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Using the modified Barthel index to estimate survival in cancer patients in hospice: observational study

Mike Bennett, consultant in palliative medicine ^a, Nicola Ryall, specialist registrar in rehabilitation medicine ^b. 

^a St Gemma's Hospice, Leeds LS17 6QD, ^b Rheumatology and Rehabilitation Research Unit, Leeds LS2 9NZ

Correspondence to: M Bennett m.bennett{at}st-gemma.co.uk

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

Top Patients, methods, and results Comment References

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 (r_s=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 (r_s=0.3, P=0.002) but more closely with mean weekly change (r_s=-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

Top Patients, methods, and results Comment References

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.

	Acknowledgments

We thank Professor Anne Chamberlain, Dr Bippin Bhakta, and Dr Jan Geddes for their comments.

Contributors: MB had the original idea, designed the study, analysed the results, and drafted the paper. NR helped to collect and interpret the data and revise the paper. MB is guarantor for the study.

	Footnotes

Funding: None.

Competing interests: None declared.

A table showing scores on admission is available on the BMJ's website

	References

Top Patients, methods, and results Comment References

1.	Evans C, McCarthy M. Prognostic uncertainty in terminal care: can the Karnofsky index help? Lancet 1985; i: 1204-1206.
2.	Yates JW, Chalmer B, McKegner FP. Evaluation of patients with advanced cancer using the Karnofsky performance status. Cancer 1980; 45: 2220-2224[CrossRef][Medline].
3.	Shah S, Vanclay F, Cooper B. Improving the sensitivity of the Barthel index for stroke rehabilitation. J Clinical Epidemiol 1989; 42: 703-709[CrossRef][Medline].
4.	Tennant A, Geddes JM, Chamberlain MA. The Barthel index: an ordinal score or interval level measure? Clin Rehab 1996; 10: 301-308[Abstract/Free Full Text].

(Accepted 7 February 2000)