Quality of care, patient needs and health-care profile in cancer inpatients: prospective observational clinical trial

Abstract

Background: Patients with advanced cancer have reduced quality of life, which tends to worsen towards the end of life. Many patients are hospitalized in the last moths of life and the referral to palliative care occurs late in the trajectory of illness at an average of 30 to 60 days before death or at all. Aim of this study was to analyzed the factors (relating illness, individual characteristics, health-care input and social support) concerning hospitalization, and to evaluate the impact of health services on patient's needs. Patients and methods: This trial included all adult inpatients with a solid tumor of Local Health Authority No.5, Veneto region, between June and November 2014. Demographics, clinical, pathological and health-care variables and reason(s) for hospital admissions were all recorded. Recurrent event survival analysis was used to evaluate the relation of potential predictors to hospital admission and death during hospitalization. Independent prognostic value of increase/decrease of Glasgow Prognostic Score/Glasgow Prognostic Score modified (GPS/mGPS) and the Palliative Prognostic Score (PaP Score) was evaluated. A stratified Cox proportional hazard model was used. Results: Of 150 patients, 39 (26%) died during hospitalization. The main reason of hospital admission was low/absent control of cancer-related symptoms (76%). 71 (47.3%) inpatients were in terminal stage and 135 (90%) had a metastatic illness with a performance status (PS) ≤50 (Karnofsky); overall survival was 69 days (CI95% 46-91). Only 31 (20.6%) inpatients had a palliative home care high intensity. No difference was found for palliative home care high intensity post admission (20.7%). Pain (p = 0.03), dispnoea (p = 0.01), confusion/delirium (p = 0.001), nausea/sickness (p = 0.06), lack of appetite (p = 0.04), PS > 50% (p < 0.0001) or worsening PS (p = 0.001) were all predictors for poor prognosis. Increased PaP Score and GPS/mGPS had independent prognostic value (HR 3.34 95% Cl 2:04 to 5:48, p and lt; 0.0001 and HR 1.37 CI 95% 1.14-1.65, p-0.001, respectively). Conclusions: This trial shows that cancer inpatients are frail patients with advanced disease, poor PS and several unmet needs. Moreover medical staff's prognostication (general practitioners, oncologists and internists) is inaccurate. PaP Score and GPS/ mGPS are simple validated instruments which permit a more accurate quantification of expected survival and therefore may be used in the routine clinical assessment of patients with cancer.