Chen Bradley, Fan Victoria Y, Chou Yiing-Jenq, Kuo Chin-Chi
Institute of Public Health, National Yang-Ming University, Taipei, Taiwan.
Department of Public Health Sciences & Epidemiology, University of Hawaii at Manoa, 1960 East-West Road, Biomed D204, Honolulu, HI, USA.
BMC Nephrol. 2017 Jan 26;18(1):36. doi: 10.1186/s12882-017-0456-2.
Despite the urgent need for evidence to guide the end-of-life (EOL) care for patients with chronic kidney disease (CKD), we have limited knowledge of the costs and intensity of EOL care in this population. The present study examined patterns and predictors for EOL care intensity among elderly patients with CKD.
We conducted a retrospective nationwide cohort study utilizing the Taiwan National Health Insurance (NHI) Research Database. A total of 65,124 CKD patients aged ≥ 60 years, who died in hospitals or shortly after discharge between 2002 and 2012 were analyzed. The primary outcomes were inpatient expenses and use of surgical interventions in the last 30 days of life. Utilization of intensive care unit (ICU), mechanical ventilation, resuscitation, and dialysis was also examined in a sub-sample of 2072 patients with detailed prescription data. Multivariate log-linear and logistic regression analyses were performed to assess patient-, physician-, and facility-specific predictors and the potential impact of a 2009 payment policy to reimburse hospice care for non-cancer patients.
During the last 30 days of life, average inpatients costs for elderly CKD patients were approximately US$10,260, with 40.9% receiving surgical interventions, 40.2% experiencing ICU admission, 45.3% undergoing mechanical ventilation, 14.7% receiving resuscitation and 42.0% receiving dialysis. Significant variability was observed in the inpatient costs and use of intensive services. Costs were lower among individuals with the following characteristics: advanced age; high income; high Charlson Comorbidity Index scores; treatment by older physicians, nephrologists, and family medicine physicians; and treatment at local hospitals. Similar findings were obtained for the use of surgical interventions and other intensive services. A declining trend was detected in the costs of EOL care, use of surgical interventions and resuscitation between 2009 and 2012, which is consistent with the impact of a 2009 NHI payment policy to reimburse non-cancer hospice care.
Overall EOL costs and rates of intensive service use among older patients with CKD were high, with significant variability across various patient and provider characteristics. Several opportunities exist for providers and policy makers to reduce costs and enhance the value of EOL care for this population.
尽管迫切需要证据来指导慢性肾脏病（CKD）患者的临终（EOL）护理，但我们对该人群临终护理的成本和强度了解有限。本研究调查了老年CKD患者临终护理强度的模式和预测因素。
我们利用台湾国民健康保险（NHI）研究数据库进行了一项全国性回顾性队列研究。分析了2002年至2012年间在医院死亡或出院后不久死亡的65124名年龄≥60岁的CKD患者。主要结局是住院费用和生命最后30天内手术干预的使用情况。还在2072名有详细处方数据的患者子样本中检查了重症监护病房（ICU）、机械通气、复苏和透析的使用情况。进行多变量对数线性和逻辑回归分析，以评估患者、医生和机构特定的预测因素，以及2009年一项为非癌症患者报销临终关怀护理的支付政策的潜在影响。
在生命的最后30天内，老年CKD患者的平均住院费用约为10260美元，40.9%的患者接受了手术干预，40.2%的患者入住了ICU，45.3%的患者接受了机械通气，14.7%的患者接受了复苏，42.0%的患者接受了透析。住院费用和强化服务的使用存在显著差异。具有以下特征的个体费用较低：高龄；高收入；高查尔森合并症指数评分；由年长医生、肾病学家和家庭医学医生治疗；在当地医院接受治疗。在手术干预和其他强化服务的使用方面也获得了类似的结果。2009年至2012年间，临终护理费用、手术干预和复苏的使用呈下降趋势，这与2009年NHI为非癌症临终关怀护理报销的支付政策的影响一致。
老年CKD患者的总体临终费用和强化服务使用率较高，不同患者和提供者特征之间存在显著差异。提供者和政策制定者有几个机会来降低成本并提高该人群临终护理的价值。
