Wednesday, August 17, 2005

Predicting prognosis in COPD

I've been digging around the literature on predicting prognosis in COPD & came across a very tidy & up to date summary in Current Opinion in Pulmonary Medicine. What has become clear, & what the COPM article corroborates, is that there are no clear ways of predicting who is 'hospice appropriate' by the 6 month criteria. All the published prediction criteria are helpful to differentiate prognosis on the order of years, not months (that is--who are most likely to die in 1-2 years as opposed to many years). Even the BODE grading system which was published in the NEJM last year (which uses BMI, FEV1, dyspnea, and exercise capacity to stratify mortality in COPD patients) differentiates people on the order of years--about half of those in the 4th quartile (worst quartile) of BODE scores were alive at 36 months. All of this makes me curious as to how physicians make decisions to enter COPD patients into hospice. Thinking about my own patients I guess it's been a gestalt of 1) severe COPD/low FEV1/hypoxia at rest/etc, 2) falling off the curve-ness (weight loss, loss of ADL's, increased frequency of hospitalizations), & 3) the patient's goals of care are hospice-congenial. All of this is very loose, but I'm not sure if the science is up to improving things currently. The natural history of COPD, though, just may make it a disease that's impossible to fit nicely into this 6 month business imposed by the Medicare hospice benefit that works well with cancer & ALS & there may never be a good way to predict mortality in COPD on the order of months. Perhaps what is needed is a more reliable way of identifying people with end stage COPD as they begin to fall off that curve...

Addendum--EPERC has recently published a Fast Fact on this very topic.

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