ObjectiveChronic liver disease continues to be a significant cause of morbidity and mortality yet remains challenging to prognosticate. This has been one of the barriers to implementing palliative care, particularly at an early stage. The Bristol Prognostic Score (BPS) was developed to identify patients with life expectancy less than 12 months and to act as a trigger for referral to palliative care services. This study retrospectively evaluated the BPS in a cohort of patients admitted to three Scottish hospitals.MethodRoutinely collated healthcare data were used to obtain demographics, BPS and analyse 1-year mortality for patients with decompensated liver disease admitted to three gastroenterology units over two 90-day periods. Statistical analysis was undertaken to assess performance of BPS in predicting mortality.Results276 patients were included in the final analysis. Participants tended to be late middle-aged men, socioeconomically deprived and have alcohol-related liver disease. A similar proportion was BPS+ve (>3) in this study compared with the original Bristol cohort though had more hospital admissions, higher ongoing alcohol use and poorer performance status. BPS performed poorer in this non-Bristol group with sensitivity 54.9% (72.2% in original study), specificity 58% (83.8%) and positive predictive value (PPV) 43.4% (81.3%).ConclusionBPS was unable to accurately predict mortality in this Scottish cohort. This highlights the ongoing challenge of prognostication in patients with chronic liver disease, furthering the call for more work in this field.

Background: People with advanced cancer frequently use the GP Out-of-Horus (GPOOH) service. Significant amounts of routine GPOOH data are uncoded, and therefore omitted from existing healthcare datasets. Aim: To conduct a free-text analysis of a GPOOH dataset, to identify reasons for attendance and care delivered through GPOOH to people with advanced cancer. Design and setting: Analysis of GPOOH healthcare dataset containing all coded and free-text information for 5,749 attendances, from a cohort of 2,443 people who died from cancer in Tayside, Scotland in 2012-2015. Method: Random sampling methods selected 575 consultations for free-text analysis, each analysed by two independent reviewers, to determine assigned presenting complaints, key and additional palliative care symptoms recorded in free-text, evidence of anticipatory care planning and free-text recording of dispensed medications. Interrater reliability concordance established through Kappa testing. Results: Over half of all coded reasons for attendance (n=293, 51.0%) were ‘other’ or missing. Free-text analysis demonstrated that nearly half (n=284, 49.4%) of GPOOH attendances by people with advanced cancer were for pain or palliative care. More than half of GPOOH attendances (n=325, 56.5%) recorded at least one key or additional palliative care symptom in free-text, with the commonest being breathlessness, nausea, vomiting and cough. Anticipatory care planning was poorly recorded in both coded and uncoded records. Uncoded medications were dispensed in over a quarter of GPOOH consultations. Conclusion: GPOOH delivers a substantial amount of pain management and palliative care, much of which is uncoded and therefore unrecognised and under-reported in existing large healthcare data analyses.

AimPrevious studies have suggested an unmet symptom burden in patients with decompensated chronic liver disease (DCLD). The Bristol Prognosis Score (BPS) has been designed to identify patients with DCLD likely to be in the last year of their life, who may benefit from Specialist Palliative Care team input. We aimed to audit the prevalence of symptoms appropriate to trigger referal to the Hospital Specialist Palliative Care Team (HSPCT), (using the Integrated Palliative care Outcome Score (IPOS)), rates of recognition of these by physicians, and rates of referral to HPSCT according to BPS status.MethodsA prospective audit of all inpatients with DCLD admitted over 3 months was conducted. Patients completed IPOS questionnaires. Demographic data were collated in order to calculate BPS. Case notes were reviewed following discharge to assess if significant symptoms (regarded as scoring ‰¥ 2 on IPOS) were identified by the medical team. Referral rates to HSPCT were also recorded.Results40 patients with DCLD were included. 36 (90%) scored ‰¥2 in at least one IPOS category. Most patients (20(55.6%)) had only some of their significant symptoms recognised by medical staff. 27/40 (67.5%) patients were BPS positive. Of these only 1 (3.7%) was referred to HSPCT.ConclusionsThis work demonstrates a significant symptom burden in patients with DCLD. This does not appear to be recognised by the medial team, meaning referral rates to HSPCT are low. Routine use of the IPOS in conjunction with BPS may aid identification and referral of patients to HSPCT, and help address this.