Walkey Allan J, Barnato Amber E, Wiener Renda Soylemez, Nallamothu Brahmajee K
1 Division of Pulmonary and Critical Care Medicine, the Pulmonary Center, and.
2 Evans Center for Implementation and Improvement Sciences, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts.
Am J Respir Crit Care Med. 2017 Oct 15;196(8):958-963. doi: 10.1164/rccm.201701-0165CP.
The importance of understanding patient preferences for life-sustaining treatment is well described for individual clinical decisions; however, its role in evaluations of healthcare outcomes and quality has received little attention. Decisions to limit life-sustaining therapies are strongly associated with high risks for death in ways that are unaccounted for by routine measures of illness severity. However, this essential information is generally unavailable to researchers, with the potential for spurious inferences. This may lead to "confounding by unmeasured patient preferences" (a type of confounding by indication) and has implications for assessments of treatment effectiveness and healthcare quality, especially in acute and critical care settings in which risk for death and adverse events are high. Through a collection of case studies, we explore the effect of unmeasured patient resuscitation preferences on issues critical for researchers and research consumers to understand. We then propose strategies to more consistently elicit, record, and harmonize documentation of patient preferences that can be used to attenuate confounding by unmeasured patient preferences and provide novel opportunities to improve the patient centeredness of medical care for serious illness.
理解患者对维持生命治疗的偏好对于个体临床决策的重要性已得到充分描述；然而，其在医疗保健结果和质量评估中的作用却很少受到关注。限制维持生命治疗的决策与高死亡风险密切相关，而常规的疾病严重程度衡量指标无法解释这些关联。然而，研究人员通常无法获得这一关键信息，这可能导致虚假推断。这可能会导致“未测量的患者偏好造成的混杂”（一种指征性混杂），并对治疗效果和医疗质量评估产生影响，尤其是在死亡和不良事件风险较高的急性和重症监护环境中。通过一系列案例研究，我们探讨了未测量的患者复苏偏好对研究人员和研究消费者理解至关重要的问题的影响。然后，我们提出了一些策略，以更一致地引出、记录和统一患者偏好的文档，这些文档可用于减轻未测量的患者偏好造成的混杂，并为改善重症医疗中以患者为中心的医疗服务提供新的机会。
