The Comprehensive Access and Delivery Research and Evaluation Center at the Iowa City Veterans Affairs Healthcare System, Iowa City, Iowa2Department of Surgery, Carver College of Medicine, University of Iowa, Iowa City.
The Comprehensive Access and Delivery Research and Evaluation Center at the Iowa City Veterans Affairs Healthcare System, Iowa City, Iowa.
JAMA Surg. 2014 Nov;149(11):1169-75. doi: 10.1001/jamasurg.2014.2101.
Many hospitals have undertaken initiatives to improve care during the end of life, recognizing that some individuals have unique needs that are often not met in acute inpatient care settings. Studies of surgical patients have shown this population to receive palliative care at reduced rates in comparison with medical patients.
To determine differences in the use of palliative care and hospice between surgical and medical patients in an integrated health care system.
DESIGN, SETTING, AND PARTICIPANTS: Veterans Health Administration (VHA) enrollment data and administrative data sets were used to identify 191,280 VHA patients who died between October 1, 2008, and September 30, 2012, and who had an acute inpatient episode in the VHA system in the last year of life. Patients were categorized as surgical if at any time during the year preceding death they underwent a surgical procedure (n = 42,143) or medical (n = 149,137) if the patient did not receive surgical treatment in the last year of life.
Receipt of palliative or hospice care and the number of days from palliative or hospice initiation to death were determined using VHA administrative inpatient, outpatient, and fee-based encounter-level data files.
Surgical patients were significantly less likely than medical patients to receive either hospice or palliative care (odds ratio = 0.91; 95% CI, 0.89-0.94; P < .001). When adjusting for demographics and medical comorbidities, this difference was even more pronounced (odds ratio = 0.84; 95% CI, 0.81-0.86). Yet, among patients who received hospice or palliative care, surgical patients lived significantly longer than their medical counterparts (a median of 26 vs 23 days, respectively; P < .001) yet had similar relative use of these services after risk adjustment.
In the VHA population, surgical patients are less likely to receive either hospice or palliative care in the year prior to death compared with medical patients, yet surgical patients have a longer length of time in these services. Determining criteria for higher-risk medical and surgical patients may help with increasing the relative use of these services. Potential barriers and differences may exist among surgical and medical services that could impact the use of palliative care or hospice in the last year of life.
许多医院已经采取措施，改善临终关怀服务，因为他们认识到一些患者有独特的需求，而这些需求在急性住院治疗环境中往往无法得到满足。研究表明，与内科患者相比，外科患者接受姑息治疗的比例较低。
在一体化医疗体系中，确定外科患者与内科患者在姑息治疗和临终关怀使用方面的差异。
设计、环境和参与者：使用退伍军人健康管理局（VHA）的登记数据和行政数据集，确定了 191280 名退伍军人健康管理局患者，这些患者于 2008 年 10 月 1 日至 2012 年 9 月 30 日期间死亡，并且在生命的最后一年中在退伍军人健康管理局系统中有一次急性住院治疗。如果在死亡前一年的任何时候进行了外科手术，则将患者归类为外科（n=42143），否则为内科（n=149137）。
使用退伍军人健康管理局行政住院、门诊和收费为基础的就诊级别数据文件，确定接受姑息治疗或临终关怀的情况以及从姑息治疗或临终关怀开始到死亡的天数。
与内科患者相比，外科患者接受临终关怀或姑息治疗的可能性显著较低（优势比=0.91；95%CI，0.89-0.94；P<.001）。调整人口统计学和合并症因素后，这种差异更为明显（优势比=0.84；95%CI，0.81-0.86）。然而，在接受临终关怀或姑息治疗的患者中，外科患者的存活时间明显长于内科患者（中位数分别为 26 天和 23 天；P<.001），但在风险调整后，这些患者使用这些服务的相对比例相似。
在退伍军人健康管理局人群中，与内科患者相比，外科患者在死亡前一年接受临终关怀或姑息治疗的可能性较低，但外科患者接受这些服务的时间更长。确定高危内科和外科患者的标准可能有助于提高这些服务的相对使用率。外科和内科服务之间可能存在潜在的差异，这可能会影响临终关怀或姑息治疗的使用。
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