Use of the Palliative Performance Scale to Estimate Survival among Home Hospice Heart Failure Patients

Abstract

Background Estimating survival is challenging in the terminal phase of advanced heart failure. Patients, families and healthcare organizations would benefit from more reliable prognostic tools. The Palliative Performance Scale Version 2 (PPSv2) has been widely used to estimate survival in patients with cancer, but rarely used in patients with heart failure. Methods We performed a retrospective analysis of 1,114 patients with a primary diagnosis of heart failure who were enrolled in the Visiting Nurse Service of New York cardiac home hospice program from January 2013 and May 2017. The primary outcome was survival time. Results The majority of home hospice patients in our analysis were female (56.6%), 85 years or older, and had a primary caregiver (83.8%). All patients lived in New York City and were racially and ethnically diverse (22.4% Hispanic, 17.8% African American and 7.6% Asian). Most patients were insured through Medicare (63.4%) or Managed Medicare (e.g., Medicare Advantage; 29.4%) and were admitted into hospice from the hospital (53.6%). PPSv2 scores on admission independently predict survival time among hospice patients with heart failure. Lower PPSv2 scores on admission were associated with decreased median survival time (PPSv2 10 = 2 (interquartile range (IQR: 4) days; PPSv2 20 = 3 (IQR: 6) days; PPSv2 30 = 13 (IQR: 48) days). Kaplan-Meier survival curves indicate a graded increase in mortality risk from higher to lower PPSv2 scores. The discrimination of the PPSv2 at baseline for predicting death was highest at 7 days (area under the curve (AUC)=0.802), followed by an AUC of 0.774 at 14 days, an AUC of 0.736 at 30 days, and an AUC of 0.705 at 90 days. Conclusions The PPSv2 tool can be used by healthcare providers for prognostication of hospice-enrolled patients with heart failure who are at high risk of near-term death. It has the greatest utility in patients who have the most functional impairment.