Department of Medicine, Division of Critical Care Medicine, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada.
Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA.
Hepatology. 2017 Nov;66(5):1585-1591. doi: 10.1002/hep.29297. Epub 2017 Sep 26.
Patients with end-stage liver disease (ESLD) often have a high symptom burden. Historically, palliative care (PC) services have been underused in this population. We investigated the use of PC services in patients with ESLD hospitalized across the United States. We used the Nationwide Inpatient Sample to conduct a retrospective nationwide cohort analysis. All patients >18 years of age admitted with ESLD, defined as those with at least two liver decompensation events, were included in the analysis. A multivariate logistic regression model predicting referral to PC was created. We analyzed 55,208,382 hospitalizations from the 2006-2012 Nationwide Inpatient Sample, with 39,349 (0.07%) patients meeting study inclusion. PC consultation was performed in 1,789 (4.5%) ESLD patients. The rate of PC referral in ESLD increased from 0.97% in 2006 to 7.1% in 2012 (P < 0.01). In multivariate analysis, factors associated with lower referral to PC were Hispanic race (odds ratio [OR], 0.77; 95% confidence interval [CI], 0.66-0.89; P < 0.01) and insurance coverage (OR, 0.74; 95% CI, 0.65-0.84; P < 0.01). Factors associated with increased referral to PC were age (per 5-year increase, OR, 1.05; 95% CI, 1.03-1.08; P < 0.01), do-not-resuscitate status (OR, 16.24; 95% CI, 14.20-18.56; P < 0.01), treatment in a teaching hospital (OR, 1.25; 95% CI, 1.12-1.39; P < 0.01), presence of hepatocellular carcinoma (OR, 2.00; 95% CI, 1.71-2.33; P < 0.01), and presence of metastatic cancer (OR, 2.39; 95% CI, 1.80-3.18; P < 0.01). PC referral was most common in west coast hospitals (OR, 1.81; 95% CI, 1.53-2.14; P < 0.01) as well as large-sized hospitals (OR, 1.49; 95% CI, 1.22-1.82; P < 0.01).
From 2006 to 2012 the use of PC in ESLD patients increased substantially; socioeconomic, geographical, and ethnic barriers to accessing PC were observed. (Hepatology 2017;66:1585-1591).
终末期肝病（ESLD）患者常伴有较高的症状负担。历史上，在这一人群中，姑息治疗（PC）服务的利用率较低。本研究旨在调查美国 ESLD 住院患者 PC 服务的使用情况。
我们使用全国住院患者样本（NIS）进行了回顾性全国队列分析。纳入标准为年龄＞18 岁、至少有 2 次肝失代偿事件的 ESLD 患者。建立了一个预测 PC 转诊的多变量逻辑回归模型。我们分析了 2006-2012 年 NIS 中 55208382 例住院患者，其中 39349 例（0.07%）符合研究纳入标准。在 39349 例 ESLD 患者中，有 1789 例（4.5%）接受了 PC 咨询。2006 年至 2012 年期间，ESLD 患者中 PC 转诊率从 0.97%增至 7.1%（P＜0.01）。多变量分析显示，与较低的 PC 转诊率相关的因素为西班牙裔（OR=0.77；95%CI，0.66-0.89；P＜0.01）和保险覆盖范围（OR=0.74；95%CI，0.65-0.84；P＜0.01）。与较高的 PC 转诊率相关的因素为年龄（每增加 5 岁，OR=1.05；95%CI，1.03-1.08；P＜0.01）、不复苏状态（OR=16.24；95%CI，14.20-18.56；P＜0.01）、在教学医院治疗（OR=1.25；95%CI，1.12-1.39；P＜0.01）、肝细胞癌（OR=2.00；95%CI，1.71-2.33；P＜0.01）和转移性癌症（OR=2.39；95%CI，1.80-3.18；P＜0.01）。西海岸医院（OR=1.81；95%CI，1.53-2.14；P＜0.01）和大型医院（OR=1.49；95%CI，1.22-1.82；P＜0.01）的 PC 转诊率最高。
2006 年至 2012 年期间，ESLD 患者中 PC 的使用率显著增加；但仍存在社会经济、地域和种族方面的障碍，影响了患者获得 PC 的机会。
