Impact of an Interdisciplinary Goals-of-Care Program Among Medical Inpatients at a Comprehensive Cancer Center During the COVID-19 Pandemic: A Propensity Score Analysis.

PURPOSE: Many hospitals have established goals-of-care programs in response to the coronavirus disease 2019 pandemic; however, few have reported their outcomes. We examined the impact of a multicomponent interdisciplinary goals-of-care program on intensive care unit (ICU) mortality and hospital outcomes for medical inpatients with cancer. METHODS: This single-center study with a quasi-experimental design included consecutive adult patients with cancer admitted to medical units at the MD Anderson Cancer Center, TX, during the 8-month preimplementation (May 1, 2019-December 31, 2019) and postimplementation period (May 1, 2020-December 31, 2020). The primary outcome was ICU mortality. Secondary outcomes included ICU length of stay, hospital mortality, and proportion/timing of care plan documentation. Propensity score weighting was used to adjust for differences in potential covariates, including age, sex, cancer diagnosis, race/ethnicity, and Sequential Organ Failure Assessment score. RESULTS: This study involved 12,941 hospitalized patients with cancer (pre n = 6,977; post n = 5,964) including 1,365 ICU admissions (pre n = 727; post n = 638). After multicomponent goals-of-care program initiation, we observed a significant reduction in ICU mortality (28.2% v 21.9%; change -6.3%, 95% CI, -9.6 to -3.1; P = .0001). We also observed significant decreases in length of ICU stay (mean change -1.4 days, 95% CI, -2.0 to -0.7; P < .0001) and in-hospital mortality (7% v 6.1%, mean change -0.9%, 95% CI, -1.5 to -0.3; P = .004). The proportion of hospitalized patients with an in-hospital do-not-resuscitate order increased significantly from 14.7% to 19.6% after implementation (odds ratio, 1.4; 95% CI, 1.3 to 1.5; P < .0001), and do-not-resuscitate order was established earlier (mean difference -3.0 days, 95% CI, -3.9 to -2.1; P < .0001). CONCLUSION: This study showed improvement in hospital outcomes and care plan documentation after implementation of a system-wide, multicomponent goals-of-care intervention.

Cross-validation of a modified score to predict mortality in cancer patients admitted to the intensive care unit.

PURPOSE: The aim of this study was to cross-validate an automated and customized severity of illness score as a means of predicting death among adult cancer patients admitted to the intensive care unit (ICU). MATERIALS AND METHODS: We conducted a retrospective study of ICU discharges between January 1, 2001, and December 31, 2005, in a university comprehensive cancer center. We randomly selected training and validation samples in 2 ICU groups (medical and surgical patients). We used logistic regression to calculate the probabilities of death in the ICU and in-hospital death in training samples and applied these probabilities to the validation samples to calculate sensitivity and specificity, construct curves, and determined the areas under the receiver operating characteristic curve (AUC). RESULTS: We included 6880 patients. In predicting ICU mortality, the AUC was 0.77 (95% confidence interval [CI], 0.73-0.82) for the medical validation group and 0.8207 (95% CI, 0.7304-0.9109) for the surgical validation group. For in-hospital mortality, the AUCs for the groups of medical and surgical patients were 0.73 (95% CI, 0.69-0.76) and 0.77 (95% CI, 0.73-0.80), respectively. CONCLUSIONS: The modified Sequential Organ Failure Assessment score is a good and valid predictor of cancer patients' risk of dying in the ICU and/or hospital despite the modifications needed to automate the score using existing electronic data.