Bruce Courtenay R, Minard Charles G, Wilhelms L A, Abraham Mackenzie, Amione-Guerra Javier, Pham Linda, Grogan Sherry D, Trachtenberg Barry, Smith Martin L, Bruckner Brian A, Estep Jerry D, Kostick Kristin M
From the Center for Medical Ethics and Health Policy (C.R.B., L.A.W., M.A., K.M.K.) and Dan L. Duncan Institute for Clinical and Translational Research (C.G.M.), Baylor College of Medicine, Houston, TX; Bioethics Program, Houston Methodist System, TX (C.R.B.); Houston Methodist Hospital, Houston Methodist DeBakey Heart and Vascular Center and J.C. Walter Jr. Transplant Center, Houston, TX (J.A.-G., L.P., S.D.G., B.T., B.A.B., J.D.E.); and Department of Bioethics, Cleveland Clinic, OH (M.L.S.).
Circ Cardiovasc Qual Outcomes. 2017 Jan;10(1). doi: 10.1161/CIRCOUTCOMES.116.002879.
How caregivers contribute to positive or negative outcomes for left ventricular assist device (LVAD) patients remains unclear. Our primary study objectives were to (1) identify caregiver support attributes through a retrospective chart review of social workers' psychosocial assessments for LVAD patients and (2) determine how these attributes associated with patients' post-LVAD placement mortality and Interagency Registry for Mechanically Assisted Circulatory Support-defined morbidity events.
We retrospectively reviewed and recorded social workers' clinical assessments of adult patients implanted with durable continuous-flow LVADs as bridge to transplant, destination therapy, or bridge to decision from January 2010 to December 2014. Associations between caregiver characteristics and patient mortality and morbidity events were analyzed using Kaplan-Meier curves and Cox proportional hazards regression. Patient follow-up time was calculated as the time from hospital discharge until the earliest among death with LVAD, transplant, or the last day of the study (December 31, 2015). Patients were censored for death with LVAD at the time of transplant or the last day of the study. A total of 96 LVAD recipients were included in this study. Having a caregiver who understands the severity of the illness and options available to the patient (as determined and documented by the social worker; P=0.01), a caregiver who has identified a backup plan (P=0.02), and a caregiver who is able to provide logistical support (P=0.04) significantly mitigated risk of death. The risk of death for an LVAD patient was also significantly lower among those who have at least 1 adult child who lives within 50 miles (P=0.03) and those who have an extended family who can care for the patient (P=0.03). The risk of death was 3.1× more likely among patients who live alone compared with those who do not live alone (P=0.04). No caregiver characteristics were significantly associated with morbidity.
This exploratory, hypothesis-generating study suggests that mortality after LVAD placement is impacted by caregiver understanding of patient severity of illness and caregiver presence. This study provides initial evidence to support further work in understanding the associations between caregivers and LVAD patients, as well as interventions that may improve patient outcomes.
URL: http://www.clinicaltrials.gov. Unique identifier: NCT02248974.
护理人员如何影响左心室辅助装置（LVAD）患者的预后，无论是积极还是消极，仍不清楚。我们的主要研究目标是：（1）通过回顾性查阅社会工作者对LVAD患者的心理社会评估记录，确定护理人员的支持特性；（2）确定这些特性与患者LVAD植入后死亡率以及机构间机械辅助循环支持注册处定义的发病事件之间的关联。
我们回顾性查阅并记录了2010年1月至2014年12月期间，社会工作者对植入耐用连续血流LVAD作为移植过渡、终末期治疗或决策过渡的成年患者的临床评估。使用Kaplan-Meier曲线和Cox比例风险回归分析护理人员特征与患者死亡率和发病事件之间的关联。患者随访时间计算为从出院到LVAD相关死亡、移植或研究最后一天（2015年12月31日）三者中最早发生的时间。在移植时或研究最后一天，患者因LVAD相关死亡而被截尾。本研究共纳入96例LVAD接受者。护理人员了解患者病情严重程度及可选择的治疗方案（由社会工作者确定并记录；P = 0.01）、护理人员制定了备用计划（P = 0.02）以及护理人员能够提供后勤支持（P = 0.04），均能显著降低死亡风险。在至少有1名成年子女居住在50英里范围内的LVAD患者中（P = 0.03）以及有大家庭能够照顾患者的患者中（P = 0.03），死亡风险也显著较低。与非独居患者相比，独居患者的死亡风险高出3.1倍（P = 0.04）。没有护理人员特征与发病显著相关。
这项探索性、产生假设的研究表明，LVAD植入后的死亡率受护理人员对患者病情严重程度的了解以及护理人员的陪伴影响。本研究提供了初步证据，以支持进一步开展工作，了解护理人员与LVAD患者之间的关联，以及可能改善患者预后的干预措施。
