Department of Health Policy & Management, Johns Hopkins University, Baltimore, Maryland 21205, USA.
J Palliat Med. 2011 Apr;14(4):451-7. doi: 10.1089/jpm.2010.0434. Epub 2011 Mar 10.
We assessed key aspects of the quality of end-of-life care using validated explicit process quality measures in an academic medical center (hospital and cancer center) before expanding to a broader palliative care initiative.
We evaluated 21 indicators most relevant to end-of-life care from the Cancer Quality-ASSIST supportive oncology indicator set for 238 patients with advanced/metastatic solid tumors who died between 2-15 months after diagnosis. These included outpatient and hospital indicators for cancer symptoms and information and care planning that met criteria for feasibility, reliability, and validity. We abstracted detailed information from medical records to specify the necessary data elements.
Overall adherence was 53% (95% confidence interval [CI], 50%-56%); this varied widely among indicators. Adherence was highest for pain indicators; in particular, 97% of eligible subjects' hospitalizations had documented screening for pain, and, after an outpatient pain medication was changed, 97% of patients had a pain assessment at the subsequent visit. For other symptoms, adherence ranged from 0% for documentation of life expectancy for patients starting parenteral or enteral nutrition to 87% for assessment of nausea or vomiting on hospital admission. For information and care planning, results ranged from 6% for documentation of ventilation preferences prior to intubation to 68% for documented communication of risks and benefits or prognosis prior to starting chemotherapy.
In conclusion, Cancer Quality-ASSIST indicators are useful for practical quality assessment of cancer end-of-life care in an academic medical center. These results will serve as useful data for targeting areas for quality improvement and measuring progress.
在扩大姑息治疗计划之前，我们使用经过验证的明确过程质量指标，在一家学术医疗中心（医院和癌症中心）评估临终关怀质量的关键方面。
我们评估了与癌症质量辅助支持肿瘤学指标集中的 238 名晚期/转移性实体瘤患者相关的 21 个最相关的临终关怀指标，这些患者在诊断后 2-15 个月死亡。这些指标包括门诊和医院的癌症症状指标，以及符合可行性、可靠性和有效性标准的信息和护理计划。我们从病历中提取详细信息，以指定必要的数据元素。
总体依从率为 53%（95%置信区间[CI]，50%-56%）；这在指标之间差异很大。对疼痛指标的依从性最高；特别是，97%符合条件的患者的住院治疗都有记录疼痛筛查，并且在门诊疼痛药物更改后，97%的患者在随后的就诊时都进行了疼痛评估。对于其他症状，从开始肠外或肠内营养的患者预期寿命的记录为 0%到入院时恶心或呕吐的评估为 87%不等。对于信息和护理计划，结果从插管前记录通气偏好的 6%到开始化疗前记录沟通风险、获益或预后的 68%不等。
总之，癌症质量辅助指标可用于学术医疗中心癌症临终关怀质量的实际评估。这些结果将作为确定质量改进领域和衡量进展的有用数据。
