Adding items that assess changes in activities of daily living does not improve the predictive accuracy of the Palliative Prognostic Index.

BACKGROUND: Changes in activities of daily living in cancer patients may predict their survival. The Palliative Prognostic Index is a useful tool to evaluate cancer patients, and adding an item about activities of daily living changes might improve its predictive value. AIM: To clarify whether adding an item about activities of daily living changes improves the accuracy of Palliative Prognostic Index. DESIGN: Multicenter prospective cohort study. SETTING: A total of 58 palliative care services in Japan. PARTICIPANTS: Patients aged >20 years diagnosed with locally extensive or metastatic cancer (including hematological neoplasms) who had been admitted to palliative care units, were receiving care by hospital-based palliative care teams, or were receiving home-based palliative care. Palliative care physicians recorded clinical variables at the first assessment and followed up patients 6 months later. RESULTS: A total of 2425 subjects were recruited and 2343 of these had analyzable data. The C-statistic of the original Palliative Prognostic Index was 0.801, and those of modified Palliative Prognostic Indices ranged from 0.793 to 0.805 at 3 weeks. For 6-week survival predictions, the C-statistic of the original Palliative Prognostic Index was 0.802, and those of modified Palliative Prognostic Indices ranged from 0.791 to 0.799. The weighted kappa of the original Palliative Prognostic Index was 0.510, and those of modified Palliative Prognostic Indices ranged from 0.484 to 0.508. CONCLUSION: Adding items about activities of daily living changes to the Palliative Prognostic Index did not improve prognostic value in advanced cancer patients.

Cooperation between Single-Handed and Group Practices Ensures the Replacement of Gastrostomy Tubes and Tracheal Cannulas in Home Medical Care Settings.

In Japan, patients who require home medical care are increasing especially in the elderly. In home medical care settings, devices such as gastrostomy tubes, tracheal cannulas, and urethral catheters are usually replaced by visiting physicians or nurses. However, device replacement services are not always available in Japan. Unless device replacement services are sufficiently provided to patients at home, patients have to suffer various disadvantages, including a forced visit to a hospital for device replacement despite inability to walk. We therefore investigated background factors of clinics and nursing stations providing home-care visits using a cross-sectional postal survey from August to September 2013. We targeted physicians from 5,828 clinics providing home medical care and nurses from 1,798 home-visit nursing stations across six prefectures (Tokyo, Kanagawa, Saitama, Chiba, Miyagi and Iwate). Responses were received from 933 clinics (16.5%) and 552 stations (31.3%). We analyzed the responses using multivariable logistic regression with two models. "Model 1" mainly included the number of full-time staff and the availability of a 24-hour care service system, and "Model 2" mainly included the number of clinics, the number of home-visit nursing stations, and the ratio of the population aged ≥ 65 years to study the influence of medical resources. We thus found that clinic staff numbers and 24-hour care availability were associated with physicians' replacement of gastrostomy tubes and tracheal cannulas (p < 0.001 for each). In conclusion, single-handed and group practices need to cooperate to ensure the replacement of these devices in home medical care settings.

Development of an inter-professional educational program for home care professionals: Evaluation of short-term effects in suburban areas.

Objective　To examine the short-term effects of an inter-professional educational program developed for physicians and other home care specialists to promote home care in the community.Methods　From March 2012 to January 2013, an inter-professional educational program (IEP) was held four times in three suburban areas (Kashiwa city and Matsudo city in the Chiba prefecture, and Omori district in the Ota ward). This program aimed to motivate physicians to increase the number of home visits and to encourage home care professionals to work together in the same community areas by promoting inter-professional work (IPW). The participants were physicians, home-visit nurses, and other home care professionals recommended by community-level professional associations. The participants attended a 1.5-day multi-professional IEP. Pre- and post-program questionnaires were used to collect information on home care knowledge and practical skills (26 indexes, 1-4 scale), attitudes toward home care practice (4 indexes, 1-6 scale), and IPW (13 indexes, 1-4 scale). Data from all of the participants without labels about the type of professionals were excluded, and both pre-test and post-test responses were used in the analysis. A Wilcoxon signed-rank test and a paired t-test were conducted to compare pre- and post-program questionnaire responses stratified for physicians and other professionals, and the effect size was calculated.Results　The total number of participants for the four programs was 256, and data from 162 (63.3%) were analyzed. The physicians numbered 19 (11.7%), while other professionals numbered 143 (88.3%). Attending this program helped participants obtain home care knowledge of IPW and a practical view of home care. Furthermore, indexes about IPW consisted of two factors: cooperation and interaction; non-physician home care professionals increased their interactions with physicians, other professionals increased their cooperation with other professionals, and physicians increased their cooperation with other physicians.Conclusion　Short-term effects to motivate physicians to increase home visits were limited. However, physicians obtained a practical view of home care by attending the IEP. Also, the participation of physicians and other home care professionals in this program triggered the beginning of IPW in suburban areas. This program is feasible when adapted for regional differences.

Multicenter cohort study on the survival time of cancer patients dying at home or in a hospital: Does place matter?

BACKGROUND: Although the place of death has a great influence on the quality of death and dying for cancer patients, whether the survival time differs according to the place of death is unclear. The primary aim of this study was to explore potential differences in the survival time of cancer patients dying at home or in a hospital. METHODS: This multicenter, prospective cohort study was conducted in Japan from September 2012 through April 2014 and involved 58 specialist palliative care services. RESULTS: Among the 2426 patients recruited, 2069 patients were analyzed for this study: 1582 receiving hospital-based palliative care and 487 receiving home-based palliative care. A total of 1607 patients actually died in a hospital, and 462 patients died at home. The survival of patients who died at home was significantly longer than the survival of patients who died in a hospital in the days' prognosis group (estimated median survival time, 13 days [95% confidence interval (CI), 10.3-15.7 days] vs 9 days [95% CI, 8.0-10.0 days]; P = .006) and in the weeks' prognosis group (36 days [95% CI, 29.9-42.1 days] vs 29 days [95% CI, 26.5-31.5 days]; P = .007) as defined by Prognosis in Palliative Care Study predictor model A. No significant difference was identified in the months' prognosis group. Cox proportional hazards analysis revealed that the place of death had a significant influence on the survival time in both unadjusted (hazard ratio [HR], 0.86; 95% CI, 0.78-0.96; P < .01) and adjusted models (HR, 0.87; 95% CI, 0.77-0.97; P = .01). CONCLUSIONS: In comparison with cancer patients who died in a hospital, cancer patients who died at home had similar or longer survival. Cancer 2016;122:1453-1460. © 2016 American Cancer Society.

Family caregivers require mental health specialists for end-of-life psychosocial problems at home: a nationwide survey in Japan.

BACKGROUND: Psychological distress is problematic for patients and their family caregivers in the oncological setting. The level of stress is influenced by the health status of the patient and their family members as well as the support system for home care. However, it remains unclear how best to support distressed caregivers providing end-of-life care at home. METHODS: The present study was performed as part of the Japan Hospice and Palliative Care Evaluation study among caregivers whose family members are provided home palliative care. The caregivers were asked whether they wished to receive psychological support from mental health specialists, and factors associated with the need for psychological support were analyzed. RESULTS: Of the 1052 caregivers, 628 completed the questionnaire. As a whole, 169 subjects [27%; 23-30% (95% confidence interval)] reported needing psychological support from a mental health specialist. According to a multiple regression analysis, factors associated with the need for psychological support included (1) emotional distress due to the need to adapt to rapid worsening of the patient's condition [adjusted odds ratio: 2.62 (95% CI 1.77-3.88), p < 0.001], (2) the poor health conditions of the caregivers [2.93 (1.61-5.36), p < 0.001], and (3) having someone else available to care for the patient in place of the caregiver [0.51 (0.34-0.78), p = 0.002]. CONCLUSIONS: Psychological support is required for caregivers tending to patients at home. Further studies are needed to construct a system to provide continuous support to caregivers. Copyright © 2015 John Wiley & Sons, Ltd.

Length of home hospice care, family-perceived timing of referrals, perceived quality of care, and quality of death and dying in terminally ill cancer patients who died at home.

PURPOSE: This study aims to clarify the length of home hospice care, family-perceived timing of referrals, and their effects on the family-perceived quality of care and quality of death and dying of terminally ill cancer patients who died at home and identify the determinants of perceived late referrals. METHODS: A multicenter questionnaire survey was conducted involving 1,052 family members of cancer patients who died at home supported by 15 home-based hospice services throughout Japan. RESULTS: A total of 693 responses were analyzed (effective response rate, 66 %). Patients received home-based hospice care for a median of 35.0 days, and 8.0 % received home hospice care for less than 1 week. While 1.5 % of the families reported the timing of referrals as early, 42 % reported the timing as late or too late. The families of patients with a length of care of less than 4 weeks were more likely to regard the timing of referrals as late or too late. The patients of family members who regarded the timing of referrals as late or too late had a significantly lower perceived quality of care (effect size, 0.18; P = 0.039) and lower quality of death and dying (effect size, 0.15, P = 0.063). Independent determinants of higher likelihoods of perceived late referrals included: frequent visits to emergency departments, patient being unprepared for worsening condition, and patient having concerns about relationship with new doctor. Discharge nurse availability was independently associated with lower likelihoods of perceived late referrals. CONCLUSIONS: A significant number of bereaved families regarded the timing of referrals to home hospices as late, and the perceived timing was associated with the family-perceived quality of care and quality of death and dying. Systematic strategies to overcome the barriers related to perceived late referrals are necessary.

Glasgow prognostic score predicts prognosis for cancer patients in palliative settings: a subanalysis of the Japan-prognostic assessment tools validation (J-ProVal) study.

PURPOSE: The Glasgow prognostic score (GPS), which uses C-reactive protein and albumin levels, is a good predictor of prognosis in cancer patients undergoing anti-tumor therapy. The objective of this study was to investigate the correlation between GPS and survival among cancer patients in palliative settings, as findings in such populations have not been well described. METHODS: This was a subanalysis of a multicenter, prospective, cohort study in patients who were adults, diagnosed with advanced cancer, and first referred to palliative care service in Japan. Patients who were not receiving anti-tumor therapy and who had undergone laboratory examinations were eligible. Clinical features were analyzed to investigate prognostic factors. RESULTS: A total of 1160 patients were enrolled (41.6 % female; median age, 72 years). The independent predictors were Eastern Cooperative Oncology Group performance status (ECOG PS) score of 4 (hazard ratio (HR), 1.54), liver metastasis (HR, 1.21), dyspnea (HR, 1.35), edema (HR, 1.25), prognostic performance index (HR, 1.56), neutrophil-lymphocyte ratio (HR, 1.43), and GPS of 2 (HR, 1.36). The sensitivity and specificity for 3-week prognosis of a GPS of 2 were 0.879 and 0.410. Median survival time with GPS of 0, 1, and 2 was 58 days (95 % confidence interval, 48-81), 43 days (37-50), and 21 days (19-24), respectively (log-rank test, p < 0.001). CONCLUSION: The GPS was a good prognostic indicator for cancer patients in palliative settings.

[Talking about home hospices with terminally ill cancer patients -- a multicenter survey of bereaved families].

INTRODUCTION: Communicating with patients is clearly an integral part of physicians' practice, and introducing home hospice care is sometimes a difficult task for oncologists. The primary aims of this study were to clarify family-reported degree of emotional distress and the necessity for improvement in communication when introducing home hospice care, and to identify factors contributing to distress levels. METHODS: A multicenter questionnaire survey was conducted involving 1,052 family members of cancer patients who died at home at 15 home-based hospice services throughout Japan. RESULTS: A total of 616 responses were analyzed(effective response rate of 60%). Fifty-nine percent of the bereaved family members reported that they were distressed or very distressed in receiving information about home hospice care, and 30% reported considerable or much improvement was necessary. There were 6 determinants of family-reported degree of emotional distress and the necessity for improvement: 1 ) Family distress was experienced when the physician stated that the disease progression defeated medicine and nothing could be done for the patient. 2 ) The physicians' explanation did not match with the state of family preparation. 3 ) There was no intimacy between hospital physician and home physician. 4 ) Physicians did not make the atmosphere relaxing enough to allow families to ask questions. 5 ) Nurses did not follow up to generate additional ideas to supplement the physician's statement. 6 ) Family members experienced pressure to make a rash decision. CONCLUSION: In receiving information about transition of home care, a considerable number of families experienced high levels of emotional distress and felt a need for improvement in the communication style. This study proposes 6 strategies to alleviate family distress.

Questionnaire survey on current status of home care and support for patients with hematological diseases.

In order to survey the current status of home care and support for patients with hematological diseases, questionnaires were sent to 3,591 hospitals and home care facilities in Tokyo and surrounding prefectures. The first survey showed that 81.7% of medical staff members at hospitals reported that they had experience with home care and support, but only 24.9% of home care facility staff members had such experience. The second questionnaire, surveying 1,202 personnel, identified four factors hampering successful establishment of home care and support networks for hematological diseases. These included insufficient familial support for patients, difficulty making end of life decisions by family members and patients, limited access to transfusion support, and financial problems.

Dying Patients' Quality of Care for Five Common Causes of Death: A Nationwide Mortality Follow-Back Survey.

Background: The importance of high-quality care for terminal patients is being increasingly recognized; however, quality of care (QOC) and quality of death and dying (QOD) for noncancer patients remain unclear. Objectives: To clarify QOC and QOD according to places and causes of death. Design, Subjects: A nationwide mortality follow-back survey was conducted using death certificate data for cancer, heart disease, stroke syndrome, pneumonia, and kidney failure in Japan. The questionnaire was distributed to 115,816 bereaved family members between February 2019 and February 2020. Measurements included QOC, QOD, and symptoms during the last week of life. Analyses used generalized estimating equations adjusting for age, sex, and region. Results: Valid responses were returned by 62,576 (54.0%). Family-reported QOC and QOD by the place of death were significantly higher at home than in other places across all causes of death (for all combinations with hospital p < 0.01). In stroke syndrome and pneumonia, QOD significantly differed between hospital and home (stroke syndrome: 57.1 vs. 72.4, p < 0.001, effect size 0.77; pneumonia: 57.3 vs. 71.1, p < 0.001, effect size 0.78). No significant differences were observed in QOC and QOD between cancer and noncancer. The prevalence of symptoms was higher for cancer than for other causes of death. Conclusions: QOC and QOD were higher at home than in other places of death across all causes of death. The further expansion of end-of-life care options is crucial for improving QOC and QOD for all terminal patients.

Enhancing end-of-life care quality and achieving a good death for the elderly in Japan.

BACKGROUND: In the context of an aging populations, there is an escalating need for palliative care tailored to the needs of the elderly. This study aimed to assess differences in symptoms and good death among the elderly, along with the structures and processes involved in end-of life care, and to explore the impact of age on achieving a good death. METHODS: We conducted a questionnaire survey for bereaved family members of patients with cancer, heart disease, stroke, pneumonia, and kidney failure in 2019 and 2020. The study population was categorized into the following age groups: ≤64, 65-74, 75-84, and ≥85. The outcomes included symptom intensity, achievement of a good death, and receipt of quality care. RESULTS: In total, 62,576 bereaved family members agreed to participate in the survey (response rate; 54.0 %). The weighted percentages of 'severe' and 'very severe' symptoms decreased with age. These trends were observed across age groups, even among the elderly. The strongest effect of age on achieving a good death was found for 'feeling that life is complete' with reference to those aged ≤64 years: 65-74 years (odds ratio [OR]; 2.09, 95 % CI; 1.94 to 2.25), 75-84 years (OR; 4.86, 95 % CI; 4.52 to 5.22) and ≥85 years (OR; 12.8, 95 % CI; 11.9 to 13.8). CONCLUSION: Age-specific differences were observed in quality of death, quality of care, and symptom intensity. It is important to provide individualized consideration for each age group rather than categorizing them broadly as the elderly when caring for them.

Exploring the perceived changes and the reasons why expected outcomes were not obtained in individual levels in a successful regional palliative care intervention trial: an analysis for interpretations.

CONTEXT: The Japan Outreach Palliative Care Trial of Integrated Model (OPTIM) study, a mixed-methods study to evaluate the effects of a comprehensive regional palliative care program, revealed that the program provided broad positive outcomes at the regional level: increased home death, palliative care use, patient- and family-reported qualities of care, and health care professionals' difficulties. Not all participants however obtained positive outcomes and thus exploring the reasons why expected outcomes were observed in individual levels could be of value. AIMS: The primary aims were to explore why expected outcomes were not obtained in individual participants, and the perceived changes in daily practices of physicians and nurses were explored. SUBJECTS AND METHODS: Postintervention questionnaire survey on 857 patients, 1,137 bereaved family members, 706 physicians, and 2,236 nurses were analyzed. RESULTS: The reasons for not achieving home deaths included unexpected rapid deterioration, caregivers unavailable, concerns about adequate responses to sudden changes, and physical symptoms uncontrolled, while lack of physician availability at home and lack of information from physicians were less frequently reported. The reasons for not receiving specialized palliative care services were the lack of recommendations from physicians and no information about palliative care services. The reason for evaluating the quality of palliative care as not high was that clinicians tried to relieve symptoms, but there were limited effects and insufficient time. Many physicians and nurses reported that they became more aware of palliative care, that the availability of palliative care specialists and knowledge about palliative care improved, and that they cooperated with other regional health care providers more easily. CONCLUSION: The OPTIM study seemed to succeed in optimizing physician availability at home, improves physician information about home care, achieved maximum efforts to relieve patient distress by clinicians, and increased communication among regional health care professionals. To achieve further better outcomes, multiple interventions to the health care system to be performed on the basis of a comprehensive regional palliative care program are proposed.

Patient-perceived usefulness and practical obstacles of patient-held records for cancer patients in Japan: OPTIM study.

BACKGROUND: Although the use of a patient-held record (PHR) for cancer patients has been introduced in many settings, little is known about the role of the PHR in palliative care settings and use in Asian cultures. AIM: This study investigated the patient-perceived usefulness and practical obstacles of using the PHR specifically designed for palliative care patients. DESIGN: This study adopted a qualitative design based on semi-structured interviews and content analysis. SETTING/PARTICIPANTS: Fifty cancer patients were recruited from two regions in Japan. They used the PHR for more than three months, and then were asked to participate in a face-to-face interview. RESULTS: The content analysis revealed the following patient-perceived usefulness of the PHR: (1) increase in patient-staff communication; (2) increase in patient-family communication; (3) increase in patient-patient communication; (4) increase in understanding of medical conditions and treatments; and (5) facilitating end-of-life care discussion. The practical obstacles to using the PHR were also indicated: (1) the lack of adequate instruction about the role of the PHR; (2) undervaluing the role of the PHR and sharing information by medical professionals; (3) patients' unwillingness to participate in decision making; (4) concerns about privacy; (5) burdensome nature of self-reporting; and (6) patients' preference for their own ways of recording. CONCLUSIONS: The PHR can be helpful in facilitating communication, understanding medical conditions and treatments, and facilitating end-of-life care discussion; however, for wide-spread implementation, resolving the obstacles related to both patients and health-care professionals is required.

[Development of a home care educational program for community physicians and other professionals-a trial in Kashiwa City].

From May to October 2011, we conducted an 8-day homecare educational program for physicians, dentists, pharmacists, visiting nurses, long-term care managers, and hospital staff in Kashiwa city, Chiba, which was primarily intended to increase home visits by physicians. The characteristics of the program were as follows: 1) active and busy community physician participation, 2) attendance of practical training by physicians, 3) interprofessional discussion, 4) recruitment of participants from the same city, 5) recommendation of participant recruitment by a community-level professional association such as Kashiwa City Medical Association. By comparison of the pre- and post-program questionnaires completed by participants, the motivation for homecare practice, knowledge about homecare, and interactions with other professionals have increased. We will further standardize and generalize this program in order to contribute to homecare promotion in Japan.

Age, gender, will, and use of home-visit nursing care are critical factors in home care for malignant diseases; a retrospective study involving 346 patients in Japan.

BACKGROUND: We aimed to clarify the factors affecting outcomes of home care for patients with malignant diseases. METHODS: Of 607 patients who were treated in 10 clinics specialized in home care between January and December 2007 at Chiba, Fukuoka, Iwate, Kagoshima, Tochigi and Tokyo prefectures across Japan, 346 (57%; 145 men and 201 women) had malignant diseases. We collected information on medical and social backgrounds, details of home care, and its outcomes based on their medical records. RESULTS: Median age of the patients was 77 years (range, 11-102), and 335 patients were economically self-sufficient. Their general condition was poor; advanced cancer (n = 308), performance status of 3-4 (n = 261), and dementia (n = 121). At the beginning of home care, 143 patients and 174 family members expressed their wish to die at home. All the patients received supportive treatments including fluid replacement and oxygenation. Median duration of home care was 47 days (range, 0-2,712). 224 patients died at home. For the remaining 122, home care was terminated due to complications (n = 109), change of attending physicians (n = 8), and others (n = 5). The factors which inhibited the continuity of home care were the non-use of home-visit nursing care (hazard ratio [HR] = 1.78, 95% confidence interval [CI]: 1.05-3.00, p = 0.03), the fact that the patients themselves do not wish to die at home (HR = 1.83, CI: 1.09-3.07, p = 0.02), women (HR = 1.81, CI: 1.11-2.94, p = 0.02), and age (HR = 0.98, CI: 0.97-1.00, p = 0.02). CONCLUSIONS: Continuation of home care is influenced by patients' age, gender, will, and use of home-visit nursing.

Retrospective study on home care for patients with hematologic malignancies.

OBJECTIVE: There is a lack of sufficient information on the employment of home care for the treatment of hematologic malignancies. METHODS: We provided home care to 580 patients from 1 January through 31 October 2007. Patients with hematologic malignancies were selected from these 580 patients; subsequently, by reviewing their medical records. RESULTS: The main clinical condition in 15 (2.6%) of 580 patients was hematologic malignancies. The median age of the patients was 78 years (range, 64-92). Of the 15 patients, 12 showed a performance status (PS) of 3-4, and the condition of 6 patients was complicated with dementia. Food intake via the oral route was possible in 14 patients. These patients were administered palliative care. Among the seven patients who required pain control, four had been opioid users; however, none had used anticancer drugs for pain relief. Furthermore, three patients received blood transfusion. Although three patients developed severe complications (acute appendicitis, pneumonia and hyperglycemia), we were able to treat all cases adequately. Eight patients died at home due to aggravation of the primary diseases. The remaining seven patients were transferred to other hospitals for the treatment of complications or for the convenience of their respective families. CONCLUSIONS: Even patients with hematologic malignancies could be candidates for home care if their underlying diseases are slowly progressive, and they can sustain themselves by oral intakes. Dementia and poor PS are not contraindicated to it.

Catheter replacement structure in home medical care settings and regional characteristics in Tokyo and three adjoining prefectures.

AIM: The present study investigated the association between the structure of catheter replacement services in home medical care settings and regional characteristics. METHODS: An anonymous self-administered questionnaire was carried out from August to September 2013. Participants were physicians from 5338 clinics that provided medical care services at home, and nurses from 1619 home-visit nursing stations in Tokyo and three adjoining prefectures. The questionnaire covered catheter replacement (gastrostomy tubes, nasogastric tubes, tracheal cannulas) during home medical care, and the professions of those who replaced urethral catheters for male and female patients. Regions were divided into two groups (higher- and lower-density regions) based on the number of clinics, number of home-visit nursing stations and the ratio of the population aged ≥65 years. The rates of respondents that reported catheter replacement was usually executed, and those who reported catheters were replaced by "physicians in principle" were compared between the groups. RESULTS: Responses were received from 842 clinics (16.3%) and 499 home-visit nursing stations (31.4%). In the higher-density regions, the rate of physicians who reported urethral catheters for male patients were replaced by "physicians in principle" was significantly higher than in the lower-density regions (P < 0.001). In the lower-density regions, the rate of nurses who reported urethral catheters for male patients were replaced by "nurses in principle" was significantly higher compared with the higher-density regions (P < 0.016). CONCLUSIONS: In home medical care settings, urethral catheters for male patients are replaced by nurses in regions where physician resources are limited. Geriatr Gerontol Int 2017; 17: 628-636.

Performance of severity scores for home care-based patients suffering from pneumonia.

AIM: The Pneumonia Severity Index (PSI) is used to determine the prognosis of community-acquired pneumonia (CAP). The concept of nursing- and healthcare-associated pneumonia (NHCAP) has recently been established in Japan. The present study aims to examine whether the PSI can predict the prognosis of home care-based patients diagnosed with NHCAP. METHODS: We retrospectively sampled 97 home care-based patients diagnosed with pneumonia in 2011 at Aozora Clinic in Kamihongo. Each case was scored using the PSI, the A-DROP and the CURB-65, and the severity of each case was evaluated. We also modified the PSI to obtain the score on the site of the home visits by omitting the scores related to the radiographic and laboratory findings. We call this new score the modified PSI for home care-based patients (PSI-HC). We assessed how well each score predicted mortality. RESULTS: The correlation efficiency of the PSI and the PSI-HC before categorization was 0.89. All the four scores well predicted the mortality, with the area under the curve of the receiver operating characteristic curves of the PSI, the PSI-HC, the A-DROP and the CURB-65 being 0.859, 0.856, 0.778, and 0.806, respectively. These scores also predicted the hospitalization rate, but more than two-thirds of high-scoring patients received therapy at home contrary to the recommendations of guidelines. CONCLUSIONS: All four scores for CAP well predicted the prognosis of pneumonia of the home care-based patients, which was categorized in NHCAP. The decision of hospitalization was made not only by considering the severity of the pneumonia.

Independent validation of the modified prognosis palliative care study predictor models in three palliative care settings.

CONTEXT: Accurate prognostic information in palliative care settings is needed for patients to make decisions and set goals and priorities. The Prognosis Palliative Care Study (PiPS) predictor models were presented in 2011, but have not yet been fully validated by other research teams. OBJECTIVES: The primary aim of this study is to examine the accuracy and to validate the modified PiPS (using physician-proxy ratings of mental status instead of patient interviews) in three palliative care settings, namely palliative care units, hospital-based palliative care teams, and home-based palliative care services. METHODS: This multicenter prospective cohort study was conducted in 58 palliative care services including 16 palliative care units, 19 hospital-based palliative care teams, and 23 home-based palliative care services in Japan from September 2012 through April 2014. RESULTS: A total of 2426 subjects were recruited. For reasons including lack of followup and missing variables (primarily blood examination data), we obtained analyzable data from 2212 and 1257 patients for the modified PiPS-A and PiPS-B, respectively. In all palliative care settings, both the modified PiPS-A and PiPS-B identified three risk groups with different survival rates (P<0.001). The absolute agreement ranged from 56% to 60% in the PiPS-A model and 60% to 62% in the PiPS-B model. CONCLUSION: The modified PiPS was successfully validated and can be useful in palliative care units, hospital-based palliative care teams, and home-based palliative care services.