背景:高强度临终(EOL)护理,以入住重症监护病房(ICU)或住院死亡为标志,可能是昂贵和繁重的。ICUs使用的最新趋势,维持生命的治疗(LST),老年晚期癌症患者在EOL住院期间的无创通气(NIV)和院内死亡模式不详.
方法:我们使用SEER-Medicare数据(2003-2017)来确定在诊断后3年内死亡的晚期实体癌(总结阶段7)受益人。我们确定了EOL住院(死亡后30天内),通过增加护理强度将其分类为:(1)无ICU;(2)有ICU但无LST(有创机械通气,气管造口术,胃造口术,急性透析)或NIV;(3)使用ICU和NIV但不使用LST;(4)使用ICU和LST。我们构建了一个多元回归模型来评估风险调整后住院的趋势,整体和跨住院类别,适应社会人口统计学,癌症特征,合并症,和脆弱。我们评估了不同类别的住院死亡趋势。
结果:在226,263名晚期癌症医疗保险受益人中,138,305(61.1%)在EOL住院[年龄,平均值(SD):77.9(7.1)年;45.5%女性]。总的来说,整个EOL住院率仍然很高,从2004年的78.1%(95%CI:77.4,78.7)到2017年的75.5%(95%CI:74.5,76.2)。未使用ICU的住院率从49.3%(95%CI:48.5,50.2)降至35.0%(95%CI:34.2,35.9),而重症监护住院率增加,从23.7%(95%CI:23.0,24.4)到28.7%(95%CI:27.9,29.5)没有LST或NIV的ICU,有NIV但无LST的ICU为0.8%(95%CI:0.6,0.9)至3.8%(95%CI:3.4,4.1),对于使用LST的ICU,为4.3%(95%CI:4.0,4.7)至8.0%(95%CI:7.5,8.5)。在那些经历过住院死亡的人中,接受ICU护理的比例从46.5%增加到65.0%.
结论:在患有晚期癌症的老年人中,从2004年至2017年,EOL住院率保持稳定。然而,EOL住院期间的护理强度增加,ICU的使用增加证明了这一点,LSTs,和NIV。
BACKGROUND: High-intensity end-of-life (EOL) care, marked by admission to intensive care units (ICUs) or in-hospital death, can be costly and burdensome. Recent trends in use of ICUs, life-sustaining treatments (LSTs), and noninvasive ventilation (NIV) during EOL hospitalizations among older adults with advanced cancer and patterns of in-hospital death are unknown.
METHODS: We used SEER-Medicare data (2003-2017) to identify beneficiaries with advanced solid cancer (summary stage 7) who died within 3 years of diagnosis. We identified EOL hospitalizations (within 30 days of death), classifying them by increasing intensity of care into: (1) without ICU; (2) with ICU but without LST (invasive mechanical ventilation, tracheostomy, gastrostomy, acute dialysis) or NIV; (3) with ICU and NIV but without LST; and (4) with ICU and LST use. We constructed a multinomial regression model to evaluate trends in risk-adjusted hospitalization, overall and across hospitalization categories, adjusting for sociodemographics, cancer characteristics, comorbidities, and frailty. We evaluated trends in in-hospital death across categories.
RESULTS: Of 226,263 Medicare beneficiaries with advanced cancer, 138,305 (61.1%) were hospitalized at EOL [Age, Mean (SD):77.9(7.1) years; 45.5% female]. Overall, EOL hospitalizations remained high throughout, from 78.1% (95% CI: 77.4, 78.7) in 2004 to 75.5% (95% CI: 74.5, 76.2) in 2017. Hospitalizations without ICU use decreased from 49.3% (95% CI: 48.5, 50.2) to 35.0% (95% CI: 34.2, 35.9) while hospitalizations with more intensive care increased, from 23.7% (95% CI: 23.0, 24.4) to 28.7% (95% CI: 27.9, 29.5) for ICU without LST or NIV, 0.8% (95% CI: 0.6, 0.9) to 3.8% (95% CI: 3.4, 4.1) for ICU with NIV but without LST, and 4.3% (95% CI: 4.0, 4.7) to 8.0% (95% CI: 7.5, 8.5) for ICU with LST use. Among those who experienced in-hospital death, the proportion receiving ICU care increased from 46.5% to 65.0%.
CONCLUSIONS: Among older adults with advanced cancer, EOL hospitalization rates remained stable from 2004-2017. However, intensity of care during EOL hospitalizations increased as evidenced by increasing use of ICUs, LSTs, and NIV.