Multisystem chronic illness prognostication in non-oncologic integrated care

BMJ Support Palliat Care. 2022 May;12(e1):e112-e119. doi: 10.1136/bmjspcare-2019-002055. Epub 2020 Jun 24.

Abstract

Objectives: To develop a mortality-predictive model for correct identification of patients with non-cancer multiple chronic conditions who would benefit from palliative care, recognise predictive indicators of death and provide with tools for individual risk score calculation.

Design: Retrospective observational study with multivariate logistic regression models.

Participants: All patients with high-risk multiple chronic conditions incorporated into an integrated care strategy that fulfil two conditions: (1) they belong to the top 5% of the programme's risk pyramid according to the adjusted morbidity groups stratification tool and (2) they suffer simultaneously at least three selected chronic non-cancer pathologies (n=591).

Main outcome measure: 1 year mortality since patient inclusion in the programme.

Results: Among study participants, 201 (34%) died within the 1 year follow-up. Variables found to be independently associated to 1 year mortality were the Barthel Scale (p<0.001), creatinine value (p=0.032), existence of pressure ulcers (p=0.029) and patient global status (p<0.001). The area under the curve (AUC) for our model was 0.751, which was validated using bootstrapping (AUC=0.751) and k-fold cross-validation (10 folds; AUC=0.744). The Hosmer-Lemeshow test (p=0.761) showed good calibration.

Conclusions: This study develops and validates a mortality prediction model that will guide transitions of care to non-cancer palliative care services. The model determines prognostic indicators of death and provides tools for the estimation of individual death risk scores for each patient. We present a nomogram, a graphical risk calculation instrument, that favours a practical and easy use of the model within clinical practices.

Keywords: chronic conditions; terminal care.

Publication types

  • Observational Study

MeSH terms

  • Chronic Disease
  • Delivery of Health Care, Integrated*
  • Humans
  • Multiple Chronic Conditions*
  • Nomograms
  • Prognosis
  • Retrospective Studies