Development of the ProPal-COPD tool to identify patients with COPD for proactive palliative care

International Journal of COPD Dovepress open access to scientific and medical research Original Research International Journal of Chronic Obstructive Pulmonary Disease downloaded from https://www.dovepress.com/ by 213.32.98.221 on 13-Jul-2018 For personal use only. Open Access Full Text Article Development of the ProPal-COPD tool to identify patients with COPD for proactive palliative care This article was published in the following Dove Press journal: International Journal of COPD 20 July 2017 Number of times this article has been viewed RG Duenk 1 C Verhagen 1 EM Bronkhorst 2 RS Djamin 3 GJ Bosman 4 E Lammers 5 PNR Dekhuijzen 6 KCP Vissers 1 Y Engels 1,* Y Heijdra 6,* Department of Anesthesiology, Pain and Palliative Medicine, 2Department of Health Evidence, Radboud University Medical Center, Nijmegen, 3 Department of Respiratory Medicine, Amphia Hospital, Breda, 4Department of Respiratory Medicine, Slingeland Hospital, Doetinchem, 5Department of Respiratory Medicine, Gelre Hospitals, Zutphen, 6Department of Pulmonary Diseases, Radboud University Medical Center, Nijmegen, the Netherlands 1 *These authors contributed equally to this work Introduction Correspondence: RG Duenk Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, PO Box 9101, 6500 HB Nijmegen, the Netherlands Tel +31 24 366 6254 Fax +31 24 361 3585 Email COPD is a progressive life-threatening lung disease.1 During the disease course, the need for disease-oriented care remains unchanged while the need for proactive palliative care increases for patients with COPD.2 Proactive palliative care, which includes advance care planning (ACP) conversations, is intended to improve the quality of life and quality of care.3,4 However, for patients with COPD, such care is not yet common.2,5 An important barrier is the identification of patients with COPD who might benefit from proactive palliative care.2 Identification for proactive palliative care is complicated by the unpredictable disease course of COPD.6 Stable phases in the disease course are interrupted by acute exacerbations; any one of which may be fatal.6 Although, general tools to identify patients for palliative care exist, they are not specifically intended or validated for the identification of patients with COPD.7,8 In addition, models of survival in stable COPD have been developed to be able to adjust and optimize care.9,10 Unfortunately, these 2121 submit your manuscript | www.dovepress.com International Journal of COPD 2017:12 2121–2128 Dovepress © 2017 Duenk et al. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php). http://dx.doi.org/10.2147/COPD.S140037 Powered by TCPDF (www.tcpdf.org) Background: Our objective was to develop a tool to identify patients with COPD for proactive palliative care. Since palliative care needs increase during the disease course of COPD, the prediction of mortality within 1 year, measured during hospitalizations for acute exacerbation COPD (AECOPD), was used as a proxy for the need of proactive palliative care. Patients and methods: Patients were recruited from three general hospitals in the Netherlands in 2014. Data of 11 potential predictors, a priori selected based on literature, were collected during hospitalization for AECOPD. After 1 year, the medical files were explored for the date of death. An optimal prediction model was assessed by Lasso logistic regression, with 20-fold crossvalidation for optimal shrinkage. Missing data were handled using complete case analysis. Results: Of 174 patients, 155 patients were included; of those 30 (19.4%) died within 1 year. The optimal prediction model was internally validated and had good discriminating power (AUC =0.82, 95% CI 0.81–0.82). This model relied on the following seven predictors: the surprise question, Medical Research Council dyspnea questionnaire (MRC dyspnea), Clinical COPD Questionnaire (CCQ), FEV1% of predicted value, body mass index, previous hospitalizations for AECOPD and specific comorbidities. To ensure minimal miss out of patients in need of proactive palliative care, we proposed a cutoff in the model that prioritized sensitivity over specificity (0.90 over 0.73, respectively). Our model (ProPal-COPD tool) was a stronger predictor of mortality within 1 year than the CODEX (comorbidity, age, obstruction, dyspnea, and previous severe exacerbations) index. Conclusion: The ProPal-COPD tool is a promising multivariable prediction tool to identify patients with COPD for proactive palliative care. Keywords: COPD, exacerbation, proactive palliative care, prognosis, mortality Dovepress International Journal of Chronic Obstructive Pulmonary Disease downloaded from https://www.dovepress.com/ by 213.32.98.221 on 13-Jul-2018 For personal use only. Duenk et al population models are of limited value to predict survival for individual patients.11 This prognostic difficulty has led to a discussion among clinicians whether or not a transition point for the initiation of proactive palliative care exists.12–15 Some clinicians argue that more specific criteria of end-stage COPD need to be explored.13 Others argue that, since such criteria may not exist, searching further may lead to prognostic paralysis.14,15 Instead, they promote early integration of palliative care according to needs.15 The focus in this discussion has been on whether or not we can accurately predict mortality instead of the intended objective, identifying patients with COPD in need of proactive palliative care. Since palliative care needs increase during the disease course of COPD,2 the prediction of mortality can be used as a proxy for the need of palliative care. To ensure minimal miss out of patients in need of such care, this tool should have a sensitivity near 100 with specificity as high as possible. Hospitalizations for an acute exacerbation COPD (AECOPD) are associated with significant mortality and therefore create an opportunity to identify patients with poor prognosis in need of palliative care.16 Recently, potential relevant variables have been identified to predict posthospital mortality in patients hospitalized for an AECOPD.16,17 This is the first prospective study to incorporate these variables with the objective to develop a multivariable prediction tool (the ProPal-COPD tool) to identify patients with COPD in need of proactive palliative care. Our objective was (...truncated)