Jun Hamano

Surprise Questions for Survival Prediction in Patients With Advanced Cancer: A Multicenter Prospective Cohort Study

BACKGROUND Predicting the short-term survival in cancer patients is an important issue for patients, family, and oncologists. Although the prognostic accuracy of the surprise question has value in 1-year mortality for cancer patients, the prognostic value for short-term survival has not been formally assessed. The primary aim of the present study was to assess the prognostic value of the surprise question for 7-day and 30-day survival in patients with advanced cancer. PATIENTS AND METHODS The present multicenter prospective cohort study was conducted in Japan from September 2012 through April 2014, involving 16 palliative care units, 19 hospital-based palliative care teams, and 23 home-based palliative care services. RESULTS We recruited 2,425 patients and included 2,361 for analysis: 912 from hospital-based palliative care teams, 895 from hospital palliative care units, and 554 from home-based palliative care services. The sensitivity, specificity, positive predictive value, and negative predictive value of the 7-day survival surprise question were 84.7% (95% confidence interval [CI], 80.7%-88.0%), 68.0% (95% CI, 67.3%-68.5%), 30.3% (95% CI, 28.9%-31.5%), and 96.4% (95% CI, 95.5%-97.2%), respectively. The sensitivity, specificity, positive predictive value, and negative predictive value for the 30-day surprise question were 95.6% (95% CI, 94.4%-96.6%), 37.0% (95% CI, 35.9%-37.9%), 57.6% (95% CI, 56.8%-58.2%), and 90.4% (95% CI, 87.7%-92.6%), respectively. CONCLUSION Surprise questions are useful for screening patients for short survival. However, the high false-positive rates do not allow clinicians to provide definitive prognosis prediction. IMPLICATIONS FOR PRACTICE The findings of this study indicate that clinicians can screen patients for 7- or 30-day survival using surprise questions with 90% or more sensitivity. Clinicians cannot provide accurate prognosis estimation, and all patients will not always die within the defined periods. The screened patients can be regarded as the subjects to be prepared for approaching death, and proactive discussion would be useful for such patients.

Inappropriate Prescribing Among Elderly Home Care Patients in Japan Prevalence and Risk Factors

Background: Although several previous studies have examined the prevalence and risk factors associated with inappropriate prescribing (IP) among elderly patients, as identified by the Screening Tool of Older Persons’ potentially inappropriate Prescriptions (STOPP) and Screening Tool to Alert doctors to Right Treatment (START) criteria, no research has been conducted among elderly home care patients. Objective: This study aimed to explore the prevalence of IP and its risk factors as identified by the STOPP/START criteria among elderly home care patients in Japan. Study Design: Cross-sectional study. Setting: Home care settings in Japan. Participants: Eighty-nine patients aged 65 years or older who received regular home visiting services from Yamato Clinic between May 2013 and June 2013. Main Outcome Measure: The prevalence of IP and its risk factors as identified by the STOPP/START criteria. Results: Of the study population, 40.4% had at least one potentially inappropriate medication and 60.7% had at least one incidence of underprescribing. Risk factors for potentially inappropriate medications were hypertension, constipation, and polypharmacy, while those for underprescription were osteoporosis and polypharmacy. Conclusion: The prevalence of IP among elderly home care patients is high, with risk factors that include not only polypharmacy but also several specific underlying medical conditions.

Palliative care physicians' practices and attitudes regarding advance care planning in palliative care units in Japan: a nationwide survey.

To clarify physicians’ practices and attitudes regarding advance care planning (ACP) in palliative care units (PCUs) in Japan, we conducted a self-completed questionnaire survey of 203 certificated PCUs in 2010. Ninety-nine physicians participated in the survey. Although most Japanese palliative care physicians recognized the importance of ACP, many failed to implement aspects of patient-directed ACP that they acknowledged to be important, such as recommending completion of advance directives (ADs), designation of health care proxies, and implementing existing ADs. The physicians’ general preference for family-centered decision making and their feelings of difficulty and low confidence regarding ACP most likely underlie these results. The discrepancy between physicians’ practices and their recognition of the importance of ACP suggests an opportunity to improve end-of-life care.

Advance directives and do-not-resuscitate orders among patients with terminal cancer in palliative care units in Japan: a nationwide survey.

Objective: To examine the current status of advance directives (ADs) and do-not-resuscitate (DNR) orders among patients with terminal cancer in palliative care units (PCUs) in Japan. Methods: We conducted a retrospective chart review of the last 3 consecutive patients who died in 203 PCUs before November 30, 2010. Results: The percentages of patients who had ADs during the final hospitalization for cardiopulmonary resuscitation, mechanical ventilation, intravenous fluid administration, tube feeding, antibiotic administration, and who had appointed a health care proxy were 47%, 46%, 42%, 19%, 18%, and 48%, respectively. Seventy-six percent of the patients had a DNR order. Of the patients with decision-making capacity, 68% were involved in the DNR decision. Conclusions: These findings may reflect positive changes in patients’ attitudes toward ADs, in Japan.

Development the Care Evaluation Scale Version 2.0: a modified version of a measure for bereaved family members to evaluate the structure and process of palliative care for cancer patient

BackgroundThe Care Evaluation Scale (CES1.0) was designed to allow bereaved family members to evaluate the structure and process of care, but has been associated with a high frequency of misresponses. The objective of this study was to develop a modified version of CES1.0 (CES2.0) that would eliminate misresponses while maintaining good reliability and validity.MethodsWe conducted a cross-sectional questionnaire survey by mail in October 2013. The participants were bereaved family members of patients who died from cancer in seven institutions in Japan. All family members were asked to complete CES2.0, the short form CES1.0, items on overall care satisfaction, the Family Satisfaction with Advanced Cancer Care (FAMCARE) Scale, the Patient Health Questionnaire-9 (PHQ-9) and the Brief Grief Questionnaire (BGQ). To examine test-retest reliability, all participants were asked to complete a second CES2.0.ResultsOf 596 questionnaires sent, 461 (77%) were returned and 393 (66%) were analyzed. In the short form CES1.0, 17.1% of the responses were identified as misresponses. No misresponses were found in CES2.0. We identified 10 CES2.0 subscales similar to those in CES1.0 using exploratory factor analysis. Cronbach’s alpha was 0.96, and the intraclass correlation coefficient was 0.83. Correlations were found between CES2.0 and overall satisfaction (r = 0.83) and FAMCARE (r = 0.58). In addition, total CES2.0 scores were negatively correlated with the PHQ-9 (r = −0.22) and BGQ (r = −0.10).ConclusionThese results suggest that CES2.0 eliminated misresponses associated with CES1.0 while maintaining good reliability and validity and greatly improving test-retest reliability.

Specialized Palliative Care Services in Japan A Nationwide Survey of Resources and Utilization by Patients With Cancer

Objective: The aim of this study was to investigate the availability and utilization of specialized palliative care services among patients with cancer in Japan. Methods: We conducted a nationwide cross-sectional survey of 828 institutions predicted to provide specialized palliative care services. Results: Responses were received from 751 institutions (response rate, 91%); of these, 541 had specialized palliative care services. Adding the census data of palliative care units, the total estimated number of institutions with specialized palliative care services was 659. Of all the patients with cancer who died in the period from April 2009 to May 2010 in Japan, the estimated proportion who utilized specialized palliative care services was 24%. Conclusions: Usage of specialized palliative care services in Japan have increased explosively in the past decade.

Usefulness of Palliative Prognostic Index for patient with advanced cancer in home care setting.

Aims: This study aimed to clarify the accuracy of the Palliative Prognostic Index (PPI) for advanced cancer patients in home care settings. Method: The study included 65 advanced cancer patients who received home visiting services between April 2007 and June 2009, and who died at home or in the hospital. Using the medical records from initial home visits, we retrospectively calculated PPI scores along with sensitivity and specificity. Results: For 3- and 6-week survival, prognostic prediction demonstrated respective sensitivities of 55% and 63%, and specificities of 79% and 77%. Conclusion: The sensitivity of the PPI for advanced cancer patients in home care settings was lower than reported for those in palliative care units. Development of prognostic tools suitable for home care settings is needed.

Multicenter cohort study on the survival time of cancer patients dying at home or in a hospital: Does place matter?

Although the place of death has a great influence on the quality of death and dying for cancer patients, whether the survival time differs according to the place of death is unclear. The primary aim of this study was to explore potential differences in the survival time of cancer patients dying at home or in a hospital.

Validation of the Simplified Palliative Prognostic Index Using a Single Item From the Communication Capacity Scale

CONTEXT Although the Palliative Prognostic Index (PPI) is a reliable and validated tool to predict the survival of terminally ill cancer patients, all clinicians cannot always precisely diagnose delirium. OBJECTIVES The primary aim of this study was to examine the predictive value of a simplified PPI. In the simplified PPI, a single item from the Communication Capacity Scale was substituted for the delirium item of the original. METHODS This multicenter prospective cohort study was conducted in Japan from September 2012 through April 2014 and involved 16 palliative care units, 19 hospital-based palliative care teams, and 23 home-based palliative care services. Palliative care physicians recorded clinical variables at the first assessment and followed up patients six months later. RESULTS A total of 2425 subjects were recruited; 2343 had analyzable data. The C-statistics of the original and simplified PPIs were 0.801 and 0.800 for three week and 0.800 and 0.781 for six-week survival predictions, respectively. The sensitivity and specificity for survival predictions using the simplified PPI were 72.9% and 67.6% (for three week) and 80.3% and 61.8% (for six week), respectively. CONCLUSION The simplified PPI showed essentially the same predictive value as the original PPI and is an alternative when clinicians have difficulties in diagnosing delirium.

Prospective Clarification of the Utility of the Palliative Prognostic Index for Patients With Advanced Cancer in the Home Care Setting

Aims: This study aimed to prospectively clarify the accuracy of the Palliative Prognostic Index (PPI) for advanced cancer patients in home care settings. Method: The study included 66 advanced cancer patients who received home visiting services between April 2010 and June 2012, and who died at home or in the hospital. Using medical records from initial home visits, we prospectively calculated PPI scores along with sensitivity and specificity. Results: For 3- and 6-week survival, prognostic prediction showed respective sensitivities of 60% and 70.6%, and specificities of 87.0% and 71.9%. Conclusion: The sensitivity of the PPI for advanced cancer patients in home care settings was lower than that reported for patients in palliative care units. Development of prognostic tools suitable for home care settings is needed.