Describir la complejidad de los pacientes tributarios de CP en Sevilla mediante el Instrumento Diagnóstico de la Complejidad en Cuidados Paliativos examinando el servicio sanitario prestado. MATERIAL Y MÉTODOS: Estudio observacional descriptivo transversal, con reclutamiento prospectivo. La herramienta Instrumento Diagnóstico de la Complejidad en Cuidados Paliativos se aplicó a 74 pacientes tributarios de CP. Los datos se analizaron con el programa estadístico SSPS versión 20 y se analizaron las variables con el test chi-cuadrado. RESULTADOS: Tanto el equipo de recursos convencionales como el avanzado de CP tratan a pacientes independientemente de su complejidad (p = 0,482). El elemento de complejidad más prevalente fue el cambio brusco del nivel de autonomía funcional (n=27), sin que exista correlación con el equipo implicado. El elemento más prevalente para activar el equipo avanzado de CP es la naturaleza oncológica de la enfermedad (n=39; p = 0,018). CONCLUSIONES: La distribución de la complejidad en los pacientes tratados por recursos convencionales y avanzados de CP en el área estudiada es homogénea. Ello puede ser un indicador de la falta de adecuación de los recursos sanitarios con respecto a la complejidad del paciente. La implementación del Instrumento Diagnóstico de la Complejidad en Cuidados Paliativos podría solventar este problema ya que ayuda a especificar cuándo y por qué se deriva un paciente a CP, evitando el exceso o defecto de dicha derivaciones

INTRODUCTION: There is currently no unanimous definition of the term complexity in palliative care (PC). The correct and objective assessment would help to classify palliative patients to enable health care professionals in their determination whether advanced or conventional PC resources are required. AIM: To describe the palliative patients' complexity, by using the Diagnostic Tool for Complexity in Palliative Care, and to examine the health care service provided. MATERIAL AND METHODS: A descriptive, cross-sectional, observational study with prospective recruiting was conducted by applying the Diagnostic Tool for Complexity in Palliative Care to 74 patients requiring PC in Seville, Spain. Data were analyzed using the statistical program SPSS version 20 and variables were analyzed using the chi-squared test. RESULTS: Both conventional and advanced PC teams treat patients regardless their degree of complexity (p= 0.482). The most prevalent complexity element was sudden change in the level of functional autonomy (n= 27), but there was no correlation with the team involved. The most prevalent element to drive involvement of the advanced PC team was the oncological nature of the disease (n= 39, p= 0.018). CONCLUSIONS: The distribution of complexity in PC patients treated by both conventional and advanced PC teams in the study area is homogeneous. This may be an indicator of the lack of appropriate health care resources as regards the complexity of the patient. Implementing the Diagnostic Tool for Complexity in Palliative Care may solve this problem by specifying when and why a PC patient is referred, and thus avoiding the excess or absence of such referrals

Precisión de los criterios definitorios de pacientes con enfermedades médicas no neoplásicas en fase terminal. Proyecto PALIAR / Reliability of different criteria in identifying end-of-life trajectory of patients with chronic medical diseases. PALIAR Project

Introducción. Existe incertidumbre para identificar adecuadamente la trayectoria del final de la vida en pacientes con enfermedades médicas crónicas en fases avanzadas, hecho que dificulta en muchos casos la planificación de servicios y el proceso de transición, de unos objetivos de supervivencia a unos terapéuticos de calidad de vida. Objetivos. Evaluar la sensibilidad, especificidad, valores predictivos positivo y negativo, e índice de validez de los criterios de enfermedad médica terminal del National Hospice Organization estadounidense, la Palliative Prognostic Index y la Eastern Cooperative Oncology Group (ECOG) en pacientes con enfermedades cardíacas, neumológicas, hepáticas, renales y/o neurológicas en estadío avanzado; y construir-validar un índice específico para determinar con mayor certidumbre esta frontera. Métodos. Estudio de cohortes prospectivas multicéntrico con inclusión de pacientes con criterios predefinidos de enfermedad avanzada en órganos comentados. Recogida de datos demográficos, clínico-asistenciales, de estratificación y estadiaje de enfermedad(es), funcionales, analíticos, criterios de la National Hospice Organization, ECOG, valores predictivos positivos y Palliative Prognostic Index; y de la variable final (fallecimiento) a los 180 días de la inclusión. Análisis de sensibilidad, especifidad, valores predictivos positivos, negativos e índice de validez de los criterios de la National Hospice Organization, escala ECOG y Palliative Prognostic Index a los 30, 60, 90, 120, 150 y 180 días. Derivación, si procede, del indice PALIAR, tras análisis multivariante y ponderación de los factores de riesgo (beta del f. riesgo/beta menor del modelo) y posterior validación en cohorte de validación y cohorte histórica PROFUND...(AU)

Introduction. It is a challenge to reliably identify the end-of-life trajectory in patients with advanced-stage chronic medical conditions. This makes advanced supportive care planning and transition from survival to comfort objectives more difficult in these emergent patient populations. Objectives. To evaluate the sensitivity (Se), specificity (Sp), positive predictive values (PPV) and negative (NPV), and validity index (IV) of NHO criteria for terminal medical conditions, PPI and ECOG in patients with advanced heart, lung, liver, kidney and/or neurological diseases, and to build and validate an accurate index to determine this border-line. Methods. A multicentre prospective cohort study, with inclusion of patients with the predefined advanced medical diseases. Demographic, clinical, care, stratification and staging of disease(s), functional, analytical, NHO criteria, ECOG, PPS and PPI data collection; The end-point (death) will be assessed 180 days after inclusion. Analysis of Se, Sp, PPV, NPV, and IV of the NHO criteria, ECOG scale and PPI at 30, 60, 90, 120, 150 and 180 days. Derivation of PALIAR Index, after multivariate analysis and appropriate weighting of risk factors (beta of risk factor/lowest beta of the model), and validation in the validation cohort, and in the historical PROFUND cohort. Results. The project is still ongoing, with 50 investigators from 33 hospitals throughout Spain, who have already included 1138 patients (92.5% during hospital admissions, 51.4% of them are male, with a mean age of 78.5 years). Mean inclusion chronic diseases were 1.4 per patient (44.5% of patients suffered chronic neurological diseases, 38.6% with heart failure, 34.2% with lung diseases, 12% with liver diseases, and 6.5% with renal diseases)...(AU)

[Reliability of different criteria in identifying end-of-life trajectory of patients with chronic medical diseases. PALIAR Project]. / Precisión de los criterios definitorios de pacientes con enfermedades médicas no neoplásicas en fase terminal. Proyecto PALIAR.

INTRODUCTION: It is a challenge to reliably identify the end-of-life trajectory in patients with advanced-stage chronic medical conditions. This makes advanced supportive care planning and transition from survival to comfort objectives more difficult in these emergent patient populations. OBJECTIVES: To evaluate the sensitivity (Se), specificity (Sp), positive predictive values (PPV) and negative (NPV), and validity index (IV) of NHO criteria for terminal medical conditions, PPI and ECOG in patients with advanced heart, lung, liver, kidney and/or neurological diseases, and to build and validate an accurate index to determine this border-line. METHODS: A multicentre prospective cohort study, with inclusion of patients with the predefined advanced medical diseases. Demographic, clinical, care, stratification and staging of disease(s), functional, analytical, NHO criteria, ECOG, PPS and PPI data collection; The end-point (death) will be assessed 180 days after inclusion. Analysis of Se, Sp, PPV, NPV, and IV of the NHO criteria, ECOG scale and PPI at 30, 60, 90, 120, 150 and 180 days. Derivation of PALIAR Index, after multivariate analysis and appropriate weighting of risk factors (beta of risk factor/lowest beta of the model), and validation in the validation cohort, and in the historical PROFUND cohort. RESULTS: The project is still ongoing, with 50 investigators from 33 hospitals throughout Spain, who have already included 1138 patients (92.5% during hospital admissions, 51.4% of them are male, with a mean age of 78.5 years). Mean inclusion chronic diseases were 1.4 per patient (44.5% of patients suffered chronic neurological diseases, 38.6% with heart failure, 34.2% with lung diseases, 12% with liver diseases, and 6.5% with renal diseases). Around 69% fulfilled the criteria of polypathological patients (mean Charlson index 3.4), and were prescribed around 8 drugs chronically. Mean Barthel index was 40 points, and 77% of them were dependent on a caregiver. Around 46% were ECOG-PS stage III or IV, and mean PPS score was 45 points. CONCLUSION: The availability of an accurate and powerful tool that could enable us to identify the end-of-life trajectory of these patients could allow us to establish specific intervention strategies for these populations. Therefore, and with these preliminary data, we believe that the PALIAR PROJECT will answer with rigour the questions and objectives of the study.