Eneanya Nwamaka D, Hailpern Susan M, O'Hare Ann M, Kurella Tamura Manjula, Katz Ronit, Kreuter William, Montez-Rath Maria E, Hebert Paul L, Hall Yoshio N
Division of Nephrology, Department of Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
Division of Nephrology and Kidney Research Institute, Department of Medicine, University of Washington, Seattle, WA.
Am J Kidney Dis. 2017 Jan;69(1):60-68. doi: 10.1053/j.ajkd.2016.07.028. Epub 2016 Sep 29.
Many dialysis patients receive intensive procedures intended to prolong life at the very end of life. However, little is known about trends over time in the use of these procedures. We describe temporal trends in receipt of inpatient intensive procedures during the last 6 months of life among patients treated with maintenance dialysis.
Mortality follow-back study.
SETTING & PARTICIPANTS: 649,607 adult Medicare beneficiaries on maintenance dialysis therapy who died in 2000 to 2012.
Period of death (2000-2003, 2004-2008, or 2009-2012), age at time of death (18-59, 60-64, 65-69, 70-74, 75-79, 80-84, and ≥85 years), and race/ethnicity (Hispanic, non-Hispanic black, or non-Hispanic white).
Receipt of an inpatient intensive procedure (defined as invasive mechanical ventilation/intubation, tracheostomy, gastrostomy/jejunostomy tube insertion, enteral or parenteral nutrition, or cardiopulmonary resuscitation) during the last 6 months of life.
Overall, 34% of cohort patients received an intensive procedure in the last 6 months of life, increasing from 29% in 2000 to 36% in 2012 (with 2000-2003 as the referent category; adjusted risk ratios [RRs] were 1.06 [95% CI, 1.05-1.07] and 1.10 [95% CI, 1.09-1.12] for 2004-2008 and 2009-2012, respectively). Use of intensive procedures increased more markedly over time in younger versus older patients (comparing 2009-2012 to 2000-2003, adjusted RR was 1.18 [95% CI, 1.15-1.20] for the youngest age group as opposed to 1.00 [95% CI, 0.96-1.04] for the oldest group). Comparing 2009 to 2012 to 2000 to 2003, the use of intensive procedures increased more dramatically for Hispanic patients than for non-Hispanic black or non-Hispanic white patients (adjusted RRs of 1.18 [95% CI, 1.14-1.22], 1.09 [95% CI, 1.07-1.11], and 1.10 [95% CI, 1.08-1.12], respectively).
Data sources do not provide insight into reasons for observed trends in the use of intensive procedures.
Among patients treated with maintenance dialysis, there is a trend toward more frequent use of intensive procedures at the end of life, especially in younger patients and those of Hispanic ethnicity.
许多透析患者在生命的最后阶段接受旨在延长生命的强化治疗。然而，对于这些治疗手段的使用随时间的变化趋势却知之甚少。我们描述了接受维持性透析治疗的患者在生命的最后6个月内接受住院强化治疗的时间趋势。
死亡率回顾性研究。
2000年至2012年间死亡的649,607名接受维持性透析治疗的成年医疗保险受益人。
死亡时间（2000 - 2003年、2004 - 2008年或2009 - 2012年）、死亡时的年龄（18 - 59岁、60 - 64岁、65 - 69岁、70 - 74岁、75 - 79岁、80 - 84岁及≥85岁）以及种族/民族（西班牙裔、非西班牙裔黑人或非西班牙裔白人）。
在生命的最后6个月内接受强化治疗的情况。接受住院强化治疗（定义为侵入性机械通气/插管、气管造口术、胃造口术/空肠造口术插管、肠内或肠外营养或心肺复苏）。
总体而言，34%的队列患者在生命的最后6个月内接受了强化治疗，从2000年的29%增至2012年的36%（以2000 - 2003年为参照组；2004 - 2008年和2009 - 2012年的调整风险比[RRs]分别为1.06[95%CI，1.05 - 1.07]和1.10[95%CI，1.09 - 1.12]）。随着时间的推移，年轻患者比老年患者强化治疗的使用增加更为明显（将2009 - 2012年与2000 - 2003年相比，最年轻年龄组的调整RR为1.18[95%CI，1.15 - 1.20]，而最年长组为1.00[95%CI，0.96 - 1.04]）。将2009 - 2012年与2000 - 2003年相比，西班牙裔患者强化治疗的使用比非西班牙裔黑人或非西班牙裔白人患者增加更为显著（调整RR分别为1.18[95%CI，1.14 - 1.22]、1.09[95%CI，1.07 - 1.11]和1.10[95%CI，1.08 - 1.12]）。
数据源无法深入了解强化治疗使用趋势的原因。
在接受维持性透析治疗的患者中，生命末期强化治疗的使用有更加频繁的趋势，尤其是在年轻患者和西班牙裔患者中。
