养老院中认知问题患者的临终过渡期。
End-of-life transitions among nursing home residents with cognitive issues.
机构信息
Brown University Program in Public Health, Department of Health Services, Policy, and Practice, Brown University, Providence, RI, USA.
出版信息
N Engl J Med. 2011 Sep 29;365(13):1212-21. doi: 10.1056/NEJMsa1100347.
BACKGROUND
Health care transitions in the last months of life can be burdensome and potentially of limited clinical benefit for patients with advanced cognitive and functional impairment.
METHODS
To examine health care transitions among Medicare decedents with advanced cognitive and functional impairment who were nursing home residents 120 days before death, we linked nationwide data from the Medicare Minimum Data Set and claims files from 2000 through 2007. We defined patterns of transition as burdensome if they occurred in the last 3 days of life, if there was a lack of continuity in nursing homes after hospitalization in the last 90 days of life, or if there were multiple hospitalizations in the last 90 days of life. We also considered various factors explaining variation in these rates of burdensome transition. We examined whether there was an association between regional rates of burdensome transition and the likelihood of feeding-tube insertion, hospitalization in an intensive care unit (ICU) in the last month of life, the presence of a stage IV decubitus ulcer, and hospice enrollment in the last 3 days of life.
RESULTS
Among 474,829 nursing home decedents, 19.0% had at least one burdensome transition (range, 2.1% in Alaska to 37.5% in Louisiana). In adjusted analyses, blacks, Hispanics, and those without an advance directive were at increased risk. Nursing home residents in regions in the highest quintile of burdensome transitions (as compared with those in the lowest quintile) were significantly more likely to have a feeding tube (adjusted risk ratio, 3.38), have spent time in an ICU in the last month of life (adjusted risk ratio, 2.10), have a stage IV decubitus ulcer (adjusted risk ratio, 2.28), or have had a late enrollment in hospice (adjusted risk ratio, 1.17).
CONCLUSIONS
Burdensome transitions are common, vary according to state, and are associated with markers of poor quality in end-of-life care.
背景
对于患有严重认知和功能障碍的末期患者，临终前几个月的医疗保健转移可能会带来负担，并且可能对临床效益有限。
方法
为了研究在死亡前 120 天内居住在养老院的患有严重认知和功能障碍的 Medicare 死者中发生的医疗保健转移，我们将来自 Medicare 最低数据集和 2000 年至 2007 年期间的索赔文件的全国性数据进行了链接。如果在生命的最后 3 天内发生转移，如果在生命的最后 90 天内住院后疗养院之间缺乏连续性，或者在生命的最后 90 天内发生多次住院，则将转移模式定义为负担沉重。我们还考虑了各种因素，以解释这些负担沉重的转移率的差异。我们检查了地区性负担沉重的转移率与喂养管插入的可能性，生命的最后一个月入住重症监护病房（ICU），IV 期褥疮的存在以及生命的最后 3 天内的临终关怀注册之间是否存在关联。
结果
在 474,829 名养老院死者中，有 19.0％的人至少有一次负担沉重的转移（范围从阿拉斯加的 2.1％到路易斯安那州的 37.5％）。在调整后的分析中，黑人，西班牙裔和没有预立指示的人面临更高的风险。处于负担沉重的转移最高五分位数的养老院居民（与处于最低五分位数的居民相比）更有可能接受喂养管（调整后的风险比，3.38），在生命的最后一个月中有 ICU 时间（调整后的风险比，2.10），患有 IV 期褥疮（调整后的风险比，2.28）或晚期接受临终关怀（调整后的风险比，1.17）。
结论
负担沉重的转移很常见，因州而异，并与临终关怀质量差的标志物相关。
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