Identification of In-hospital Patients in Need of Palliative Care Using a New Simplified Screening Tool (SST2017)

Accuracy of a New Simplified Screening Tool in Identifying the In-hospital Patients in Need of Palliative Care

Every day many patients affected by chronic life-limiting illnesses are admitted into Internal Medicine wards, coming from the Emergency Department. Many studies suggest that providing palliative care to these patients may improve their end-of-life care while reducing costs by minimizing futile treatments and unwanted intensive care unit admissions. Consequently, there is a strong need for acute care hospitals to more vigorously identify patients entering the final phase of their lives as well as their specific care needs.

In a previous study the investigators screened for need of palliative care patients affected by progressive chronic diseases by means of a tool, based on the Italian Society of Anesthesia, Analgesia, Resuscitation, and Intensive Care - SIAARTI - position paper reporting criteria for patients with end-stage chronic organ failures, and on the specific clinical indicators elaborated by the National Comprehensive Cancer Network (NCCN) for patients with locally advanced/metastatic cancer. In a further pilot study, the investigators compared the outcomes of PC patients depending on whether the palliative care team evaluated such patients only if requested by the physician staff or routinely, irrespectively of a specific request, finding a significant increase of discharges after the activation of an appropriate PC service or scheduled PC ambulatory visit.

In the present study the investigators enroll chronically ill patients admitted to an Internal Medicine Unit from the Emergency Department, to be screened for palliative care need, using the previously cited SIAARTI/NCCN screening tool (Extended Screening Tool - EST), or using a Simplified Screening Tool (SST), derived from the first instrument, which preliminary showed a superimposable efficacy. This latter tool has advantages related to much more shortness and therefore simplicity in the administration to a seriously ill patient and is much less time consuming, allowing the physician to use it routinely.

The aim of the study is to verify the accuracy of the SST in identifying chronically ill patients in need of a PC approach, in comparison to the SIAARTI/NCCN tool (EST). If the SST would show good accuracy, an easily manageable tool for the assessment of PC needs in chronically ill patients would be available for the daily routine.

Study Overview

• Status: Completed
• Conditions: Chronic Heart Failure; Metastatic Cancer; Chronic Respiratory Failure; Chronic Liver Failure; Chronic Renal Failure; Locally Advanced Cancer
• Intervention / Treatment: Other: Screening for PC by means of two different screening tools

Detailed Description

Due to population aging and advances in medicine and public health, the prevalence of people affected by progressive, chronic, life-limiting diseases is increasing. Many studies documented that patients with progressive chronic diseases received care that was more aimed at the prolongation of life than palliation of symptoms during their last 6-12 months of life, as well as frequent hospitalizations. These data suggested that providing palliative care (PC) to these patients may improve their end-of-life care while reducing costs by minimizing futile treatments and unwanted ICU care.

Consequently, there is a strong need for acute care hospitals to more vigorously identify patients entering the final phase of their lives as well as their specific care needs.

Historically, Hospice and PC services have focused on the needs of cancer patients. However, the majority of patients needing PC worldwide suffer from life-limiting non-cancer illnesses, like cardiovascular diseases, chronic obstructive pulmonary disease (COPD), renal failure, cirrhosis of the liver, Alzheimer's and other dementias, multiple sclerosis, Parkinson's disease, HIV/AIDS, rheumatoid arthritis, and diabetes. The main illnesses requiring PC are cardiovascular diseases (38%), cancer (34%), and COPD (10%).

In order to correctly identify such patients, adequate screening tools are needed.

In a previous study, the investigators employed for this aim a screening tool derived from the Italian Society of Anesthesia, Analgesia, Resuscitation, and Intensive Care (SIAARTI) position paper based on expert panel opinions reporting criteria to identify patients with end-stage chronic organ failures. For cancer patients, the screening was done according to specific clinical indicators elaborated by the National Comprehensive Cancer Network (NCCN). A Simplified Screening Tool was also created, in order to make available an easier instrument for the same aim.

The SIAARTI/NCCN screening tool (Extended Screening Tool - EST) is, in fact, an instrument validated by many scientific societies, but it is very articulated and its compilation is too much time-consuming. The Simplified Screening Tool (SST) has been created through a statistical process in order to include all the critical variables, with the advantage of being shorter and therefore easier to administer in a routinely use.

The aim of the current study is to demonstrate that the SST has accuracy comparable to that of the SIAARTI/NCCN tool in identifying chronically ill patients in need of a PC approach, thus making available an easily manageable tool for the assessment of PC needs in chronically ill patients.

In order to do this, every enrolled patient will be administered both the SST and the SIAARTI/NCCN tool, in a randomized sequence.

After completion of the enrollment and data collection, an appropriate statistical methodology will be employed for the comparison between the established SIAARTI/NCCN tool and the SST.

• Study Type: Interventional
• Enrollment (Actual): 660
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Italy
  • Turin, Italy, 10126
    • Pain Management and Palliative Care, Department of Anesthesia, Intensive Care and Emergency, Molinette Hospital, University of Turin

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (ADULT, OLDER_ADULT)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

Patients admitted to Molinette Hospital (A.O.U. "Città della Salute e della Scienza"), affected by:

• locally advanced/metastatic cancer not suitable to antineoplastic therapy
• locally advanced/metastatic cancer suitable for palliative antineoplastic therapy
• locally advanced/metastatic cancer with uncontrolled symptoms
• end-stage heart failure
• end-stage respiratory failure
• end-stage liver failure
• end-stage renal failure

Exclusion Criteria:

• not able to be administered the screening tool
• major psychiatric disorders
• informed consent refusal

Study Plan

How is the study designed?

Design Details

• Primary Purpose: SUPPORTIVE_CARE
• Allocation: RANDOMIZED
• Interventional Model: CROSSOVER
• Masking: DOUBLE

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
ACTIVE_COMPARATOR: Extended Screening Tool (EST); The SIAARTI/NCCN (EST) screening tool is, in fact, an instrument validated by many scientific societies, but it is very articulated and its compilation is too much time-consuming.	Other: Screening for PC by means of two different screening tools; Screening of chronically ill patients admitted to an Internal Medicine Unit from the Emergency Department, for palliative care need, using of both the SIAARTI/NCCN screening tool (EST), and the Simplified Screening Tool (SST), derived from the first instrument.
EXPERIMENTAL: Simplified Screening Tool (SST); The Simplified Screening Tool (SST) has been created through a statistical process in order to include all the critical variables, with the advantage of being shorter and therefore easier to administer in a routinely use.	Other: Screening for PC by means of two different screening tools; Screening of chronically ill patients admitted to an Internal Medicine Unit from the Emergency Department, for palliative care need, using of both the SIAARTI/NCCN screening tool (EST), and the Simplified Screening Tool (SST), derived from the first instrument.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Accuracy of the Simplified Screening Tool (SST) with respect to the SIAARTI/NCCN screening tool (EST)	BACKGROUND: The aims of this study were to evaluate the feasibility of an Emergency Department (ED)-initiated screening to identify seriously ill patients in need of palliative care (PC) and to develop a simplified screening tool (SST). METHODS: Eligible patients with a known diagnosis of chronic heart, lung, liver, and kidney failures, or advanced cancer, awaiting to be hospitalized after an ED visit, were assessed with both screening tools (ie, EST and SST). The outcome of this study is to evaluate the accuracy of the SST in identifying chronically ill patients in need of a palliative care assessment in the hospital setting.	Through study completion, an average of 1 year

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Accuracy of Surprise Question (SQ)	BACKGROUND: The surprise question (SQ), "Would the investigator be surprised if this patient died within the next year?" is effective in identifying the end-stage disease patients and therefore potentially unmet palliative care needs. The SG is one of the criteria assessed by screening tools to identify people in need of palliative care assessment. METHODS: Eligible patients with a known diagnosis of chronic heart, lung, liver, and kidney failures, or advanced cancer, awaiting to be hospitalized after an ED visit, underwent an evaluation of life expectancy using the Surprise Question (SQ). The outcome of this study is to evaluate the accuracy of SQ in identifying palliative care patients in their last year of life.	Through study completion, an average of 1 year
Symptom control in palliative care patients	BACKGROUND: Good symptom control is important for delivering effective palliative care METHODS: Patients with a diagnosis of chronic heart, lung, liver, and kidney failures, or advanced cancer, hospitalized after an ED visit, fully according to the screening tool score, in an acute palliative care unit due to uncontrolled symptoms OUTCOME MEASURE: Measurements will be aggregated to arrive at a comparison between admission and discharge times of: frequency (n,%) of following symptoms: pain, activity, nausea, depression, anxiety, drowsiness, appetite, sense of well-being and shortness of breath; frequency (n,%) of use of pain killer, interventional procedures, palliative sedation	Through study completion, an average of 1 year
Intensity of symptoms in patients admitted in an acute palliative care unit	BACKGROUND: Good symptom control is important for delivering effective palliative care METHODS: Patients with a diagnosis of chronic heart, lung, liver, and kidney failures, or advanced cancer, hospitalized after an ED visit, fully according to the screening tool score, in an acute palliative care unit due to uncontrolled symptoms OUTCOME MEASURE: Measurements will be aggregated to arrive at a comparison between admission and discharge times of the intensity of symptoms using the Edmonton Symptom Assessment System, that consists of nine verbal numerical scales (0 as minimum value/better outcome; 10 as maximum value/ worse outcome)	Through study completion, an average of 1 year
Survival of patients in need of palliative care assessment	BACKGROUND: Acute palliative care units (APCU) are new programs aimed at improving palliative care in hospitalized patients. Although most deaths in palliative care patients with end-stage diseases are expected, no data are available on survival. METHODS: Eligible patients with a known diagnosis of chronic heart, lung, liver, and kidney failures, or advanced cancer, hospitalized after an ED visit, fully according to the screening tool score in an APCU, due to uncontrolled symptoms. OUTCOME MEASURE DESCRIPTION: The aim of this study is to evaluate the survival time (day, months, years) from APCU admission to death for any cause (overall survival).	Through study completion, an average of 1 year
Discharge and unplanned hospital readmissions of patients in need of palliative care assessment	BACKGROUND: Discharge planning represents one of the most important and complex decisions for patients admitted to an acute palliative care unit (APCU). METHODS: Eligible patients with a known diagnosis of chronic heart, lung, liver, and kidney failures, or advanced cancer, hospitalized after an ED visit, fully according to the screening tool score, in an APCU. OUTCOME MEASURE DESCRIPTION: This study is to evaluate: the frequency of discharge at home and to hospice care; the frequency of unplanned hospital readmissions of palliative care patients discharged from our APCU.	Through study completion, an average of 1 year
Clinical characteristics and outcomes of palliative care patients referred to an acute palliative care unit	BACKGROUND: Acute palliative care units (APCU) admit patients for symptom control, the transition to palliative care programs (home or hospice care), or end-of-life care. METHODS: Patients with a known diagnosis of chronic heart, lung, liver, and kidney failures, or advanced cancer, hospitalized after an ED visit, fully according to the screening tool score, in an APCU. OUTCOME MEASURE: multiple measurements will be aggregated to arrive at one detailed description of: frequency (n,%) of following symptoms: pain, activity, nausea, depression, anxiety, drowsiness, appetite, sense of well-being and shortness of breath; frequency (n,%) of discharge at home and to hospice care	Through study completion, an average of 1 year

Collaborators and Investigators

• Sponsor: Azienda Ospedaliera Città della Salute e della Scienza di Torino
• Investigators: Principal Investigator: Paolo Cotogni, MD, MSc, Pain Manage&Palliative Care Dept Anesthesia Molinette University Hospital Turin

Publications and helpful links

General Publications

• Cotogni P, DE Luca A, Evangelista A, Filippini C, Gili R, Scarmozzino A, Ciccone G, Brazzi L. A simplified screening tool to identify seriously ill patients in the Emergency Department for referral to a palliative care team. Minerva Anestesiol. 2017 May;83(5):474-484. doi: 10.23736/S0375-9393.16.11703-1. Epub 2017 Jan 17.
• Au DH, Udris EM, Fihn SD, McDonell MB, Curtis JR. Differences in health care utilization at the end of life among patients with chronic obstructive pulmonary disease and patients with lung cancer. Arch Intern Med. 2006 Feb 13;166(3):326-31. doi: 10.1001/archinte.166.3.326.
• Kahn JM, Benson NM, Appleby D, Carson SS, Iwashyna TJ. Long-term acute care hospital utilization after critical illness. JAMA. 2010 Jun 9;303(22):2253-9. doi: 10.1001/jama.2010.761.
• Jassal SV, Watson D. Dialysis in late life: benefit or burden. Clin J Am Soc Nephrol. 2009 Dec;4(12):2008-12. doi: 10.2215/CJN.04610709. Epub 2009 Nov 5.
• Glare PA, Chow K. Validation of a Simple Screening Tool for Identifying Unmet Palliative Care Needs in Patients With Cancer. J Oncol Pract. 2015 Jan;11(1):e81-6. doi: 10.1200/JOP.2014.001487. Epub 2014 Nov 12.
• Cotogni P, De Luca A, Saini A, Brazzi L. Unplanned hospital admissions of palliative care patients: a great challenge for internal and emergency medicine physicians. Intern Emerg Med. 2017 Aug;12(5):569-571. doi: 10.1007/s11739-017-1671-3. Epub 2017 May 5. No abstract available.

Study record dates

Study Major Dates

• Study Start (ACTUAL): May 23, 2017
• Primary Completion (ACTUAL): May 22, 2019
• Study Completion (ACTUAL): October 15, 2019

Study Registration Dates

• First Submitted: October 15, 2019
• First Submitted That Met QC Criteria: October 26, 2019
• First Posted (ACTUAL): October 29, 2019

Study Record Updates

• Last Update Posted (ACTUAL): October 29, 2019
• Last Update Submitted That Met QC Criteria: October 26, 2019
• Last Verified: October 1, 2019

More Information

Terms related to this study

• Keywords: palliative care; cancer; survival; end of life; screening tool; prognostic score; palliative care team; palliative care unit; unplanned hospital admission; end-stage disease; palliative sedation
• Additional Relevant MeSH Terms: Digestive System Diseases; Hepatic Insufficiency; Respiratory Tract Diseases; Respiration Disorders; Kidney Diseases; Urologic Diseases; Liver Diseases; Renal Insufficiency; Renal Insufficiency, Chronic; End Stage Liver Disease; Liver Failure; Respiratory Insufficiency; Kidney Failure, Chronic
• Other Study ID Numbers: 0014892

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No