背景:高强度临终(EoL)护理对患者来说可能是繁重的,看护者,和卫生系统,并不赋予任何有意义的临床益处。然而,关于高强度EoL护理的预测因素存在显著的知识差距.在这项研究中,我们在患有四种最常见恶性肿瘤的老年人中确定了与高强度EoL护理相关的危险因素,包括乳房,前列腺,肺,还有结直肠癌.
方法:使用SEER-Medicare数据,我们对65岁及以上死于乳腺癌的医疗保险受益人进行了回顾性分析,前列腺,肺,或结直肠癌在2011年至2015年之间。我们使用多变量逻辑回归来确定临床,人口统计学,社会经济,以及高强度EoL护理的地理预测因子,我们定义为在急性护理医院死亡,在死亡后14天内接受任何口服或肠胃外化疗,在死亡后30天内有一次或多次入住重症监护室,死亡后30天内两次或两次以上的急诊科就诊,或在死亡后30天内两次或两次以上住院。
结果:在59,355名死者中,与接受高强度EOL护理的可能性增加相关的因素是合并症负担增加(比值比[OR]:1.29;95%置信区间[CI]:1.28-1.30),女性(OR:1.05;95%CI:1.01-1.09),黑人种族(OR:1.14;95%CI:1.07-1.23),其他种族/民族(OR:1.20;95%CI:1.10-1.30),III期疾病(OR:1.11;95%CI:1.05-1.18),生活在人口>1,000,000的县(OR:1.23;95%CI:1.16-1.31),生活在10%-<20%贫困(OR:1.09;95%CI:1.03-1.16)或20%-100%贫困(OR:1.12;95%CI:1.04-1.19)的人口普查区域,并拥有国家补贴的医疗保险保费(OR:1.18;95%CI:1.12-1.24)。在年龄较大的患者中,高强度EoL护理的风险较低(OR:0.98;95%CI:0.98-0.99),居住在中西部(OR:0.69;95%CI:0.65-0.75),南部(OR:0.70;95%CI:0.65-0.74),或西部(OR:0.81;95%CI:0.77-0.86),大部分生活在农村地区(OR:0.92;95%CI:0.86-1.00),并且表现不佳(OR:0.26;95%CI:0.25-0.28)。不同癌症类型的结果基本一致。
结论:我们研究中确定的危险因素可以为可能接受高强度EoL治疗的癌症患者提供新干预措施的开发。卫生系统应考虑将这些风险因素纳入决策支持工具,以帮助临床医生确定哪些患者应接受临终关怀和姑息治疗。
BACKGROUND: High-intensity end-of-life (EoL) care can be burdensome for patients, caregivers, and health systems and does not confer any meaningful clinical benefit. Yet, there are significant knowledge gaps regarding the predictors of high-intensity EoL care. In this
study, we identify risk factors associated with high-intensity EoL care among older adults with the four most common malignancies, including breast, prostate, lung, and colorectal cancer.
METHODS: Using SEER-Medicare data, we conducted a retrospective analysis of Medicare beneficiaries aged 65 and older who died of breast, prostate, lung, or colorectal cancer between 2011 and 2015. We used multivariable logistic regression to identify clinical, demographic, socioeconomic, and geographic predictors of high-intensity EoL care, which we defined as death in an acute care hospital, receipt of any oral or parenteral chemotherapy within 14 days of death, one or more admissions to the intensive care unit within 30 days of death, two or more emergency department visits within 30 days of death, or two or more inpatient admissions within 30 days of death.
RESULTS: Among 59,355 decedents, factors associated with increased likelihood of receiving high-intensity EoL care were increased comorbidity burden (odds ratio [OR]:1.29; 95% confidence interval [CI]:1.28-1.30), female sex (OR:1.05; 95% CI:1.01-1.09), Black race (OR:1.14; 95% CI:1.07-1.23), Other race/ethnicity (OR:1.20; 95% CI:1.10-1.30), stage III disease (OR:1.11; 95% CI:1.05-1.18), living in a county with >1,000,000 people (OR:1.23; 95% CI:1.16-1.31), living in a census tract with 10%-<20% poverty (OR:1.09; 95% CI:1.03-1.16) or 20%-100% poverty (OR:1.12; 95% CI:1.04-1.19), and having state-subsidized Medicare premiums (OR:1.18; 95% CI:1.12-1.24). The risk of high-intensity EoL care was lower among patients who were older (OR:0.98; 95% CI:0.98-0.99), lived in the Midwest (OR:0.69; 95% CI:0.65-0.75), South (OR:0.70; 95% CI:0.65-0.74), or West (OR:0.81; 95% CI:0.77-0.86), lived in mostly rural areas (OR:0.92; 95% CI:0.86-1.00), and had poor performance status (OR:0.26; 95% CI:0.25-0.28). Results were largely consistent across cancer types.
CONCLUSIONS: The risk factors identified in our
study can inform the development of new interventions for patients with cancer who are likely to receive high-intensity EoL care. Health systems should consider incorporating these risk factors into decision-support tools to assist clinicians in identifying which patients should be referred to hospice and palliative care.