Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York.
J Palliat Med. 2018 Mar;21(S2):S7-S16. doi: 10.1089/jpm.2017.0548. Epub 2017 Nov 10.
To ensure seriously ill people and their families receive high-quality primary and specialty palliative care services, rigorous methods are needed to prospectively identify this population.
To define and operationalize a definition of serious illness for the purpose of identifying patients and caregivers who need primary or specialty palliative care services.
DESIGN/SETTING: Two stages of work included (1) building expert consensus around a conceptual definition of serious illness and (2) using the National Health and Aging Trends Study linked to Medicare claims data to test a range of operational definitions composed of diagnoses, utilization, and markers of care needs.
One-year outcomes included mean total Medicare costs, mortality, and percent hospitalized, as well as those reporting ≥2 measures of need and functional impairment. Sensitivity, specificity, and c-statistics (unadjusted and adjusted for age, sex, race, and Medicaid status) were calculated for each definition across the outcomes.
Conceptually, "Serious illness" is a health condition that carries a high risk of mortality AND either negatively impacts a person's daily function or quality of life, OR excessively strains their caregivers. The range of operational definitions simulated all had low sensitivity and high specificity across all outcomes. None of the definitions reached an unadjusted c-statistic >0.6 (or adjusted >0.7) for identifying a population with ≥2 indicators of care needs.
Standard administrative data are inadequate to identify this population. Defining the seriously ill denominator with high specificity, as described here, will focus efforts toward the highest-need segment of the population, who may indeed benefit most.
为确保重病患者及其家属获得高质量的初级和专科姑息治疗服务，需要采用严格的方法来前瞻性地确定这一人群。
定义和操作化严重疾病的定义，以便识别需要初级或专科姑息治疗服务的患者和照护者。
设计/设置：两个阶段的工作包括（1）围绕严重疾病的概念定义达成专家共识，以及（2）使用与医疗保险索赔数据相关联的国家健康与老龄化趋势研究来测试一系列由诊断、利用和护理需求指标组成的操作定义。
一年的结果包括医疗保险总费用、死亡率和住院率的平均值，以及报告≥2项需求和功能障碍指标的患者比例。针对每个定义，计算了在所有结果中灵敏度、特异性和 c 统计量（未调整和调整年龄、性别、种族和医疗补助状况）。
从概念上讲，“严重疾病”是一种具有高死亡率风险的健康状况，并且（1）对个人的日常功能或生活质量产生负面影响，或（2）过度给照护者带来压力。模拟的一系列操作定义在所有结果中均具有较低的灵敏度和较高的特异性。在未调整的 c 统计量方面，没有任何定义（或调整后的）>0.6 （或>0.7），无法识别出≥2项护理需求指标的人群。
标准的行政数据不足以识别这一人群。如本文所述，用高特异性来定义重病患者分母，将重点放在人口中需求最高的部分，他们可能确实受益最大。
