Validation Study of the PALCOM Scale of Complexity of Palliative Care Needs: A Cohort Study in Advanced Cancer Patients

Abstract

Background: In a patient-centred model of care, referral to early palliative care (EPC) depends on both the prognosis and the complexity of care needs. The PALCOM scale is a 5-domain multidimensional assessment tool developed to identify the level of complexity of palliative care needs of cancer patients. The aim of this study was to validate the PALCOM scale. Patient and methods: We conducted a prospective cohort study of cancer patients to compare the PALCOM scale and expert empirical assessment (EA) of the complexity of palliative care needs. The EA had to categorise patients according to their complexity, considering that medium to high levels required priority attention from specialist EPC teams, while those with low levels could be managed by non-specialist teams. Systematically collected multidimensional variables were recorded in an electronic report form and stratified by level of complexity and rating system (PALCOM scale versus EA). The correlation rank (Kendall’s tau test) and accuracy test (F1-score) between the two rating systems were analysed. ROC curve analysis was used to determine the predictive power of the PALCOM scale. Results: A total of 283 advanced cancer patients were included. There were no significant differences in the frequency of the levels of complexity between the EA and the PALCOM scale (low 22.3–23.7%; medium 57.2–59.0%; high 20.5–17.3%). The prevalence of high symptom burden, severe pain, functional impairment, socio-familial risk, existential/spiritual problems, 6-month mortality and in-hospital death was significantly higher (p < 0.001) at the high complexity levels in both scoring systems. Comparative analysis showed a high correlation rank and accuracy between the two scoring systems (Kendall’s tau test 0.81, F1 score 0.84). The predictive ability of the PALCOM scale was confirmed by an area under the curve in the ROC analysis of 0.907 for high and 0.902 for low complexity. Conclusions: In a patient-centred care model, the identification of complexity is a key point to appropriate referral and management of shared care with EPC teams. The PALCOM scale is a high precision tool for determining the level of complexity of palliative care needs.

Evolution of Complexity of Palliative Care Needs and Patient Profiles According to the PALCOM Scale (Part Two): Pooled Analysis of the Cohorts for the Development and Validation of the PALCOM Scale in Advanced Cancer Patients

“…This was a prospective, observational, multicenter study with a longitudinal follow-up of 6 months based on the pooled data of the development and validation cohorts of the PALCOM scale in patients with advanced cancer. Part one of this project was the external validation of the PALCOM scale [46], and part two, which we now present, is the pooled analysis of the development and validation cohorts and also the analysis of the evolutionary behavior of palliative complexity during patient follow-up.…”

“…The PALCOM scale was developed in 2018 [31] and validated in 2023 [46] specifically for patients with advanced cancer. It is a multidimensional scale with five domains of evaluation: (a) symptom burden; (b) refractory pain; (c) functional impairment; (d) socio-familial risk factors; (e) spiritual/existential problems (Table 1).…”

“…Complex systems are characterized by depending on the continuous interaction of multiple variables within an unstable equilibrium that is very sensitive to rapid, and not always predictable, changes from the initial conditions [37][38][39][40][41][42][43][44][45][46]. In accordance with this argument, the analysis of evolutionary instability is essential to understanding the model of palliative complexity.…”

“…The intrinsic difficulty of a targeted referral model, which is easy to accept from a theoretical point of view, is that the categorization of the complexity of PC needs is neither agreed upon nor well-defined. A recent review of the literature identified six models of classification of the complexity of PC needs, aimed at managing referral and shared care with the specialized EPC teams (Hex-Com, Perroca-Scale, AN-SNAP, Hui-Major-Criteria, IDC-Pal, PALCOM) [29][30][31][32][33][34][35][36][37][38][39][40][41][42][43][44][45][46]. The use of these tools allows the complexity of PC needs to be categorized as low, in which basic PC would be indicated (primary or secondary PC) or medium-high, in which care by specialized EPC teams would be systematically indicated (tertiary PC).…”

“…The hypothesis is that the levels of greatest complexity present an evolution characterized by greater instability, resource consumption and mortality. [31,46].…”