Background
For cancer patients with an unplanned hospitalization, estimating survival has been limited. We examined factors predicting survival and investigated the concept of using a ...deficit‐accumulation survival index (DASI) in this population.
Methods
Data were ed from medical records of 145 patients who had an unplanned 30‐day readmission between 01/01/16 and 09/30/16. Comparison data were obtained for patients who were admitted as close in time to the date of index admission of a study patient, but who did not experience a readmission within 30 days of their discharge date. Our survival analysis compared those readmitted within 30 days versus those who were not. Scores from 23 medical record elements used in our DASI system categorized patients into low‐, moderate‐, and high‐score groups.
Results
Thirty‐day readmission was strongly associated with the survival (adjusted hazard ratio HR 2.39; 95% confidence interval CI, 1.46‐3.92). Patients readmitted within 30 days of discharge from index admission had a median survival of 147 days (95% CI, 85‐207) versus patients not readmitted who had not reached median survival by the end of the study (P < .0001). DASI was useful in predicting the survival; median survival time was 78 days (95% CI, 61‐131) for the high score, 318 days (95% CI, 207‐426) for the moderate score, and not reached as of 426 days (95% CI, 251 to undetermined) for the low‐score DASI group (P < .0001).
Conclusions
Patients readmitted within 30 days of an unplanned hospitalization are at higher risk of mortality than those not readmitted. A novel DASI developed from clinical documentation may help to predict survival in this population.
Cancer patients readmitted within 30 days of an unplanned hospitalization are at a higher risk of mortality. A novel index developed from clinical documentation may help to predict survival in this population.
Background
Frailty is a state of increased vulnerability to stressors, and predicts risk of adverse outcomes, such as mortality. Frailty can be defined by a frailty index (FI) using an accumulation ...of deficits approach. An FI comprised of 20 items derived from our previously studied test‐based frailty index (TBFI) and an additional 33 survey‐based elements sourced from the standard CGA was developed to evaluate if predictive validity of survival was improved.
Methods
One hundred eighty‐nine cancer patients during acute hospitalization were consented between September 2018 and May 2019. Frailty scores were calculated, and patients were categorized into four groups: non‐frail (0–0.2), mildly frail (0.2–0.3), moderately frail (0.3–0.4), and severely frail (>0.4). Patients were followed for 1‐year to assess FI and TBFI prediction of survival. Area under the curve (AUC) statistics from ROC analyses were compared for the FI versus TBFI.
Results
Increasing frailty was similarly associated with increased risk of mortality (HR, 4.5 95% CI, 2.519–8.075 and HR, 4.1 95%CI, 1.692–9.942) and the likelihood of death at 6 months was about 11‐fold (odds ratio, 10.9 95% CI, 3.97–33.24) and 9.73‐fold (95% CI, 2.85–38.50) higher for severely frail patients compared to non‐frail patients for FI and TBFI, respectively. This association was independent of age and type of cancer. The FI and TBFI were predictive of survival for older and younger cancer patients with no significant differences between models in discriminating survival (FI AUC, 0.747 95% CI, 0.6772–0.8157 and TBFI AUC, 0.724 95% CI, 0.6513–0.7957).
Conclusions
The TBFI was predictive of survival, and the addition of an in‐person assessment (FI) did not greatly improve predictive validity. Increasing frailty, as measured by a TBFI, resulted in a meaningfully increased risk of mortality and may be well‐suited for screening of hospitalized cancer patients.
A simplified test based frailty index (TBFI) is similarly predictive of survival as a more comprehensive CGA based frailty index in the hospitalized cancer patient. This index may be useful as a screening tool in the acute cancer patient.
Individuals with cancer anorexia cachexia syndrome (CACS) experience multifaceted distress. To address CACS patient concerns regarding their experience of care, our cancer center established a ...specialized CACS clinic in 2016. We applied the team science principle of the team mental model (TMM) to support development of an effective interprofessional collaborative CACS care team. In 2020, cessation of CACS clinic in-person visits during coronavirus disease 2019 (COVID-19) threatened the viability of the entrenched TMM and once again jeopardized the patient experience of care.
We present a case-based vignette as a representative composite of patient experiences to illustrate the challenges. A 48-year-old female was referred to our CACS clinic for pancreatic cancer-associated appetite and weight loss during COVID-19. To reduce risk of infection, in-person clinic visits were curtailed. When informed about the resulting need to defer the CACS assessment, the patient and her spouse expressed concern that postponement would adversely affect her ability to undergo anticancer treatments or achieve beneficial outcomes.
To minimize delays in CACS treatment and optimize the patient experience of care, we applied the team science principle of sense-making to help the team rapidly reformulate the TMM to provide interprofessional collaborative CACS care via telemedicine. The sense-making initiative highlights opportunities to examine sense-making within health care teams more broadly during and after the pandemic. The application of sense-making within interprofessional cancer care teams has not been described previously.
The COVID-19 pandemic presented myriad of unprecedented and daunting ethical dilemmas to healthcare workers, patients, their families, and the public health. Here we present a case of a 42-years-old ...Hispanic female with underlying hematological malignancy that developed severe SARS-COV-2 infection amidst the pandemic. This case illustrates some remarkable ethical dilemmas during pandemic times, including the lack of advanced directive planning, the repercussions of restricting family visits, and what ethics in crisis and moral injury entails. Identifying the ethical challenges emerging from the pandemic will assist physicians and other providers in making proper decisions and maintaining the best standard of care.
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