Warren Alpert Medical School of Brown University, 121 S Main St, Providence, RI 02912, USA.
JAMA. 2013 Feb 6;309(5):470-7. doi: 10.1001/jama.2012.207624.
A recent Centers for Disease Control and Prevention report found that more persons die at home. This has been cited as evidence that persons dying in the United States are using more supportive care.
To describe changes in site of death, place of care, and health care transitions between 2000, 2005, and 2009.
DESIGN, SETTING, AND PATIENTS: Retrospective cohort study of a random 20% sample of fee-for-service Medicare beneficiaries, aged 66 years and older, who died in 2000 (n = 270,202), 2005 (n = 291,819), or 2009 (n = 286,282). A multivariable regression model examined outcomes in 2000 and 2009 after adjustment for sociodemographic characteristics. Based on billing data, patients were classified as having a medical diagnosis of cancer, chronic obstructive pulmonary disease, or dementia in the last 180 days of life.
Site of death, place of care, rates of health care transitions, and potentially burdensome transitions (eg, health care transitions in the last 3 days of life).
Our random 20% sample included 848,303 fee-for-service Medicare decedents (mean age, 82.3 years; 57.9% female, 88.1% white). Comparing 2000, 2005, and 2009, the proportion of deaths in acute care hospitals decreased from 32.6% (95% CI, 32.4%-32.8%) to 26.9% (95% CI, 26.7%-27.1%) to 24.6% (95% CI, 24.5%-24.8%), respectively. However, intensive care unit (ICU) use in the last month of life increased from 24.3% (95% CI, 24.1%-24.5%) to 26.3% (95% CI, 26.1%-26.5%) to 29.2% (95% CI, 29.0%-29.3%). (Test of trend P value was <.001 for each variable.) Hospice use at the time of death increased from 21.6% (95% CI, 21.4%-21.7%) to 32.3% (95% CI, 32.1%-32.5%) to 42.2% (95% CI, 42.0%-42.4%), with 28.4% (95% CI, 27.9%-28.5%) using a hospice for 3 days or less in 2009. Of these late hospice referrals, 40.3% (95% CI, 39.7%-40.8%) were preceded by hospitalization with an ICU stay. The mean number of health care transitions in the last 90 days of life increased from 2.1 (interquartile range [IQR], 0-3.0) to 2.8 (IQR, 1.0-4.0) to 3.1 per decedent (IQR, 1.0-5.0). The percentage of patients experiencing transitions in the last 3 days of life increased from 10.3% (95% CI, 10.1%-10.4%) to 12.4% (95% CI, 12.3%-2.5%) to 14.2% (95% CI, 14.0%-14.3%).
Among Medicare beneficiaries who died in 2009 and 2005 compared with 2000, a lower proportion died in an acute care hospital, although both ICU use and the rate of health care transitions increased in the last month of life.
最近疾病预防控制中心的一份报告发现，更多的人在家中死亡。这被认为是美国死亡人数使用更多支持性护理的证据。
描述 2000 年、2005 年和 2009 年期间死亡地点、护理地点和医疗保健过渡的变化。
设计、地点和患者：对随机抽取的 20%的 2000 年（n=270202）、2005 年（n=291819）或 2009 年（n=286282）死亡的年龄在 66 岁及以上的 Medicare 受益人的回顾性队列研究。在调整社会人口统计学特征后，使用多变量回归模型检查 2000 年和 2009 年的结果。根据计费数据，将患者分类为在生命的最后 180 天内患有癌症、慢性阻塞性肺疾病或痴呆的医学诊断。
死亡地点、护理地点、医疗保健过渡率和潜在负担过渡（例如，生命最后 3 天的医疗保健过渡）。
我们的随机抽取的 20%样本包括 848303 名 Medicare 死亡患者（平均年龄 82.3 岁；57.9%为女性，88.1%为白人）。与 2000 年、2005 年和 2009 年相比，急性护理医院的死亡比例从 32.6%（95%CI，32.4%-32.8%）降至 26.9%（95%CI，26.7%-27.1%）至 24.6%（95%CI，24.5%-24.8%）。然而，生命最后一个月的 ICU 使用从 24.3%（95%CI，24.1%-24.5%）增加到 26.3%（95%CI，26.1%-26.5%）至 29.2%（95%CI，29.0%-29.3%）。（每个变量的趋势检验 P 值均<.001。）临终时使用临终关怀的比例从 21.6%（95%CI，21.4%-21.7%）增加到 32.3%（95%CI，32.1%-32.5%）至 42.2%（95%CI，42.0%-42.4%），其中 28.4%（95%CI，27.9%-28.5%）在 2009 年使用临终关怀的时间为 3 天或更短。在这些晚期临终关怀转诊中，40.3%（95%CI，39.7%-40.8%）之前有 ICU 住院的住院治疗。生命最后 90 天的医疗保健过渡平均次数从 2.1（四分位距[IQR]，0-3.0）增加到 2.8（IQR，1.0-4.0）至 3.1 次/死者（IQR，1.0-5.0）。生命最后 3 天经历过渡的患者比例从 10.3%（95%CI，10.1%-10.4%）增加到 12.4%（95%CI，12.3%-2.5%）至 14.2%（95%CI，14.0%-14.3%）。
与 2000 年相比，2009 年和 2005 年死亡的 Medicare 受益人中，死于急性护理医院的比例较低，尽管 ICU 使用和医疗保健过渡率在生命的最后一个月都有所增加。
