ABSTRACT
Aims
To translate the Supportive and Palliative Care Indicators Tool (SPICT) into Chinese and conduct preliminarily tests of its performance in hospitalized patients with cancer.
Design
A cross‐sectional validation study conducted from January to March 2024.
Methods
SPICT 2022 was translated in both directions, following the Brislin translation model, and the Chinese version culturally debugged through expert consultation and pre‐testing. Content validity was evaluated by expert scoring. Tool internal consistency was evaluated using KR‐20 coefficient, and retest reliability was evaluated using kappa coefficient. The screening performance was evaluated by sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV).
Results
Of 388 hospitalized cancer patients included, approximately one‐quarter had potential palliative care needs. Content validity of the Chinese version of SPICT was good, as were internal consistency and test–retest reliability. Accuracy (0.905), sensitivity (0.806), specificity (0.943), PPV (0.845), and NPV (0.926) for the Chinese version of SPICT indicated that it is an acceptable instrument.
Conclusion
The Chinese version of SPICT can be applied for screening of palliative care needs in hospitalized patients with cancer in China.
Implications for the Profession and/or Patient Care
The Chinese version of SPICT had been adapted to assist clinicians or nurses in quickly identifying hospitalized patients with cancer who may have palliative care needs. This is conducive to help clinical team to start palliative care consultation, care goal discussion and (or) referral for patients in clinical practice. And it probably helps to advance integration between palliative care assessment and routine oncology care assessment.
Impact
This study provided a screening tool for palliative care, with good validity and reliability, as well as excellent screening performance to facilitate palliative care need screening in clinical practice, promote palliative care referrals and improve patient quality of life.
Reporting Method
This study was reported according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement.
Patient or Public Contribution
No patient or public contribution.
Keywords: palliative care, screening, SPICT, translation, validation
Summary.
- What does this paper contribute to the wider global clinical community?
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○In this paper we described the adaption of the widely used Supportive and Palliative Care Indicators Tool, according to a standardized translation process, to expand the application scope of the tool.
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○Our data verify the performance of the tool in clinical practice in China, according to a rigorous statistical approach, and provide a reference for future research into palliative care need.
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○
1. Introduction
Palliative care is a multidisciplinary ``'practice centred on dying patients and their families, with aims of improving patient quality of life and death at the end of life, allowing people to die with dignity (National Health Commission of the People's Republic of China n.d.). Accurately identifying patients with palliative care needs can support care teams in initiating timely discussions about palliative care (Gemmell, Yousaf, and Droney 2020); however, identifying terminally ill patients is an extremely complex and rigorous process (Zhang, Wang, and Gu 2022). Overly optimistic expectations of patients and families about disease, as well as uncertainty about patient outcomes, often lead to delays in discussing palliative care with patients and families (Procter et al. 2019). A major obstacle to identification of relevant patients is the lack of appropriate criteria or tools for assessing whether a patient requires palliative care (Zeng et al. 2019). In clinical practice, decisions are often based on disease progression, subjective feelings and underlying conditions, combined with the subjective experience of doctors, to determine whether a patient has entered the end‐of‐life period and consider whether they need palliative care (Zeng et al. 2019, 2020; Wang et al. 2022).
Screening tools for identifying the potential palliative care needs of patients and predicting the risk of health deterioration/mortality are significantly more accurate than subjective empirical judgement (Glare and Chow 2015; Yen et al. 2022; Hurst et al. 2018). Rebecca et al. (Gemmell, Yousaf, and Droney 2020) showed that 62%–91% of patients who died during unplanned hospital admissions could be identified using a palliative care needs screening tool prior to admission. Taiwan Scholars (Yen et al. 2022) prospectively followed 130,361 patients and found that use of the palliative care needs screening tool was significantly superior to the intuitive judgement of clinical nurses in identifying six‐month mortality (0.723 vs. 0.679; p < 0.001). Hurst et al. (2018) conducted an intervention study in the intensive care unit and showed that use of screening tools triggered more palliative care consultations relative to a control group in which tools were not used. Therefore, there is a need to develop an effective tool to identify the palliative care needs and health deterioration/mortality risk of patients in Chinese clinical practice.
2. Background
To the best of our knowledge, there are currently limited palliative care screening tools (PCST) available in China. Zhou et al. (2009) developed the Chinese prognostic scale for advanced cancer patients scale (GhPS) in 2009 by analysing the medical records of 1019 patients with advanced cancer who received home palliative care in Shanghai, but the tool only judged the need for palliative care from the perspective of prognosis, lacked an assessment of the willingness of patients and their families and lacked application and evidence in different populations and regions.
Some researchers have successively introduced tools from other countries such as the PCST for cancer patients. Zhou and Li (2022) argued that the Chinese version of PCST has good reliability and validity in hospitalized cancer patients in China. However, the original PCST development study only investigated patients with gastrointestinal tumours (Glare and Chow 2015), although the investigators indicated that PCST can be used to screen the palliative care needs of all cancer patients, the other versions that included diverse survey subjects showed lower internal consistency than the original version (0.612, 0.600 and 0.808) (Glare and Chow 2015; Zhou and Li 2022; Ostgathe et al. 2019), suggesting that there may be differences in the screening ability for palliative care need of PCST for different cancer patients.
Second, some items in the tool require familiarity with palliative care by the evaluator and patients/families, the evaluation of some items relies on other assessment tools (such as Edmonton symptom assessment scale and Distress Management Screening Measure). These may lead to the extension of the assessment time and increasing of the burden on the busy clinical practice. In addition, the assessment of comorbidities is not enough in the screening items for PCST.
The advent of the Supportive and Palliative Care Tool (SPICT) has compensated for the shortcomings of PCST. SPICT was formally developed in 2014 through a participatory peer‐review approach by the Primary Palliative Care Research Group at the University of Edinburgh in the United Kingdom, with the aim of helping healthcare professionals to identify patients with palliative care needs as early as possible and to support patients who frequently switch between different care settings (Boyd and Murray 2010; Highet et al. 2014). The full SPICT is available from the official website: https://www.spict.org.uk/. First of all, the screening object of the tool can be patients with any life‐limiting diseases, including but not limited to cancer, liver disease, kidney disease, respiratory disease and cardiovascular disease; it can be used to screen the palliative care need of patients with various advanced diseases (Highet et al. 2014). The design allows the evaluator to screen the main disease indicators of the patient and facilitate the simultaneous assessment of the patient's possible comorbidities. Second, all SPICT entries can be presented on a single A4 sheet of paper and are easy to understand and concise, so even ordinary non‐palliative care professionals can quickly grasp how to use them and can be completed within 3–10 min (Fachado et al. 2018; Casale et al. 2020). This tool has been demonstrated to be useful for screening palliative care needs in different settings (De Bock, Van Den Noortgate, and Piers 2018; Hamano, Oishi, and Kizawa 2018; Sulistio et al. 2015). The developers, Highet et al. (Highet et al. 2014), conducted a prospective case‐finding study using SPICT 2014 and found that 48% of patients with positive screening died within 1 year. Fachado et al. (2018) assessed the tool in 188 patients and found that its internal consistency, measured using the Kuder–Richardson 20 (KR‐20) coefficient, was 0.71. In the Italian version, the kappa statistic values for all items were > 0.74 and S‐CVI/Ave was 0.86, indicating good reliability and validity (Casale et al. 2020). SPICT has a sensitivity of 0.841 and a specificity of 0.579 for predicting one‐year mortality in the elderly population (De Bock, Van Den Noortgate, and Piers 2018) and has been translated and verified in many countries and regions, including Spain (Fachado et al. 2018), Japan (Oishi et al. 2022), Italy (Casale et al. 2020) and Germany (Afshar et al. 2018, 2022); however, no Chinese version of SPICT is available, potentially limiting the availability of palliative care in China. The primary objectives of this study were to translate and adapt SPICT to generate a Chinese version, evaluate the content validity and stability of the Chinese version and conduct preliminary tests of its performance when applied for hospitalized patients with cancer.
3. The Study
3.1. Aims
The aims of this study were the translation, cross‐cultural adaptation and validation of SPICT in hospitalized patients with cancer in China.
4. Methods
4.1. Design
Authorization from the developer of the tool, Dr. Kirsty Boyd, was obtained by email. A two‐centre cross‐sectional study to validate SPICT was conducted at a cancer centre and general hospital in China. This study was reported according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement.
4.2. Participants
This cross‐sectional descriptive study was completed in Guangzhou, Guangdong Province, China, from January to March 2024. Hospitalized patients with cancer attending the oncology and radiation oncology departments of an oncology centre and a general hospital who met the inclusion criteria were recruited as survey subjects by convenience sampling. The inclusion criteria were: (1) age ≥ 18 years, (2) diagnosed with malignant tumours and (3) aware of their own condition. The exclusion criteria were (1) important information missing or incomplete data in the electronic medical record system and (2) refusal to participate in this study. All study subjects agreed to participate and signed an informed consent form.
The sample size for the evaluation of the screening test was estimated according to the calculation formula:
where Z α /2 is the Z value when the cumulative probability is equal to α/2 in a normal distribution. The test level α = 0.05 is taken, then the statistic Z α /2 = 1.96, Se is an estimate of the sensitivity of the screening tool and the Chinese version of SPICT is expected to be 80% Se in cancer patients (80% of the screening tool Se ≥ is generally considered acceptable). The allowable error L is 0.08. P is the expected prevalence, based on previous research (Zhou and Li 2022), the positive rate of palliative care need of cancer patients was 35.3% and the sample size was calculated is 237.1 cases, which was rounded to 238 cases. The estimated sample size was at least 285 cases considering a loss to follow‐up rate of 10%–20% and sampling error.
In this study, the sample size of the cross‐sectional study was calculated using the following formula:
where U α/2 is the U value corresponding to the test level, π is the overall rate and δ is the allowable error. According to a previous study (Zhou and Li 2022), the positive rate of palliative care needs among hospitalized patients with cancer was 35.3%. Applying a 95% confidence interval and a tolerance of 0.05, the required sample size was calculated as ≥ 386 people, considering a loss to follow‐up rate of 10%–20% and sampling error. Due to the Chinese version of SPICT it had not been modified in the verification phase; finally, 388 samples were included in this study.
4.3. Assessment Tool
The PCST was originally developed by Glare et al. (2011) in 2011, based on the Clinical Practice Guidelines for Palliative Care published by the National Comprehensive Cancer Network to assess the palliative care needs of patients with cancer. PCST contains 10 items including cancer trajectory, functional status, cancer complications, comorbidities, specific palliative care problems and prolonged hospital stay, with a score range of 0–14 points; a score of ≥ 5 indicates that the patient has palliative care needs. At a cut‐off score of 5 for palliative care needs screening, the positive predictive value (PPV) of PCST is 80% and the negative predictive value (NPV) 44%, as demonstrated in several studies to assess palliative care needs in hospitalized patients with cancer (Ostgathe et al. 2019; Le et al. 2020). The Chinese version of PCST was introduced by Zhou and Li (2022) and has good reliability and validity (item‐level content validity index (I‐CVI) = 0.430–1.000, scale‐level‐CVI (S‐CVI) = 0.940, Cronbach's α = 0.612).
4.4. The Introduction of SPICT
The 2022 version of SPICT comprises three parts (The SPICT 2021): the first assesses identification of seven indicators of general health deterioration and mortality risk; the second evaluates 23 indicators of clinically advanced disease; and the third reviews current nursing measures and nursing plans to guide the adjustment of nursing plans, with a total of five items. The criterion for positivity of this tool is ‘at least have two indicators of general condition and one indicator of clinically advanced disease’ (Fachado et al. 2018; Farfán‐Zúñiga and Zimmermann‐Vildoso 2022). Therefore, we defined patients who met the screening criteria for the tool as positive as the positive group and those who did not meet the positive criteria as the negative group in our study.
4.5. Translation and Cross‐Cultural Adaptation
4.5.1. Translation
Dr. Kirsty Boyd, the original author of the tool, was contacted by email to obtain official authorization to introduce SPICT and the English version of SPICT 2022 obtained from the SPICT website. The Brislin translation model was used to translate the SPICT 2022 as follows: (1) Literal translation: two native Chinese translators, proficient in English, independently translated the English version of SPICT2022, and then the researchers and translators summarized and compared the two translations with the original version as a reference to generate a first literal translation draft version of SPICT (V1); (2) Back translation: two Chinese and English bilingual scholars, who had not been exposed to the original scale or the previous translation process, were invited to independently back‐translate the first literal translation draft version of SPICT (V1), compare it with the original tool, discuss the semantic equivalence, correct deviations in the translation process and form a first draft of the Chinese version of SPICT (V2).
4.5.2. Cross‐Cultural Adaptation
Expert consultation was conducted by inviting 14 experts in related fields to evaluate whether the content of the scale was clear, the language of the scale was appropriate and whether there was ambiguity in the expression of items. The inclusion criteria for experts were (1) Individuals who worked and conducted research in related fields such as palliative care, oncology or social work; (2) ≥ 10 years work experience; (3) Bachelor's degree or above. Experts were asked to evaluate the importance and relevance of items in the first draft (V2) of SPICT‐CH, using a 4‐level Likert scoring method. When an expert believed that an item needed to be added or deleted, or that the content was inaccurate or the description unclear, it was noted in the ‘Amendment Opinion’ column. Considering expert opinions, versions V1 and V2 were compared with the original scale, and the research team discussed and reached an agreement to form the Chinese version of SPICT (pre‐survey version).
For pre‐testing, 30 nurses who met the inclusion criteria were selected by convenience sampling and invited to screen patients using SPICT‐CH (pre‐survey version), record the screening time and ask and record opinions on the clarity, comprehensibility and language fluency of items on the spot, as well as recording unclear aspects of the questionnaire description, response method or items. According to the opinions of respondents, the expression of some items was revised to form the Chinese version of the Supportive and Palliative Care Indicator Tool (Chinese version of SPICT, SPICT‐CH).
4.6. Validity Test
4.6.1. Content Validity Index (CVI)
In this study, expert evaluation methods were used to invite expert group members (content validity experts and cultural adjustment experts) to evaluate whether each item of the scale is reasonable, accurate and semantically correct, and whether it can assess patients' palliative care needs and propose revisions. The content validity of SPICT‐CH was assessed by expert evaluation. Each item was scored using a 4‐level Likert scoring method, with 1–4 points assigned to ‘not relevant’ to ‘very relevant’, respectively, and S‐CVI/Ave and I‐CVI calculated. When the number of experts is not less than 6, the tools with an I‐CVI of no less than 0.78 and an S‐CVI/Ave of no less than 0.90 are considered to have good content validity (Polit, Beck, and Owen 2007).
4.6.2. Known Population Validity
The results of palliative care screening in patients with different characteristics of cancer were compared to evaluate the known population validity of the SPICT‐CH.
4.7. Reliability Test
4.7.1. Internal Consistency
The screening results of the SPICT‐CH are dichotomous data, so the Kuder–Richardson 20 (KR‐20) coefficient was used to evaluate the internal consistency of SPICT‐CH, with values between 0.70 and 0.90 considered acceptable (Choo et al. 2023).
4.7.2. Test–Retest Reliability
The test–retest reliability, also known as the stability coefficient, refers to the use of the same measurement tool to test the same group of research subjects twice before and after, which can reflect the stability and consistency of the scale across time. Three days after the first assessment, 30 patients will be re‐evaluated by the same researchers using SPICT‐CH. The kappa coefficient was used to measure the consistency of the investigator's evaluation of the subjects before and after the screening (Gisev, Bell, and Chen 2013). The kappa value is generally believed to be greater than 0.75 indicates a high degree of consistency between the two results (Gisev, Bell, and Chen 2013).
4.7.3. Screening Performance Assessment
In this paper, we evaluate the screening performance of the Chinese version of SPICT using the accuracy, sensitivity, specificity, PPV and NPV. These five evaluation indicators are calculated by means of a confusion matrix in which four categorical indicators are defined (Zhang 2024): true‐positive (TP), false‐positive (FP), true‐negative (TN) and false‐negative (FN). TP is a true class, i.e., the classification result is positive and the actual is positive; FP is a false‐positive, i.e., the classification result is positive but actually negative; TN is a true‐negative class, i.e., the classification result is negative and the actual is negative; FN is a false‐negative class, i.e., the classification result is negative but actually positive. In this study, the screening results of the Chinese version of the palliative care tool served as a gold standard, five evaluation indicators were calculated to evaluate the screening performance of SPICT‐CH. The specific definitions are as follows: (1) Accuracy = (TP + TN)/(TP + FP + TN + FN); (2) Sensitivity = Recall = TP/(TP + FN); (3) Specificity = TN/(TN + FP); (4) Precision = PPV = TP/(TP + FP); (5) NPV = TN/(FN + TN).
4.8. Data Collection
Data collectors were recruited and uniformly trained to reduce survey error and bias. Prior to the formal investigation, the investigator explained the purpose of the study to participants and obtained their consent, with the head of the relevant department. During patient hospitalization, the investigator used SPICT‐CH and the Chinese version of PCST to screen patients by asking questions in person and consulting the inpatient medical records available in the electronic medical record system to collect the general information of survey subjects. The authenticity and accuracy of the information for each dataset collected were verified. A total of 388 hospitalized patients with cancer were included from January to March 2024.
4.9. Data Analysis
The ‘double entry’ method was used to enter data, and SPSS26.0 statistical software was used for data analysis. Normally distributed data are presented as mean ± standard deviation, while median and interquartile range are used for non‐normally distributed data, with frequencies and percentages for count data. Comparisons between groups were performed using the chi‐square test or Fisher's exact probability method. p < 0.05 was considered significant.
4.10. Ethical Considerations
This study was approved by the Ethics Committee of Guangzhou Medical University in December 2023 (202312004). All procedures in this study were performed in accordance with the Ethics Commitee of Guangzhou Medical University. Written informed consent for publication was obtained from all study participants.
5. Results
5.1. Translation and Cross‐Cultural Adaptation
In the process of adapting the tool into Chinese, the following differences required special consultation among the researchers:
The name of the tool ‘Supportive and Palliative Care Indicators Tool’ was initially translated as a supportive and palliative care indicator tool, but in China, hospice care, palliative care, supportive care, etc. are collectively referred to as palliative care (National Health Commission of the People's Republic of China n.d.); therefore, when we called it the ‘palliative care indicator tool’. After two rounds of expert consultation, it was agreed that the details of the tool's original name should be retained, and we eventually revised it to the ‘Supportive and Palliative Care Indicator Tool’.
‘Look for clinical indicators of one or multiple life‐limiting conditions’ was initially literally translated as ‘looking for clinical indicators of one or more life‐limiting diseases’ and the experts proposed that the expression ‘look for’, directly translated as ‘searching’, was not easy to understand in the Chinese context, so we revised it to ‘exist’. The research team also agreed that the word ‘conditions’ should be translated as ‘circumstances’, and ‘condition’ was discussed as ‘disease’; eventually, the sentence was translated as ‘clinical indicators of the presence of one or more life‐limiting diseases’.
Regarding the item ‘The person's carer needs more help and support’, one expert suggested adding something specific, and two experts suggested that the entry should be deleted. After discussion by the research team, it was decided that this item should be retained for the following reasons: the lower the patient's self‐care ability, the heavier the care burden and psychological pressure faced by the patient's caregiver, and this item can reflect the patient's need for palliative care from the perspective of the patient's family. Finally, we revised it to ‘The patient's carer needs more help and support (such as care help and emotional support)’.
Regarding the item ‘Progressive weight loss; persistently low body weight; Low muscle mass’. One expert suggested that the time horizon should be ‘increased’, and one suggested that objective metrics should be added. After reviewing the literature, we provided a reference standard and reference scale for evaluating this item based on data from the relevant Chinese guidelines (Jiang et al. 2020; Yue et al. 2021; Cui et al. 2023): progressive weight loss (for reference: > 10% weight loss in the past 6 months or 20% weight loss over > 6 months); persistently low body weight (reference: BMI < 18.5 kg/m2); low muscle mass (reference: Sarcopenia Screening Scale, SARC‐F).
For the item ‘The person (or family) asks for palliative care; chooses to reduce, stop or not have treatment; or wishes to focus on quality of life’, in the first round of expert consultation, four experts believed that the content of the item was insufficiently clear and did not conform to the domestic cultural situation, and one expert said that ‘the expression of “focus on quality of life” is too vague and it is difficult to understand what it means’. After discussion by the research group, we provided additional explanation of the content and revised it to ‘patients (or family members) request palliative care; choose to reduce, discontinue, or not receive treatment for the cause; or a desire to focus on quality of life (e.g., pain control and comfort care as the primary goals of treatment and care)’.
The item ‘Kidney failure complicating other life limiting conditions or treatments’. was initially translated as ‘Kidney failure complicates other life‐limiting diseases or treatments;’ however, the experts felt that the entry was difficult to understand and did not conform to the Chinese expression. Eventually we revised it to ‘kidney failure combined with other life‐limiting diseases or kidney failure complicating treatment’.
5.2. Participant Characteristics
Enrolled patients (n = 388) included 203 males (52.3%) and 185 females (47.7%), aged 18–89 years (median, interquartile range = 57.00, 50.00–66.00) years. Of cases, 268 (69.1%) had junior high school education or below, 365 cases (94.1%) were married, 195 cases (50.3%) were no longer working, 248 cases (63.9%) had a monthly household income < 3000 yuan, 298 (76.8%) lived in cities/towns and 24 (6.2%) currently lived alone. In 70 cases (18.0%), the primary tumour location was colorectal, while in 63 (16.2%) the primary tumour location was in the lung and 45 patients (11.6%) had nasopharyngeal carcinoma as the primary tumour. Two hundred eight‐two patients (72.7%) had advanced/metastatic cancer and 311 (80.2%) were hospitalized for 1–7 days. The characteristics of all 388 patients with cancer are summarized in Table 1.
TABLE 1.
Clinical characteristics of hospitalised patients with cancer based on the results of screening for different palliative care needs using SPICT‐CH (n = 388).
| Variable | SPICT‐CH palliative care needs screening results | χ 2/Ζ | p | |
|---|---|---|---|---|
| Positive group (n = 103) | Negative group (n = 285) | |||
| Sex | 1.267 | 0.260 | ||
| Male | 49 (47.6%) | 154 (54.0%) | ||
| Female | 54 (52.4%) | 131 (46.0%) | ||
| Age, years a | 9.258 | 0.026 | ||
| < 40 | 7 (6.8%) | 30 (10.5%) | ||
| 40–59 | 44 (42.7%) | 148 (51.9%) | ||
| 60–79 | 49 (47.6%) | 106 (37.2%) | ||
| ≥ 80 | 1 (2.9%) | 3 (0.4%) | ||
| Education a | 3.616 | 0.306 | ||
| Elementary school and below | 37 (35.9%) | 81 (28.4%) | ||
| Junior middle school | 39 (37.9%) | 111 (38.9%) | ||
| High school/technical secondary school | 16 (15.5%) | 66 (23.2%) | ||
| College degree or above | 11 (10.7%) | 27 (9.5%) | ||
| Working conditions | 2.055 | 0.152 | ||
| None/retired | 58 (56.3%) | 137 (48.1%) | ||
| Still performing some work or labor | 45 (43.7%) | 148 (51.9%) | ||
| Marital status | 0.190 | 0.663 | ||
| Not married | 7 (6.8%) | 16 (5.6%) | ||
| Married | 96 (93.2%) | 269 (94.4%) | ||
| Residence | 3.537 | 0.171 | ||
| City | 42 (40.8%) | 102 (35.8%) | ||
| Town | 44 (42.7%) | 110 (38.6%) | ||
| Countryside | 17 (16.5%) | 73 (25.6%) | ||
| Residency | 1.281 | 0.258 | ||
| Living alone | 4 (3.9%) | 20 (7.0%) | ||
| Not living alone | 99 (96.1%) | 265 (93.0%) | ||
| Monthly income per capita, yuan | 4.461 | 0.216 | ||
| < 1500 | 23 (22.3%) | 41 (14.4%) | ||
| 1500–3000 | 44 (42.7%) | 140 (49.1%) | ||
| 3000–5000 | 28 (27.2%) | 88 (30.9%) | ||
| > 5000 | 8 (7.8%) | 16 (5.6%) | ||
| Primary tumour location a | 26.944 | < 0.001 | ||
| Nasopharyngeal | 5 (4.9%) | 47 (16.5%) | ||
| Lung | 27 (26.2%) | 36 (12.6%) | ||
| Hepatobiliary | 10 (9.7%) | 21 (7.4%) | ||
| Colorectal | 22 (21.4%) | 48 (16.8%) | ||
| Stomach/oesophagus | 10 (9.7%) | 19 (6.7%) | ||
| Breast mammary glands | 4 (3.9%) | 31 (10.9%) | ||
| Pancreatic | 3 (2.9%) | 2 (0.7%) | ||
| Other | 22 (21.4%) | 81 (28.4%) | ||
| Cancer stage | 13.308 | < 0.001 | ||
| Advanced or metastatic cancer | 89 (86.4%) | 193 (67.7%) | ||
| Non‐advanced or metastatic cancer | 14 (13.6%) | 92 (32.3%) | ||
| Admission type | 39.156 | < 0.001 | ||
| Planned hospital admission | 83 (80.6%) | 280 (98.2%) | ||
| Unplanned hospital admission | 20 (19.4%) | 5 (1.8%) | ||
| Number of days in hospital, day(s) a | 6.334 | 0.042 | ||
| 1–7 | 74 (71.8%) | 237 (83.2%) | ||
| 8–14 | 16 (15.5%) | 29 (10.2%) | ||
| > 14 | 13 (12.6%) | 19 (6.7%) | ||
| Length of hospital stay | 11.260 | < 0.001 | ||
| Less than the average length of stay in the department | 81 (78.6%) | 260 (91.2%) | ||
| Longer than the average length of stay in the department | 22 (21.4%) | 25 (8.8%) | ||
Due to numerical revision, the composition ratio of the variable is not 100%.
According to the results of the screening using SPICT‐CH, there were no significant differences between the positive and negative groups in terms of sex, occupation, education level, work status, marital status, family residence, residence situation and per capita monthly household income; however, age (χ 2 = 9.258, p = 0.026), primary tumour location (χ 2 = 26.944, p < 0.001), cancer stage (χ 2 = 13.308, p < 0.001), admission type (χ 2 = 39.156, p < 0.001), number of days in hospital (χ 2 = 6.334, p = 0.042) and length of hospital stay (χ 2 = 11.260, p < 0.001) differed significantly between groups. Comparisons between hospitalized patients with cancer screened as positive and negative for palliative care needs are presented in Table 1.
5.3. Validity
5.3.1. Content Validity
In the first round of expert consultation, the CVI of each item was 0.800–1.000, and the S‐CVI was 0.965. After revision, the final CVI for each item was 0857–1.000, while the S‐CVI was 0.981. The content validity of all items of the SPICT‐CH is presented below (Table 2).
TABLE 2.
Content validity of the indicators of SPICT‐CH.
| No. | Item | N | A | I‐CVI a | Pc b | K* c |
|---|---|---|---|---|---|---|
| General indicator | ||||||
| G01 | Unplanned hospital admission(s) | 7 | 7 | 1.000 | 0.00781 | 1.000 |
| G02 | Poor or deteriorating functional status with limited reversibility (e.g., the patient spends more than half of the day in bed or in a chair) | 7 | 7 | 1.000 | 0.00781 | 1.000 |
| G03 | Dependent on others for care due to growing physical and/or mental health problems | 7 | 7 | 1.000 | 0.00781 | 1.000 |
| G04 | The patient's carer needs more help and support (such as care help and emotional support) | 7 | 7 | 1.000 | 0.00781 | 1.000 |
| G05 | Progressive weight loss (for reference: > 10% weight loss in the past 6 months, or 20% weight loss over > 6 months); Persistently low body weight (reference: BMI < 18.5 kg/m2); low muscle mass (reference: Sarcopenia Screening Scale, SARC‐F) | 7 | 7 | 1.000 | 0.00781 | 1.000 |
| G06 | Symptoms persist despite appropriate treatment of the underlying condition | 7 | 7 | 1.000 | 0.00781 | 1.000** |
| G07 | Patients (or family members) request palliative care; choose to reduce, discontinue or not receive treatment for the cause; or a desire to focus on quality of life (e.g., pain control and comfort care as the primary goals of treatment and care) | 7 | 7 | 1.000 | 0.00781 | 1.000** |
| Clinical indicator | ||||||
| C01 | As the cancer progresses, it leads to a deterioration in the body's functions | 7 | 7 | 1.000 | 0.00781 | 1.000** |
| C02 | The body is too weak to receive cancer treatment/cancer treatment to control symptoms | 7 | 7 | 1.000 | 0.00781 | 1.000** |
| C03 | Inability to dress, walk or eat without assistance | 7 | 7 | 1.000 | 0.00781 | 1.000** |
| C04 | Reduced food and water intake or difficulty swallowing | 7 | 7 | 1.000 | 0.00781 | 1.000** |
| C05 | Incontinence | 7 | 7 | 1.000 | 0.00781 | 1.000** |
| C06 | Inability to communicate verbally or little social interaction | 7 | 6 | 0.857 | 0.05469 | 0.85873 |
| C07 | Frequent falls or the presence of a femur fracture | 7 | 7 | 1.000 | 0.00781 | 1.000** |
| C08 | Recurrent fever or infection or aspiration pneumonia | 7 | 6 | 0.857 | 0.05469 | 0.84873 |
| C09 | Despite optimal treatment, physical and/or cognitive function deteriorates progressively | 7 | 7 | 1.000 | 0.00781 | 1.000** |
| C10 | Speech problems with increasing communication difficulties and/or progressive dysphagia | 7 | 7 | 1.000 | 0.00781 | 1.000** |
| C11 | Recurrent aspiration pneumonia; shortness of breath or respiratory failure | 7 | 6 | 0.857 | 0.05469 | 0.8 |
| C12 | Persistent paralysis after stroke, with significant loss of function and disability | 7 | 7 | 1.000 | 0.00781 | 1.000** |
| C13 | Heart failure or extensive, untreatable coronary artery disease; shortness of breath or chest pain at rest or with a little exertion | 7 | 7 | 1.000 | 0.00781 | 1.000** |
| C14 | Severe, inoperable peripheral vascular disease | 7 | 6 | 0.857 | 0.05469 | 0.84873 |
| C15 | Severe chronic lung disease; shortness of breath at rest or minimal activity during exacerbations | 7 | 7 | 1.000 | 0.00781 | 1.000** |
| C16 | Persistent hypoxia requiring long‐term oxygen therapy | 7 | 7 | 1.000 | 0.00781 | 1.000** |
| C17 | Requires mechanical ventilation due to respiratory failure or has contraindications to mechanical ventilation | 7 | 7 | 1.000 | 0.00781 | 1.000** |
| C18 | Stage 4 or 5 chronic kidney disease (eGFR < 30 mL/min) with deteriorating health | 7 | 7 | 1.000 | 0.00781 | 1.000** |
| C19 | Kidney failure combined with other life‐limiting diseases or kidney failure complicating treatment | 7 | 7 | 1.000 | 0.00781 | 1.000** |
| C20 | Discontinuation or non‐dialysis treatment | 7 | 7 | 1.000 | 0.00781 | 1.000** |
| C21 | Cirrhosis has had one or more complications in the past year:
|
7 | 7 | 1.000 | 0.00781 | 1.000** |
| C22 | Liver transplantation is not possible | 7 | 7 | 1.000 | 0.00781 | 1.000** |
| C23 | irreversible deterioration of other diseases, multiple diseases and/or complications; The optimal treatment regimen used is not effective | 7 | 7 | 1.000 | 0.00781 | 1.000** |
| S‐CVI/Ave d | 0.981 | |||||
Item content validity index = number giving a rating of 3 or 4/number of experts.
Pc (probability of a chance occurrence) = N!/A!(N‐A)!×0.5N.
K* = kappa designating agreement on relevance. K*=(I‐CVI‐Pc)/(1‐Pc).
S‐CVI/Ave (average scale validity index) = mean of I‐CVI.
5.3.2. Known Population Validity
Significant differences in age, location of primary tumour, advanced cancer/metastatic cancer, type of admission and length of hospital stay were detected between patients classified in the positive and negative groups by the Chinese version of SPICT screening results (Table 1).
5.4. Reliability
5.4.1. Internal Consistency and Test–Retest Reliability
The KR‐20 value of SPICT‐CH was 0.743. After an interval of 3 days, 30 patients were re‐evaluated by the same researchers using SPICT‐CH, and the test–retest reliability of SPICT‐CH was 0.923 (p < 0.001).
5.4.2. Screening Performance
The results of PCST screening in Chinese were used as the gold standard in this study, and the data results of the confusion matrix data for Chinese SPICT were shown in Table 3. The accuracy of the Chinese version of SPICT was 0.905. The sensitivity of the Chinese version of SPICT was 0.806, specificity was 0.943, PPV was 0.840 and NPV was 0.936 (Table 4). In patients with advanced/metastatic cancer, the sensitivity was 0.781, and specificity was 0.925.
TABLE 3.
Confusion matrix of the SPICT‐CH (N = 388).
| Prediction (SPICT‐CH) | |||
|---|---|---|---|
| Positive (+) | Negative (−) | ||
| Reference (PCST‐CH) | Positive (+) | TP = 87 | FN = 21 |
| Negative (−) | FP = 16 | TN = 264 | |
Note: The Chinese version of the PCST screening results were used as the standard.
Abbreviations: FN, false negative (the true category of the sample is a positive class, but the SPICT‐CH identifies it as a negative class); FP, false positive (the true category of the sample is a negative class, but the SPICT‐CH identifies it as a positive class); PCST‐CH, The Chinese version of the Palliative Care Screening Tool; SPICT‐CH, The Chinese version of Supportive and Palliative Care Indicators Tool; TN, true negative (the true category of the sample is negative, and the SPICT‐CH identifies it as negative); TP, true positive (the true category of the sample is positive, and the result of the SPICT‐CH identification is also positive).
TABLE 4.
Evaluation index of SPICT‐CH.
| Index | SPICT‐CH | General indicators | Clinical indicators |
|---|---|---|---|
| Accuracy | 0.905 | / | / |
| Sensitivity | 0.806 | 0.870 | 0.833 |
| Specificity | 0.943 | 0.900 | 0.764 |
| Positive predictive value (PPV) | 0.845 | / | / |
| Negative predictive value (NPV) | 0.926 | / | / |
| p | < 0.001 | < 0.001 | < 0.001 |
Abbreviation: SPICT‐CH, The Chinese version of Supportive and palliative care indicators tool.
5.5. Screening Results
Of hospitalized patients with cancer, 26.5% (103/388) had potential palliative care needs, while 31.6% (89/282) of hospitalized patients with advanced/metastatic cancer had potential palliative care needs. Further, 122 (31.4%) patients met at least two general status indicators, while 156 patients (40.2%) had at least one clinically advanced disease index. The positive rates for general indicators 5, 6 and 7 were high (28.1%, 22.2% and 33.5%, respectively). Only 13 (3.4%) patients reported that ‘Performance status is poor or deteriorating, with limited reversibility’ and 25 (6.4%) patients with unplanned hospital admissions. The positivity general indicators determined using SPICT‐CH are shown in Figure 1.
FIGURE 1.
Positive general indicators in 388 patients with cancer. G01: Unplanned hospital admission(s); G02: Poor or deteriorating functional status with limited reversibility (e.g., the patient spends more than half of the day in bed or in a chair); G03: Dependent on others for care due to growing physical and/or mental health problems; G04: The patient's carer needs more help and support (such as care help and emotional support); G05: progressive weight loss (for reference: > 10% weight loss in the past 6 months, or 20% weight loss over > 6 months); persistently low body weight (reference: BMI < 18.5 kg/m2); low muscle mass (reference: Sarcopenia Screening Scale, SARC‐F); G06: Symptoms persist despite appropriate treatment of the underlying condition: G07: Patients (or family members) request palliative care; choose to reduce, discontinue, or not receive treatment for the cause; or a desire to focus on quality of life (e.g., pain control and comfort care as the primary goals of treatment and care).
6. Discussion
Our main research findings related to SPICT‐CH are as follows: (1) SPICT‐CH achieved semantic, idiomatic and empirical equivalence with the source tool; (2) The reliability and validity of SPICT‐CH are good; (3) SPICT‐CH has good screening performance in hospitalized patients with cancer.
6.1. SPICT‐CH Has Good Validity and Reliability
The I‐CVI values for SPICT‐CH were 0.857–1.000, and the S‐CVI/Ave value was 0.981, which are slightly higher than those of the Italian (mean S‐CVI, 0.86) (Casale et al. 2020) and Chilean (Lawshe coefficient, 0.84) versions (Farfán‐Zúñiga and Zimmermann‐Vildoso 2022). These results suggest that SPICT‐CH has good content validity and achieved conceptual, semantic and content equivalence between the target and the source scales (Guo and Li 2012).
The test–retest reliability of the Chinese version of SPICT was 0.923 (p < 0.001), indicating that it had good stability and equivalence. SPICT‐CH had a KR‐20 value of 0.743. This result is similar to that reported for the Spanish version (KR‐20 = 0.71) (Fachado et al. 2018), but lower than the Chilean version (Cronbach's α = 0.84) (Farfán‐Zúñiga and Zimmermann‐Vildoso 2022). The internal consistency between SPICT‐CH and other versions was not high, possibly attributable to the fact that the Chinese version of SPICT was used to evaluate the palliative care needs of hospitalized patients with cancer based on two dimensions (general indicators of patient condition and various indicators of life‐limiting disease) and there is some heterogeneity among the indicators of the seven life‐limiting disease types analysed; however, this also shows that the items are independent of one another, indicating that the possibility of content duplication is low.
6.2. SPICT‐CH Has Good Screening Performance
Using the Chinese version of PCST as the reference standard, SPICT‐CH showed good discrimination ability in identifying patients with cancer with palliative care needs. In this study, SPICT‐CH had high accuracy, sensitivity (80.6%) and specificity (94.3%) values, which are close to those reported for the Dutch version of the study (van Wijmen et al. 2020) (81% and 98%) and slightly lower than that published by the British scholars Low et al. (Low et al. 2022) and Bourmorck et al. (96.2% and 90.5%) (Bourmorck et al. 2023). The differences among studies may be related to the following reasons: (1) The study subjects were different. The UK and Belgian studies included patients with liver disease and older patients in the emergency setting, respectively, rather than those with life‐limiting diseases. Our study included all adult, disease‐informed patients with cancer (almost all malignant tumour types) in cancer hospitals, oncology departments of general hospitals and radiotherapy departments; (2) Selection of different reference standards. We used the screening results of the Chinese version of PCST, a palliative care needs screening tool for cancer patients, as a reference, as a preliminary test of the ability of SPICT‐CH to identify patients with potential palliative care need. This heterogeneity among the gold standards used for reference may underlie the large discrepancies between the results of the current study and those of some previous investigations.
The time to complete the screening was 2–10 min, which was similar to that reported for the Spanish (4 min 45 s) (Fachado et al. 2018) and German (7.5 min) (Afshar et al. 2018) versions. Screening times varied greatly among screeners, which may have been related to the complexity of the patient's condition in the pre‐survey, the screener's familiarity with the patient's condition and the screener's familiarity with the concepts and practices of supportive and palliative care. Overall, the screening time for this tool was short, which is conducive to rapid screening during busy clinical work.
6.3. The Palliative Care Needs of Hospitalized Cancer Patients Still Need Attention
About a quarter of cancer patients in this study were identified as having palliative care need in this study. This is lower than the results reported by Chan et al. (60.0%) (Chan et al. 2022) and Dogbey et al. (46.4%) (Dogbey et al. 2022), who also used SPICT for screening patients with cancer. The result suggested that the quality of life of inpatients with cancer in the sample areas was better, and the demand for palliative care was lower than that in other countries and regions.
On the one hand, it may be related to the fact that fewer severely ill patients were included in this study. The data collection site is located at tertiary hospitals in economically developed urban areas, and the quality of medical care services was high the basic care needs and psychological needs of patients were met. Although 70% of the participants were patients with advanced or metastatic cancer, the data showed that most patients were stable and still had good self‐care skills, so the quality of life of most patients was relatively high, the burden of family care was relatively light and the care problems and difficulties encountered were relatively few. On the other hand, it may be related to the more introverted East Asian culture and the maintenance of self‐dignity in cancer patients. Where balance and moderate emotional experience are more valued, in East Asian culture, negative emotions are generally rated as less desirable, and they value emotional control and extroverted expression of inhibiting emotions (Senft et al. 2021). During chemotherapy, cancer patients often experience drastic changes in one's appearance or become a burden to others, such as hair loss, rashes and disease states, and are prone to feel worthless or unvalued or unable to perform important roles or lack meaning and purpose, resulting in low self‐esteem (Reck et al. 2019; Xiao et al. 2022). These may result in patients tending to express lighter feelings and lower demands than they actually do at the time of data collection.
Our study found that poor nutritional status and symptom burden in cancer patients are still prominent problems. During tumour progression and anti‐tumour therapy, the competition for nutrients and energy between the bodies of patients and malignant tumours leads to significant weight loss, and patients with cancer often experience symptoms that are difficult to eliminate such as pain, dyspnea, nausea and vomiting, and fatigue (Henson et al. 2020). Although the number of patients identified as positive for palliative care needs in this study is lower than those in other countries and regions, however, patients still have unmet needs for palliative care, suggesting the importance of combining palliative care needs screening with daily cancer assessment as soon as possible to facilitate early initiation of palliative care consultations or care goal discussions for patients with cancer in a timely manner.
6.4. Application Value of the SPICT‐CH in Care Practice
First of all, the tool has been widely used in liver disease patients, cancer patients and elderly emergency patients in the United Kingdom, the United States, Spain, Japan and Denmark (Fachado et al. 2018; Casale et al. 2020; De Bock, Van Den Noortgate, and Piers 2018; Oishi et al. 2022; van Wijmen et al. 2020; Low et al. 2022; Bourmorck et al. 2023; Chan et al. 2022; Dogbey et al. 2022). It is thought to help identify patients' palliative care needs early and help adjust care plans. This study introduced and combined with the Chinese cultural background and clinical situation for cross‐cultural adjustment and formed a Chinese version of SPICT, which provides a new tool for the screening of palliative care needs of cancer patients in China. Second, the Chinese version of SPICT demonstrated a high level of accuracy in screening the needs of hospitalized cancer patients, which means that the Chinese version of SPICT was relatively accurate in distinguishing patients in need of palliative care from other patients. It helps the medical team to identify patients who may be facing the end of life as early as possible, especially when the course of the disease is complex or the symptoms are not obvious, so as to avoid delaying the best time for palliative care. On the other hand, a reliable screening tool can be an effective basis for the medical team to start a palliative care conversation with the family as early as possible (Gemmell, Yousaf, and Droney 2020). It helps patients and their families to better understand the progress of the disease, make treatment decisions that are more in line with the patient's wishes as soon as possible and reduce unnecessary pain caused by improper treatment selection or delay. Furthermore, the entries in the Chinese version of SPICT are concise and easy to understand, and the burden on screeners is light [the screening time was between 2 and 10 min (Fachado et al. 2018; Afshar et al. 2018)]. On the basis of considering the physiological functions of deteriorating health status, the burden of symptoms and the subjective needs of patients and their families, the SPICT‐CH also covers a variety of life‐limiting diseases including cancer, frailty, heart, liver and kidney. The tool has the potential to be used as a standardized tool for the implementation of palliative care in the future, helping medical institutions to carry out routine screening and referral in patients with different medical systems and diseases, promoting more patients to receive scientific and professional palliative care services and improving the overall level of care.
6.5. Limitations
First, the reference standard used in this study was the screening results of the Chinese version of PCST. At the time of this study, there was a lack of gold standards or widely used screening tools to identify the palliative care needs of patients with cancer in China. In previous studies, PCSTs have generally been validated based on patients who received palliative care counselling or died (Gemmell, Yousaf, and Droney 2020; Hurst et al. 2018; Hui et al. 2020). As no formal palliative care consultation has been conducted in China, and it is challenging to observe the clinical outcomes of patients in short term in cross‐sectional studies, the conditions for validation studies are not currently available. In this study, Chinese version of PCST as the gold standard was used to measurement SPICT‐CH, the screening performance results of SPICT‐CH obtained may be not accurate enough, and the results should be only considered a preliminary reference. We plan to conduct a prospective follow‐up study in the future to further verify the ability of SPICT‐CH to predict health deterioration and death and ultimately provide a scientific reference standard for palliative care needs screening. Second, SPICT is a universal screening tool while the subjects included in this study were all patients with cancer; hence the results can only reflect the preliminary application of SPICT‐CH in patients with cancer; the sample was not representative, and it is expected that more types of patients will be included in future studies to comprehensively evaluate the screening ability of SPICT‐CH for palliative care need.
7. Conclusion
The Chinese version of SPICT is an effective tool for identifying potential palliative care need, with good reliability and validity. In this study, the sensitivity of SPICT‐CH to identify the palliative care need of hospitalized patients with cancer was 0.806, with a specificity of 0.943, and good screening performance, indicating that this instrument can be rapidly and easily applied in the clinic; however, more research is needed for in‐depth verification of SPICT‐CH and to further revise and improve the tool.
Author Contributions
All authors have contributed substantially to the conception and design of the manuscript. H‐YP, H‐YF and P‐MF were involved in the study concept and design, H‐YF, D‐CQ, L‐HY contributed for acquisition of the data, H‐YF, D‐CQ, L‐HY performed data analysis, H‐YF and H‐YP drafted the manuscript, H‐YP and PMF made critical revisions to the manuscript. All authors approved the final manuscript.
Ethics Statement
This study was approved by the Ethics Committee of Guangzhou Medical University in December 2023 (202312004).
Consent
Written informed consent for publication was obtained from all study participants.
Conflicts of Interest
The authors declare no conflicts of interest.
Peer Review
The peer review history for this article is available at https://www.webofscience.com/api/gateway/wos/peer‐review/10.1111/jan.16782.
Funding: This work was supported by the Guangzhou Municipal Health Commission (funded research on the Construction of Palliative Care Service System in Guangzhou; no. J2427X002) to Yanping Hao.
Contributor Information
Meifang Peng, Email: pengmeifang02@163.com.
Yanping Hao, Email: haoyp2024@sina.com.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.