Professionals in palliative care often base clinical decisions on estimated prognosis, but it has been shown that they are less accurate than the Karnofsky index at predicting prognosis in terminally ill patients.1,2 Because our clinical experience suggested that in patients in hospice the rate of change in physical functioning was a more useful indicator of survival than absolute measures, we investigated the use of rate of change of physical function in estimating survival of terminally ill patients with cancer by using the modified Barthel index. This comprises 10 activities of daily living, each with five levels of dependency; the maximum score is 100 points, representing independence in daily living. We thought it was a more sensitive index for measuring physical functioning in this patient group than the Karnofsky index.3,4
Patients, methods, and results
We studied two samples of patients with cancer from the same hospice to generate and test the model. We determined sample sizes empirically from patients admitted consecutively over two different periods of two months (January-February and March-April 1998), in whom the modified Barthel index was determined weekly from admission for the duration of inpatient stay. Barthel score at admission, mean weekly change in score during inpatient stay (defined as final score minus admission score divided by length of stay), and survival from date of admission were recorded.
The two populations were similar with respect to Barthel score at admission, length of stay, and survival (table). In sample 1, survival correlated with Barthel score at admission (rs=0.25, P=0.014) but more closely with mean weekly change (rs=–0.52, P<0.001). To examine this relation further, three groups were pragmatically constructed from the first sample on the basis of mean weekly change in Barthel scores. These represented clinical patterns commonly seen in terminally ill patients: stable physical functioning (no loss of points), moderate deterioration (1-9 points lost per week), and marked deterioration (10 or more points lost per week).
This model was applied to sample 2 to assess its ability to estimate survival. Survival correlated with Barthel score at admission (rs=0.3, P=0.002) but more closely with mean weekly change (rs=–0.52, P<0.001). Corresponding groups between samples had similar median survival, but the differences in survival between the three groups within each sample were significant (table).
Comment
In terminally ill patients in a hospice, rates of change were more important indicators of survival than absolute measures. Mean change in weekly Barthel scores was calculated to provide a crude clinical marker of changing physical function. Using mean change assumes that the modified Barthel index is an interval measure, but this has not been supported.4 Despite this, half of patients with advanced cancer who lose 10 or more points per week die within two weeks (95% confidence interval 8.6 days to 19.4 days), and three quarters are dead at three weeks. In contrast, 50% of patients in whom the weekly score does not deteriorate survive for two months (35.2 days to 76.8 days).
Although Barthel score at admission correlated with overall survival, no differences in scores on admission were found among the three groups in either sample (sample 1, P=0.08, and sample 2, P=0.74, Kruskal-Wallis; see table on website). Admission score therefore cannot be used to determine pattern of subsequent change and hence to estimate survival more accurately.
Supplementary Material
Table.
Barthel score, change in Barthel score, and survival time of patients in hospice with cancer
| Sample 1 (n=93) | Sample 2 (n=104) | P value (Mann-Whitney U test) | |
|---|---|---|---|
| Mean (range) Barthel score at admission | 66 (3-100) | 58 (2-100) | 0.056 |
| Median (range) length of stay (days) | 18 (5-104) | 19 (3-86) | 0.82 |
| Median (range) survival (days) | 35 (5-473) | 27 (3-349) | 0.2 |
| Median (interquartile range) change in Barthel index: | |||
| No loss of points | 56 (23-137) (n=50) | 68 (19-128) (n=41) | 0.91 |
| 1-9 points lost | 32 (17-56) (n=24) | 31 (15-45) (n=39) | 0.51 |
| ⩾10 points lost | 14 (11-20) (n=19) | 15 (6-20) (n=24) | 0.65 |
| P value (Kruskal-Wallis test) | <0.001 | <0.001 | – |
Acknowledgments
We thank Professor Anne Chamberlain, Dr Bippin Bhakta, and Dr Jan Geddes for their comments.
Footnotes
Funding: None.
Competing interests: None declared.
A table showing scores on admission is available on the BMJ's website
References
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