Prevalence and clinical characteristics of patients with Advanced Chronic Illness and Palliative Care needs, identified with the NECPAL CCOMS-ICO© Tool at a Tertiary Care Hospital.

BACKGROUND: The identification of patients with advanced chronic conditions and palliative care needs is essential since their care represents one of the main challenges for public health systems. The study aimed to determine the prevalence and characteristics of inpatients with palliative care needs in different services of a tertiary care hospital using the NECPAL CCOMS-ICO© tool. METHODS: A descriptive, cross-sectional cohort study was conducted in a tertiary hospital. The NECPAL tool identifies patients who require palliative care. Any patient with the Surprise Question with the answer "NO" and at least another question of the tool with a positive answer is considered a positive identification. Patients were classified as Non-NECPAL, NECPAL I-II, and NECPAL III, depending on the NECPAL tool criteria they met. The presence of physical symptoms, emotional distress, and social risk factors was assessed. RESULTS: Of the 602 inpatients, 236 (39.2%) were enrolled. Of them, 34 (14.4%) non-NECPAL, 202 (85.6%) NECPAL+ [105 (44.5%) NECPAL I-II, and 97 (41.1%) NECPAL III]. Physical symptom burden was high (pain intensity ≥ 1 in 68.3% of patients; tiredness ≥ 1 in 83.5%; somnolence ≥ 1 in 50.6%; dyspnea ≥ 1 in 37.9%; anorexia ≥ 1 in 59.5%). 64.1% had emotional distress, and 83.6% had social risk factors. The NECPAL-III group contained a higher percentage of cancer patients, higher demand for palliative care, and greater need for palliative care (p < 0.001). In 50.8% of cases, no referrals were made to psychology, social work, or hospital palliative and supportive care teams. The three services with the higher number of patients with palliative care needs were: Palliative Care Unit (100%), Oncology (54.54%), and Emergency Short-stay Unit (54.16%). CONCLUSION: A high percentage of patients admitted to tertiary care hospitals presented palliative care needs, with multiple unmet physical, emotional, and social needs. Less than 50% are referred to specialized care teams, such as hospital palliative and supportive care teams.

Switching Ratio from Parenteral to Oral Methadone 1:1.2 Is Safer Compared with Ratio 1:2 in Patients with Controlled Cancer Pain: A Multicenter Randomized-Controlled Trial (RATIOMTD-010810).

Background: The most commonly used switching ratio from parenteral to oral methadone is 1:2. Methadone is highly bioavailable and a lower ratio might result in similar analgesia with less toxicity. Objective: To compare success and side effects with two ratios from parenteral to oral methadone: 1:2 versus 1:1.2 in hospitalized patients with cancer pain. Design: A multicenter double-blind randomized clinical trial. Settings/Particiants: Inpatients with well-controlled cancer pain with parenteral methadone requiring rotation to the oral route. Measurements: Outcomes included pain intensity (Brief Inventory Pain), opioid toxicity (Common Toxicology Criteria for Adverse Events), and methadone dose. Success was defined as no toxicity with good pain control at 72 hours. Results: Thirty-nine of forty-four randomized patients were evaluable: 21 in ratio 1:2 and 18 in ratio 1:1.2. Seventy-one percent male. Median age 65 years. No significant differences in basal clinical characteristics between both groups. Median methadone dose pre/post switching was 24.5 mg ±13.5 and 49 mg ±27.3 for ratio 1:2, versus 23.3 mg ±9.4 (p: not significant) and 28 mg ±11.3 (p < 0.01) for ratio 1:1.2. Pain was well controlled without differences between both ratios. Drowsiness at day +1 (p < 0.017) and myoclonus at day +3 (p < 0.019) were more prevalent in group 1:2. Success was observed in 12 patients in ratio 1:2 versus 18 in ratio 1:1.2 (p < 0.001). Methadone side effects were observed in 12 patients in ratio 1:2 (mainly neurotoxicity symptoms) versus 2 in ratio 1:1.2 (p < 0.005). Conclusion: Ratio 1:1.2 when changing from parenteral to oral methadone resulted in lower toxicity and no difference in analgesia. More conservative dose adjustment during methadone route change should be considered. European Clinical Trials Register (EudraCT No. 2010-024092-39).

Intrahospital Mortality and Survival of Patients with Advanced Chronic Illnesses in a Tertiary Hospital Identified with the NECPAL CCOMS-ICO© Tool.

BACKGROUND: Between 69% and 82% of patients with advanced chronic illness require palliative care (PC). The NECPAL CCOMS-ICO© tool can identify these individuals. Tools to estimate survival are available, but have limited predictive ability, and therefore we sought to assess if NECPAL could improve survival prediction. OBJECTIVE: To describe hospital mortality, survival rates, and related variables in a sample of inpatients identified with the NECPAL tool. DESIGN: Cross-sectional study with longitudinal cohort follow-up. Sociodemographic and clinical data were analyzed. A predictive model (Cox regression analysis) was performed to assess survival. SETTING/SUBJECTS: Patients admitted to a tertiary hospital. Included patients were considered to be especially affected by their chronic condition and NECPAL+ patients (surprise question [SQ]+ plus ≥1 of the tool's other three criteria). Patients were classified into three subgroups: non-NECPAL (either SQ- or not meeting any additional NECPAL criteria); NECPAL I-II (SQ+ with one to two additional criteria); and NECPAL III (SQ+ with all three additional criteria). RESULTS: Of the 602 inpatients, 236 (39.2%) were included. Of these, 49 (20.3%) died during hospitalization: 14 (13.3%) were NECPAL I-II; 34 (35.1%) were NECPAL III; and none were non-NECPAL (p < 0.001). At two years, 146 deaths (61.9%) were observed: 9 (26.5%) non-NECPAL; 57 (54.3%) NECPAL I-II; and 80 (82.5%) NECPAL III (p < 0.001). Median survival was 9.1 months. Variables associated with higher mortality were NECPAL III classification (hazard ratio [HR]: 1.75 [1.19-2.57]); in need of PC (HR: 2 [1.27-3.13]); dysphagia (HR: 1.7 [1.12-2.58] 6); cancer (HR: 3.21 [2.19-4.71]); and age >85 years (HR: 2.52 [1.46-4.35]). At six months, the NECPAL had an area under the curve (AUC) of 0.7 (95% confidence interval [CI]: 0.632-0.765), and at 24 months, the NECPAL AUC was 0.717 (95% CI: 0.650-0.785). CONCLUSIONS: The NECPAL CCOMS-ICO© tool can improve the prediction of mortality. The presence of all three NECPAL criteria (NECPAL III) increases the tool's predictive ability.