Zeenat Qureshi Stroke Institute, St. Cloud, Minnesota, USA.
Zeenat Qureshi Stroke Institute, St. Cloud, Minnesota, USA.
World Neurosurg. 2014 Nov;82(5):e579-84. doi: 10.1016/j.wneu.2014.07.008. Epub 2014 Jul 5.
The use of "withdrawal of care" and impact upon outcomes among patients with subarachnoid hemorrhage (SAH) is not well studied.
To identify the rate and determinants of "withdrawal of care" among SAH patients.
We determined the frequency of "withdrawal of care" and compared the demographic, clinical characteristics, and in-hospital outcomes among patients with SAH stratified by use of "withdrawal of care."
"Withdrawal of care" during hospitalization was instituted in 8912 (3.4%) of the 266,067 patients with SAH. In the stepwise logistic regression, age >65 (odds ratio [OR] 4.5, 95% confidence interval [95% CI] 3.3-6.1), women (OR 1.2, 95% CI 1.0-1.3), African American (OR 0.7, 95% CI 0.5-0.8), Hispanic ethnicity (OR 0.4, 95% CI 0.3-0.6), renal failure (OR 1.6, 95% CI 1.2-1.9), intracerebral hemorrhage (OR 2.0, 95% CI 1.7-2.4, All Patient Refined Diagnosis-Related Groups severity score of extreme loss of function (OR 40.1, 95% CI 6.0-270.7), All Patient Refined Diagnosis-Related Groups severity score of severe loss of function (OR 15.0, 95% CI 2.1-103.8), insurance status of private health maintenance organization (OR 0.7, 95% CI 0.5-0.9), and hospital region south United States (OR 0.7, 95% CI 0.5-0.8), were significant predictors of "withdrawal of care" among patients with SAH. In-hospital mortality was significantly greater, but mean hospitalization charges and length of stay were significantly lower among those with "withdrawal of care."
Although "withdrawal of care" was effective in limiting hospital charges and resource use, caution is needed to avoid disproportionately high mortality. The prominent relationship between race/ethnicity, insurance status, and hospital location with "withdrawal of care" raises concerns that factors other than severity of disease influence decision making.
在蛛网膜下腔出血 (SAH) 患者中，使用“停止治疗”及其对结局的影响尚未得到充分研究。
确定 SAH 患者中“停止治疗”的发生率和决定因素。
我们确定了“停止治疗”的频率，并比较了根据是否使用“停止治疗”对 SAH 患者进行分层的患者的人口统计学、临床特征和住院结局。
在 266067 例 SAH 患者中，8912 例（3.4%）在住院期间实施了“停止治疗”。在逐步逻辑回归中，年龄＞65 岁（比值比 [OR] 4.5，95%置信区间 [95%CI] 3.3-6.1）、女性（OR 1.2，95%CI 1.0-1.3）、非裔美国人（OR 0.7，95%CI 0.5-0.8）、西班牙裔（OR 0.4，95%CI 0.3-0.6）、肾衰竭（OR 1.6，95%CI 1.2-1.9）、脑实质内出血（OR 2.0，95%CI 1.7-2.4，所有患者精细诊断相关组严重程度评分极度功能丧失（OR 40.1，95%CI 6.0-270.7）、所有患者精细诊断相关组严重程度评分严重功能丧失（OR 15.0，95%CI 2.1-103.8）、私人健康维护组织的保险状态（OR 0.7，95%CI 0.5-0.9）和美国南部的医院区域（OR 0.7，95%CI 0.5-0.8）是 SAH 患者“停止治疗”的显著预测因素。有“停止治疗”的患者住院死亡率显著更高，但住院费用和住院时间的平均值显著更低。
尽管“停止治疗”在限制住院费用和资源使用方面是有效的，但需要谨慎，以避免不成比例的高死亡率。种族/民族、保险状况和医院位置与“停止治疗”之间的突出关系引起了人们的关注，即除疾病严重程度外，其他因素可能会影响决策。
