Mudge Alison M, Douglas Carol, Sansome Xanthe, Tresillian Michael, Murray Stephen, Finnigan Simon, Blaber Cheryl Ruth
Department of Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia.
Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.
BMJ Support Palliat Care. 2018 Jun;8(2):213-220. doi: 10.1136/bmjspcare-2017-001441. Epub 2018 Mar 2.
People with serious life-limiting disease benefit from advance care planning, but require active identification. This study applied the Gold Standards Framework Proactive Identification Guidance (GSF-PIG) to a general hospital population to describe high-risk patients and explore prognostic performance for 12-month mortality.
Prospective cohort study conducted in a metropolitan teaching hospital in Australia. Hospital inpatients on a single day aged 18 years and older were eligible, excluding maternity and neonatal, mental health and day treatment patients. Data sources included medical record and structured questions for medical and nursing staff. High-risk was predefined as positive response to the surprise question (SQ) plus two or more SPICT indicators of general deterioration. Descriptive variables included demographics, frailty and functional measures, treating team, advance care planning documentation and hospital utilisation. Primary outcome for prognostic performance was 12-month mortality.
We identified 540 eligible inpatients on the study day and 513 had complete data (mean age 60, 54% male, 30% living alone, 19% elective admissions). Of these, 191 (37%) were high-risk; they were older, frailer, more dependent and had been in hospital longer than low-risk participants. Within 12 months, 92 participants (18%) died (72/191(38%) high-risk versus 20/322(6%) low-risk, P<0.001), providing sensitivity 78%, specificity 72%, positive predictive value 38% and negative predictive value 94%. SQ alone provided higher sensitivity, adding advanced disease indicators improved specificity.
The GSF-PIG approach identified a large minority of hospital inpatients who might benefit from advance care planning. Future studies are needed to investigate the feasibility, cost and impact of screening in hospitals.
患有严重危及生命疾病的患者可从预先护理计划中获益，但需要积极识别。本研究将金标准框架主动识别指南（GSF-PIG）应用于综合医院人群，以描述高危患者并探讨12个月死亡率的预后表现。
在澳大利亚一家大都市教学医院进行前瞻性队列研究。年龄在18岁及以上的当日住院患者符合条件，排除产科和新生儿、精神健康及日间治疗患者。数据来源包括病历以及针对医护人员的结构化问题。高危被预先定义为对意外问题（SQ）回答为阳性，再加上两个或更多一般病情恶化的SPICT指标。描述性变量包括人口统计学、虚弱和功能指标、治疗团队、预先护理计划文件记录以及医院利用情况。预后表现的主要结局是12个月死亡率。
我们在研究当日确定了540名符合条件的住院患者，其中513名有完整数据（平均年龄60岁，54%为男性，30%独居，19%为择期入院）。其中，191名（37%）为高危；他们比低危参与者年龄更大、更虚弱、依赖性更强且住院时间更长。在12个月内，92名参与者（18%）死亡（72/191（38%）高危患者与20/322（6%）低危患者，P<0.001），敏感性为78%，特异性为72%，阳性预测值为38%，阴性预测值为94%。仅SQ具有更高的敏感性，加上晚期疾病指标可提高特异性。
GSF-PIG方法识别出了可能从预先护理计划中获益的一大部分住院患者。未来需要研究调查在医院进行筛查的可行性、成本和影响。
