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. 2021 Apr 28;16(4):e0249297.
doi: 10.1371/journal.pone.0249297. eCollection 2021.

The Prognosis in Palliative care Study II (PiPS2): A prospective observational validation study of a prognostic tool with an embedded qualitative evaluation

P C Stone  1 , A Kalpakidou  1 , C Todd  2   3   4 , J Griffiths  2   3 , V Keeley  5 , K Spencer  2   3 , P Buckle  1 , D Finlay  1 , V Vickerstaff  1 , R Z Omar  6 ; PiPS2 investigators’ group
Collaborators, Affiliations

The Prognosis in Palliative care Study II (PiPS2): A prospective observational validation study of a prognostic tool with an embedded qualitative evaluation

P C Stone et al. PLoS One. .

Abstract

Background: Prognosis in Palliative care Study (PiPS) models predict survival probabilities in advanced cancer. PiPS-A (clinical observations only) and PiPS-B (additionally requiring blood results) consist of 14- and 56-day models (PiPS-A14; PiPS-A56; PiPS-B14; PiPS-B56) to create survival risk categories: days, weeks, months. The primary aim was to compare PIPS-B risk categories against agreed multi-professional estimates of survival (AMPES) and to validate PiPS-A and PiPS-B. Secondary aims were to assess acceptability of PiPS to patients, caregivers and health professionals (HPs).

Methods and findings: A national, multi-centre, prospective, observational, cohort study with nested qualitative sub-study using interviews with patients, caregivers and HPs. Validation study participants were adults with incurable cancer; with or without capacity; recently referred to community, hospital and hospice palliative care services across England and Wales. Sub-study participants were patients, caregivers and HPs. 1833 participants were recruited. PiPS-B risk categories were as accurate as AMPES [PiPS-B accuracy (910/1484; 61%); AMPES (914/1484; 61%); p = 0.851]. PiPS-B14 discrimination (C-statistic 0.837) and PiPS-B56 (0.810) were excellent. PiPS-B14 predictions were too high in the 57-74% risk group (Calibration-in-the-large [CiL] -0.202; Calibration slope [CS] 0.840). PiPS-B56 was well-calibrated (CiL 0.152; CS 0.914). PiPS-A risk categories were less accurate than AMPES (p<0.001). PiPS-A14 (C-statistic 0.825; CiL -0.037; CS 0.981) and PiPS-A56 (C-statistic 0.776; CiL 0.109; CS 0.946) had excellent or reasonably good discrimination and calibration. Interviewed patients (n = 29) and caregivers (n = 20) wanted prognostic information and considered that PiPS may aid communication. HPs (n = 32) found PiPS user-friendly and considered risk categories potentially helpful for decision-making. The need for a blood test for PiPS-B was considered a limitation.

Conclusions: PiPS-B risk categories are as accurate as AMPES made by experienced doctors and nurses. PiPS-A categories are less accurate. Patients, carers and HPs regard PiPS as potentially helpful in clinical practice.

Study registration: ISRCTN13688211.

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Conflict of interest statement

Competing interests - Prof Stone, Prof Todd, Prof Omar, Prof Keeley and Dr Griffiths received grants from National Institute for Health Research, during the conduct of the study; Members of the PiPS2 investigators group, in non-NHS units, received funds from NIHR (via UCL) for recruitment of participants. No authors declare any financial relationships with any organisations that might have an interest in the submitted work in the previous three years, and no other relationships or activities that could appear to have influenced the submitted work. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Figures

Fig 1
Fig 1. PiPS-A all patients.
Observed and predicted proportion of events using PiPS-A14 and PiPS-A56 in all patients. Vertical bars represent observed (dark grey) and model-based predicted (light grey) probabilities of surviving either days (left) or months (right). The risk groups were created using the model-based predicted probabilities with an equal number of participants being allocated into each risk group. The predicted probabilities used for each risk group are shown. These groups are selected for the purpose of validation rather than clinical decision making. PiPS-A14: n = 1802; Proportion of events = 1407/1802 (78.1%). PiPS-A56: n = 1803; Proportion of events = 815/1803 (45.2%).
Fig 2
Fig 2. PiPS-B all patients.
Observed and predicted proportion of events using PiPS-B14 and PiPS-B56 in all patients. Vertical bars represent observed (dark grey) and model-based predicted (light grey) probabilities of surviving either days (left) or months (right). The risk groups were created using the model-based predicted probabilities with an equal number of participants being allocated into each risk group. The predicted probabilities used for each risk group are shown. These groups are selected for the purpose of validation rather than clinical decision making. PiPS-B14: n = 1497; Proportion of events = 1238/1497 (82·7%). One participant was removed from this analysis as their PiPS-B14 value was an outlier. PiPS-B56: n = 1498; Proportion of events = 727/1498 (48·5%).
Fig 3
Fig 3. PiPS-A patients receiving non-hormonal SACT.
Observed and predicted proportion of events using PiPS-A14 and PiPS-A56 in patients receiving non-hormonal SACT. Vertical bars represent observed (dark grey) and model-based predicted (light grey) probabilities of surviving either days (left) or months (right). The risk groups were created using the model-based predicted probabilities with an equal number of participants being allocated into each risk group. The predicted probabilities used for each risk group are shown. These groups are selected for the purpose of validation rather than clinical decision making. PiPS-A14: n = 1573; Proportion of events = 1206/1573 (76.7%). PiPS-A56: n = 1574; Proportion of events = 655/1574 (41.6%).
Fig 4
Fig 4. PiPS-B patients receiving non-hormonal SACT.
Observed and predicted proportion of events using PiPS-B14 and PiPS-B56 in patients receiving non-hormonal SACT. Vertical bars represent observed (dark grey) and model-based predicted (light grey) probabilities of surviving either days (left) or months (right). The risk groups were created using the model-based predicted probabilities with an equal number of participants being allocated into each risk group. The predicted probabilities used for each risk group are shown. These groups are selected for the purpose of validation rather than clinical decision making. PiPS-B14: n = 1300; Proportion of events = 1063/1300 (81.8%). PiPS-B56: n = 1299; Proportion of events = 586/1299 (45.1).
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References

    1. Steinhauser K, Christakis N, Clipp E, McNeilly M, Grambow SC, Parker J, et al.. Preparing for the End of Life: Preferences of Patients, Families, Physicians, and Other Care Providers. journal of Pain and Symptom Management. 2001;22(3):727–37. 10.1016/s0885-3924(01)00334-7 - DOI - PubMed
    1. Chu C, White N, Stone P. Prognostication in palliative care. Clinical Medicine 2019;19(4):306–10. 10.7861/clinmedicine.19-4-306 - DOI - PMC - PubMed
    1. Ravdin P, Siminoff L, Davis G, Mercer M, Hewlett J, Gerson N, et al.. Computer program to assist in making decisions about adjuvant therapy for women with early breast cancer. J Clin Oncol 2001;19:980–91. 10.1200/JCO.2001.19.4.980 - DOI - PubMed
    1. White N, Reid F, Harris A, Harries P, Stone P. A Systematic Review of Predictions of Survival in Palliative Care: How Accurate Are Clinicians and Who Are the Experts? PLoS ONE [Electronic Resource]. 2016;11(8):e0161407. 10.1371/journal.pone.0161407 . - DOI - PMC - PubMed
    1. Pirovano M, Maltoni M, Nanni O, Marinari M, Indelli M, Zaninetta G, et al.. A new palliative prognostic score: a first step for the staging of terminally ill cancer patients. Italian Multicenter and Study Group on Palliative Care. J Pain Symptom Manage. 1999;17(4):231–9. Epub 1999/04/16. 10.1016/s0885-3924(98)00145-6 . - DOI - PubMed

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