Transcript association with prolonged length of hospital stay among patients

Pretreatment malnutrition and quality of
life - association with prolonged length of
hospital stay among patients with
gynecological cancer: a cohort study
Laky et al. BMC Cancer 2010, 10:232
99/11/28
鄒季臻
Abstract


Background:

Length of hospital stay (LOS) is a surrogate marker for patients'
well-being during hospital treatment and is associated with health
care costs.

Identifying pretreatment factors associated with LOS in surgical
patients may enable early intervention in order to reduce
postoperative LOS.
Methods:

This cohort study enrolled 157 patients with suspected or proven
gynecological cancer at a tertiary cancer centre (2004-2006).

Before commencing treatment, the scored Patient Generated Subjective Global Assessment (PGSGA) measuring nutritional
status and the Functional Assessment of Cancer Therapy-General
(FACT-G) scale measuring quality of life (QOL) were completed.

Clinical and demographic patient characteristics were prospectively
obtained.

Patients were grouped into those with prolonged LOS if their
hospital stay was greater than the median LOS and those with
average or below average LOS.
Abstract

Results:

Patients' mean age was 58 years (SD 14 years).
Preoperatively, 81 (52%) patients presented with
suspected benign disease/pelvic mass, 23 (15%) with
suspected advanced ovarian cancer, 36 (23%)
patients with suspected endometrial and 17 (11%) with
cervical cancer, respectively.

In univariate models prolonged LOS was associated
with low serum albumin or hemoglobin, malnutrition
(PG-SGA score and PG-SGA group B or C), low
pretreatment FACT-G score, and suspected diagnosis
of cancer.

In multivariable models, PG-SGA group B or C, FACTG score and suspected diagnosis of advanced ovarian
cancer independently predicted LOS.
外科手術前
良性診斷/骨盆腫瘤
疑後階卵巢癌
子宮內膜癌
子宮頸癌
人數
81
23
36
17
%
52
15
23
11
Abstract

Conclusions:

Malnutrition, low quality of life scores and being diagnosed
with advanced ovarian cancer are the major determinants
of prolonged LOS amongst gynecological cancer patients.

Interventions addressing malnutrition and poor QOL may
decrease LOS in gynecological cancer patients.
Background





Previous research has shown that preoperative serum
albumin (a marker of chronic malnutrition), hemoglobin and
lymphocyte status are associated with LOS and mortality in
the gynecological oncology setting .
Malnutrition has been found to be associated with increased
risk of morbidity and mortality, complication rates such as
wound infections, costs of hospitalisation, and decreased QOL
in various cancer populations .
Using the PG-SGA, we have observed high levels of
nutritional deficiencies among patients with gynecological
cancer, especially those diagnosed with ovarian cancer. but to
date no study has assessed whether the scored PG-SGA can
predict prolonged LOS among gynecological cancer patients.
Health-related QOL before treatment commences has been
suggested as an important prognostic factor in ovarian cancer
patients .
To our knowledge, no study to date evaluated the association
between preoperative QOL, malnutrition and LOS among a
wider range of gynecological cancer patients.
Methods
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
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2004/05~2006/12 primary gynecological 194 patients

excluded
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if they presented with recurrent cancer
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treatment for other cancers within the past five years

impairments (e.g. schizophrenia, dementia)
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were non-English speaking
32 study participants declined(FACT-G)
5 participants had to be excluded from analyses due to
incomplete data
157 women completed both the scored PG-SGA and the
FACT-G questionnaire before commencing treatment.
6 women did not undergosurgery, because chemotherapy
and/or radiotherapy treatment.
Methods

Nutritional assessment

The scored PG-SGA is a validated nutritional assessment
tool for cancer patients
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Women were classified as well nourished (PG-SGA A);
moderately malnourished or suspected of being
malnourished (PG-SGA B); or severely malnourished (PGSGA C).

The PG-SGA also incorporates a numerical score (PGSGA score). with higher scores reflecting greater risk of
malnutrition.
Methods

QOL assessment

QOL was measured by the FACT-G questionnaire, which
is a widely utilized and validated instrument.

Version 4 of the FACT-G is a 27-item self-report measure
and allows patients to rate their current physical (7 items,
range: 0-28), social and family (7 items, range: 0-28),
motional (6 items, range: 0-24), and functional wellbeing
(7 items, range: 0-28). The FACT-G is scored using a 5point scale (0 = not at all, 1 = a little bit, 2 = somewhat, 3
= quite a bit, 4 = very much).
Methods
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Statistical analysis
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Prolonged LOS was defined as LOS of greater than five
days for patients who underwent open abdominal surgery
and greater than two days for patients who underwent
vaginal of laparoscopic surgery.

univariate: adjusted for age and surgical approach;

Multivariable: adjusted for albumin, FACT-G score, PGSGA score and PG-SGA global rating; age and surgical
approach.
Results
Patient Characteristics

Patients' mean age was
58 years (SD 14 years).

外科手術前
良性診斷/骨盆腫瘤
疑後階卵巢癌
子宮內膜癌
子宮頸癌
人數
81
23
36
17
%
52
15
23
11
治療
剖腹手術
內視鏡手術
陰道手術
化/放療
人數
94
40
17
6
Results
Discussion
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Malnutrition and low QOL were found to predict prolonged
LOS independent of patients' age at diagnosis, surgical
approach (laparoscopy or laparotomy), albumin and
hemoglobin and suspected clinical diagnosis.
Patients suspected to have stage III or IV ovarian cancer were
also independently at greater risk for prolonged LOS
compared to other patients.
in our study the PG-SGA score was the weaker predictor
compared to the global rating in multivariable analysis.
Our findings show that LOS was not equally istributed
between tumor types. Even after adjustment for age and
surgical approach, 96% of all suspected advanced stage
ovarian cancer patients had prolonged hospital stay, ompared
with only 50% of patients with endometrial cancer and 42% of
patients with a pelvic mass.
Discussion
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A previous study by Dean and colleagues found that
gynecological cancer patients with two or more pre-existing
co-morbidities had significantly longer LOS than those with
one or no co-morbidities .
Our findings suggest that in this sample of gynecological
cancer patients, neither the number of co-morbidities nor the
type of co-morbidity are predictive of prolonged LOS.
In this study, we found low preoperative hemoglobin and
lymphocyte counts in a small number of atients and these
patients were more likely to experience prolonged LOS, but
this difference was no longer statistically significant in adjusted
modelling.
Discussion
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
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However, our current results demonstrated that when albumin
and PG-SGA global rating were assessed concurrently, the
PG-SGA was a stronger predictor of LOS, and therefore more
sensitive to detect malnutrition in gynecological cancer atients.
In the present study we found that poor QOL prior to initial
treatment was associated with prolonged LOS, and this
association remained significant when adjusted for other
variables.
A limitation of our study was that data on nutritional status and
QOL were only assessed before commencement of initial
treatment and not at any time point afterwards.
Conclusions
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
prolonged LOS was found to be associated with low presurgical QOL and malnutrition.
Strategies to reduce LOS and improve patients' well-being
during hospital stay will need to address these potentially
modifiable factors, particularly among women with suspected
advanced ovarian cancer.