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Design and Participants: This prognostic study (at a large academic medical center) generated updated prognostic estimates by PPS score, care setting, and illness category, and examined how well PPS predicts short- and longer-term survival, using EHR data linked with California Vital Records. Participants received a palliative care consultation between 2018 and 2020. The primary outcomes were predicted 1-, 6-, and 12-month mortality and median survival by PPS score in inpatient and outpatient settings, and PPS performance across survival times. In subgroup analyses, mortality risk by score was estimated in patients with cancer vs noncancer illnesses and those seen in-person vs by outpatient video telemedicine.
Results: Patients (N=4,779; 48% inpatient, 64% outpatient) were aged mean 64 years old (SD=15); 51% female; and 57% White, 17% Asian, 13% Latine, 6.2% Black, 0.6% Pacific Islander, and 0.5% American Indian/Alaska Native. In both settings, 1-, 6-, and 12-month mortality was higher and median survival was shorter for patients with lower scores. Prognostic estimates associated with scores were longer (2.3- to 12-fold) than previous estimates commonly used. PPS had good ability to discriminate between patients who lived vs who died in inpatient settings (integrated time-dependent area under the curve=0.74), but its discriminative ability was lower in outpatient settings (0.67). PPS better predicted 1-month survival than longer-term survival. Mortality was higher for patients with cancer than other serious illnesses at most PPS levels. There was no difference between median survival by score for in-person vs video telemedicine.
Commentary: PPS, described in 1996, remains useful in contemporary practice as a marker of functional status. This study details its utility in different settings (inpatient vs outpatient including telemedicine; cancer vs noncancer) for prognosticating overall survival. The data show longer survival estimates for outpatients compared to inpatients with similar PPS scores, though whether inpatient consultation PPS described the preadmission baseline or the “when seen” status is not addressed. The analysis included an order of magnitude more patients than 20-year-old prognostic detail for PPS and found longer survival estimates overall. Updating online tools (eg, Fast Facts) to reflect these findings can ensure more accurate prediction of survival.
Bottom Line: What’s in a number? This study validates PPS via telemedicine and updates its utility for prognosticating life remaining. It remains an open question as to whether inpatient providers should determine PPS based on the date of service or the preadmission baseline.
Reviewer: Christine Khandelwal, DO MHPE FAAHPM, Campbell University School of Osteopathic Medicine, Buies Creek, NC
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Source: Bischoff KE, Patel K, Boscardin WJ, O’Riordan DL, Pantilat SZ, Smith AK. Prognoses associated with Palliative Performance Scale scores in modern palliative care practice. JAMA Netw Open. 2024;7(7):e2420472. doi:10.1001/jamanetworkopen.2024.20472.
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