Rose J H, O'Toole E E, Dawson N V, Thomas C, Connors A F, Wenger N, Phillips R S, Hamel M B, Reding D T, Cohen H J, Lynn J
Department of Medicine-Geriatrics, Case Western Reserve University School of Medicine, Celeveland, Ohio 44120, USA.
Med Care. 2000 Nov;38(11):1103-18. doi: 10.1097/00005650-200011000-00005.
The objective of this work was to identify similarities and differences in primary attending physicians' (generalists' versus oncologists') care practices and outcomes for seriously ill hospitalized patients with malignancy.
This was a prospective cohort study (SUPPORT project).
Subjects were recruited from 5 US teaching hospitals; data were gathered from 1989 to 1994.
Included in the study was a matched sample of 642 hospitalized patients receiving care for non-small-cell lung cancer, colon cancer metastasized to the liver, or multiorgan system failure associated with malignancy with either a generalist or an oncologist as the primary attending physician.
Care practices and patient outcomes were determined from hospital records. Length of survival was identified with the National Death Index. Physicians' perceptions of patient's prognosis, preference for cardiopulmonary resuscitation (CPR), and length of relationship were assessed by interview. A propensity score for receiving care from an oncologist was constructed. After propensity-based matching of patients, practices and outcomes of oncologists' and generalists' patients were assessed through group comparison techniques.
Generalist and oncologist attendings showed comparable care practices, including the number of therapeutic interventions, eg, "rescue care" and chemotherapy, and the number of care topics discussed with patients/ families. Length of stay, discharge to supportive care, readmission, total hospital costs, and survival rates were similar. For both physician groups, perception of patients' wish for CPR was associated with rescue care (P < 0.03), and such care was related to higher hospital costs (P < 0.000). Poorer prognostic estimates predicted aggressiveness-of-care discussions by both types of physicians. Length of the patient-doctor relationship was associated with oncologists' care practices. More documented discussion about aggressiveness of care was related to higher hospital costs and shorter survival for patients in both physician groups (P < 0.001).
Generalists and oncologists showed similar care practices and outcomes for comparable hospitalized late-stage cancer patients. Physicians' perceptions about patients' preferences for CPR and prognosis influenced decision making and outcomes for patients in both physician groups. Length of relationship with patients was associated only with oncologists' care practices. Rescue care increased hospital costs but had no effect on patient survival. Future studies should compare physicians' palliative care as well as acute-care practices in both inpatient and ambulatory care settings. Patients' end-of-life quality and interchange between physician groups should also be documented and compared.
本研究旨在确定在为身患恶性肿瘤的重症住院患者提供治疗时，初级主治医师（全科医生与肿瘤医生）的护理方法及治疗结果的异同。
这是一项前瞻性队列研究（SUPPORT项目）。
研究对象招募自美国5家教学医院；数据收集时间为1989年至1994年。
本研究纳入了642名住院患者的匹配样本，这些患者因非小细胞肺癌、转移至肝脏的结肠癌或与恶性肿瘤相关的多器官系统衰竭接受治疗，其初级主治医师为全科医生或肿瘤医生。
护理方法及患者治疗结果由医院记录确定。生存时长通过国家死亡指数确定。通过访谈评估医生对患者预后的看法、对心肺复苏（CPR）的偏好以及医患关系时长。构建了接受肿瘤医生治疗的倾向得分。在对患者进行基于倾向得分的匹配后，通过组间比较技术评估肿瘤医生和全科医生所治疗患者的护理方法及治疗结果。
全科医生和肿瘤医生的护理方法相近，包括治疗干预措施的数量（如“抢救护理”和化疗）以及与患者/家属讨论的护理话题数量。住院时长、出院后接受支持性护理、再次入院、总住院费用及生存率相似。对于两组医生而言，对患者进行心肺复苏意愿的认知均与抢救护理相关（P < 0.03），且此类护理与更高的住院费用相关（P < 0.000）。预后评估较差预示着两类医生都会进行积极的护理讨论。医患关系时长与肿瘤医生的护理方法相关。更多关于积极护理的书面讨论与两组医生所治疗患者的更高住院费用及更短生存期相关（P < 0.001）。
对于情况相当的晚期癌症住院患者，全科医生和肿瘤医生的护理方法及治疗结果相似。医生对患者心肺复苏偏好及预后的认知影响了两组医生对患者的决策及治疗结果。与患者的关系时长仅与肿瘤医生的护理方法相关。抢救护理增加了住院费用，但对患者生存无影响。未来研究应比较医生在住院及门诊护理环境中的姑息治疗及急症护理方法。还应记录并比较患者的临终质量及不同医生群体之间的交替情况。
