姑息治疗和临终关怀的人群与干预措施：一项系统评价。
Populations and Interventions for Palliative and End-of-Life Care: A Systematic Review.
作者信息
Singer Adam E, Goebel Joy R, Kim Yan S, Dy Sydney M, Ahluwalia Sangeeta C, Clifford Megan, Dzeng Elizabeth, O'Hanlon Claire E, Motala Aneesa, Walling Anne M, Goldberg Jaime, Meeker Daniella, Ochotorena Claudia, Shanman Roberta, Cui Mike, Lorenz Karl A
机构信息
1 David Geffen School of Medicine, University of California at Los Angeles , Los Angeles, California.
2 RAND Corporation , Santa Monica, California.
出版信息
J Palliat Med. 2016 Sep;19(9):995-1008. doi: 10.1089/jpm.2015.0367. Epub 2016 Aug 17.
IMPORTANCE
Evidence supports palliative care effectiveness. Given workforce constraints and the costs of new services, payers and providers need help to prioritize their investments. They need to know which patients to target, which personnel to hire, and which services best improve outcomes.
OBJECTIVE
To inform how payers and providers should identify patients with "advanced illness" and the specific interventions they should implement, we reviewed the evidence to identify (1) individuals appropriate for palliative care and (2) elements of health service interventions (personnel involved, use of multidisciplinary teams, and settings of care) effective in achieving better outcomes for patients, caregivers, and the healthcare system.
EVIDENCE REVIEW
Systematic searches of MEDLINE, EMBASE, PsycINFO, Web of Science, and Cochrane Database of Systematic Reviews databases (1/1/2001-1/8/2015).
RESULTS
Randomized controlled trials (124) met inclusion criteria. The majority of studies in cancer (49%, 38 of 77 studies) demonstrated statistically significant patient or caregiver outcomes (e.g., p < 0.05), as did those in congestive heart failure (CHF) (62%, 13 of 21), chronic obstructive pulmonary disease (COPD; 58%, 11 of 19), and dementia (60%, 15 of 25). Most prognostic criteria used clinicians' judgment (73%, 22 of 30). Most interventions included a nurse (70%, 69 of 98), and many were nurse-only (39%, 27 of 69). Social workers were well represented, and home-based approaches were common (56%, 70 of 124). Home interventions with visits were more effective than those without (64%, 28 of 44; vs. 46%, 12 of 26). Interventions improved communication and care planning (70%, 12 of 18), psychosocial health (36%, 12 of 33, for depressive symptoms; 41%, 9 of 22, for anxiety), and patient (40%, 8 of 20) and caregiver experiences (63%, 5 of 8). Many interventions reduced hospital use (65%, 11 of 17), but most other economic outcomes, including costs, were poorly characterized. Palliative care teams did not reliably lower healthcare costs (20%, 2 of 10).
CONCLUSIONS
Palliative care improves cancer, CHF, COPD, and dementia outcomes. Effective models include nurses, social workers, and home-based components, and a focus on communication, psychosocial support, and the patient or caregiver experience. High-quality research on intervention costs and cost outcomes in palliative care is limited.
重要性
有证据支持姑息治疗的有效性。鉴于劳动力限制和新服务的成本，支付方和医疗服务提供者需要帮助来确定投资的优先次序。他们需要知道针对哪些患者、雇佣哪些人员以及哪些服务能最好地改善治疗效果。
目的
为了告知支付方和医疗服务提供者应如何识别“晚期疾病”患者以及他们应实施的具体干预措施，我们回顾了相关证据，以确定（1）适合姑息治疗的个体，以及（2）能有效改善患者、护理人员和医疗系统结局的卫生服务干预措施要素（涉及的人员、多学科团队的使用以及护理场所）。
证据回顾
对MEDLINE、EMBASE、PsycINFO、科学引文索引和Cochrane系统评价数据库进行系统检索（2001年1月1日至2015年8月1日）。
结果
124项随机对照试验符合纳入标准。癌症研究中的大多数（49%，77项研究中的38项）显示患者或护理人员的结局具有统计学意义（如p < 0.05），充血性心力衰竭（CHF）研究中的情况也是如此（62%，21项中的13项），慢性阻塞性肺疾病（COPD；58%，19项中的11项）以及痴呆症研究（60%，25项中的15项）。大多数预后标准采用临床医生的判断（73%，30项中的22项）。大多数干预措施包括一名护士（70%，98项中的69项），且许多是仅由护士实施的（39%，69项中的27项）。社会工作者参与度较高，且以家庭为基础的方法很常见（56%，124项中的70项）。有家访的家庭干预比没有家访的更有效（64%，44项中的28项；相比之下，46%，26项中的12项）。干预措施改善了沟通和护理计划（70%，18项中的12项）、心理社会健康（36%，33项中针对抑郁症状的12项；41%，22项中针对焦虑的9项）以及患者（40%，20项中的8项）和护理人员的体验（63%，8项中的5项）。许多干预措施减少了住院次数（65%，17项中的11项），但包括成本在内的大多数其他经济结局描述不佳。姑息治疗团队并未可靠地降低医疗成本（20%，10项中的2项）。
结论
姑息治疗改善了癌症、CHF、COPD和痴呆症的结局。有效的模式包括护士、社会工作者和以家庭为基础的组成部分，并注重沟通、心理社会支持以及患者或护理人员的体验。关于姑息治疗干预成本和成本结局的高质量研究有限。
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