Sunday, January 27, 2013

PPS Trajectories in Hospice

Functional status is all the rage in research these days, especially with the impending but often delayed roll out of ICD-10. Any seasoned hospice and palliative care (HPC) clinician will tell you how critical functional status is to understanding trajectories of patients as function has been part of our assessment for quite a long time.  Most of us know functional assessments through the more clinical acronyms of ADL (Activities of Daily Living) and the PPS (Palliative Performance Status).  On a whole HPC staff routinely use function as a key metric of prognostication, but we have not really had a lot of data that looked beyond PPS at admission.  

This week in the Journal of the American Geriatric Society, Pam Harris, Joan Teno, David Casarett and the CHOICE* group published Patterns of Functional Decline in Hospice Care, an important insight into the dynamic (or sometimes not quite so dynamic) change in functional status (as measured by the PPS) for patients who died on hospice.

The data all came from three hospices (KS/MO, PA, FL) using the Suncoast electronic medical record and looked at nearly 9,000 patients who died on hospice services and their PPS over the time they were admitted to hospice services.  The findings note three basic trajectories that emerged: cancer and stroke, cardiac and pulmonary, and debility and dementia:


Disease group PPS Decline

Cancer 8.44/week
Stroke 7.67/week
Pulmonary 5.02/week
Cardiac   4.53/week
Dementia 1.98/week
Debility 1.86/week
(Note: The above data are weighted average across groups and not indicative of any one patients average decline.  Thus the ability to readily apply to any individual patient is challenging to say the least.)

The data do help give us data to back up what many of us observe naturally in hospice, that patients with cancer have a short time on hospice marked by significant decline, and those with dementia and adult failure to thrive tend to have slower rates of decline and therefore may have longer lengths of stay.   

Two interesting findings did come up which could have an impact on how medical directors interpret hospice eligibility guidelines. First, of the 23% of patients who had a PPS recorded on the last day of life, 36% (weighted distribution) had a PPS of 40 or greater (mostly 40 or 50).  Those patients with a PPS of 40 or greater tended to be male, white and carry a cancer diagnosis.  Second, approximately 12 % of patients actually had an increase of PPS during this retrospective period, which is important to acknowledge because they still died.  This is good evidence that an improvement of PPS alone should not necessarily disqualify someone from hospice eligibility.  PPS decline is not a one-way street.

Some limitations of the study are important to realize before you make a drastic change in how you use functional assessment in determining eligibility.  The authors only analyzed patients who died during the 10 month follow-up period, but since you may try to apply this data prospectively instead of retrospectively as the study did, you will not know as you observe the decline of patients if they will die in the 10 month follow-up period or not.  It may be best for you to replicate this own study with your own team or own organization as a QAPI study (or even better publishable research!) so you can best understand how this applies to your unique case mix of hospice patients.  

I highly recommend you bring this study into your next IDG and discuss how it applies to your work in hospice and palliative care.  I’m excited to see more studies come from the CHOICE group and you can see them at the AAHPM meeting in New Orleans in March at one of the paper sessions.


* CHOICE = Coalition of Hospices to Investigate Comparitive Effectiveness

  ResearchBlogging.orgHarris P, Wong E, Farrington S, Craig TR, Harrold JK, Oldanie B, Teno JM, & Casarett DJ (2013). Patterns of Functional Decline in Hospice: What Can Individuals and Their Families Expect? Journal of the American Geriatrics Society PMID: 23347201



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