Faculty of Health, Queensland University of Technology, Brisbane, Australia.
National Health and Medical Research Council, Centre for Research Excellence in End of Life Care, Brisbane, Australia.
BMC Palliat Care. 2018 Apr 5;17(1):57. doi: 10.1186/s12904-018-0310-8.
Chronic kidney disease (CKD) is a growing global problem affecting around 10% of many countries' populations. Providing appropriate palliative care services (PCS) to those with advanced kidney disease is becoming paramount. Palliative/supportive care alongside usual CKD clinical treatment is gaining acceptance in nephrology services although the collaboration with and use of PCS is not consistent.
The goal of this study was to track and quantify the health service utilisation of people with CKD stages 3-5 over the last 12 months of life. Patients were recruited from a kidney health service (Queensland, Australia) for this prospective, longitudinal study. Data were collected for 12 months (or until death, whichever was sooner) during 2015-17 from administrative health sources. Emergency department presentations (EDP) and inpatient admissions (IPA) (collectively referred to as critical events) were reviewed by two Nephrologists to gauge if the events were avoidable.
Participants (n = 19) with a median age of 78 years (range 42-90), were mostly male (63%), 79% had CKD stage 5, and were heavy users of health services during the study period. Fifteen patients (79%) collectively recorded 44 EDP; 61% occurred after-hours, 91% were triaged as imminently and potentially life-threatening and 73% were admitted. Seventy-four IPA were collectively recorded across 16 patients (84%); 14% occurred on weekends or public holidays. Median length of stay was 3 days (range 1-29). The median number of EDP and IPA per patient was 1 and 2 (range 0-12 and 0-20) respectively. The most common trigger to both EDP (30%) and IPA (15%) was respiratory distress. By study end 37% of patients died, 63% were known to PCS and 11% rejected a referral to a PCS. All critical events were deemed unavoidable.
Few patients avoided using acute health care services in a 12 month period, highlighting the high service needs of this cohort throughout the long, slow decline of CKD. Proactive end-of-life care earlier in the disease trajectory through integrating renal and palliative care teams may avoid acute presentations to hospital through better symptom management and planned care pathways.
慢性肾脏病（CKD）是一个日益严重的全球性问题，影响着许多国家约 10%的人口。为晚期肾病患者提供适当的姑息治疗服务（PCS）变得至关重要。姑息/支持性治疗与常规 CKD 临床治疗相结合在肾脏病服务中得到了认可，尽管与 PCS 的合作和使用并不一致。
本研究的目的是跟踪和量化过去 12 个月中 CKD 3-5 期患者的卫生服务利用情况。这项前瞻性、纵向研究招募了来自肾脏健康服务（澳大利亚昆士兰州）的患者。2015-17 年期间，从行政健康资源中收集了 12 个月的数据（或直至死亡，以先发生者为准）。两位肾脏病专家审查了急诊科就诊（EDP）和住院（IPA）（统称为危急事件），以评估这些事件是否可以避免。
研究对象（n=19）的中位年龄为 78 岁（范围为 42-90 岁），主要为男性（63%），79%为 CKD 5 期，在研究期间是卫生服务的重度使用者。15 名患者（79%）共记录了 44 次 EDP；61%发生在非工作时间，91%被分诊为紧急且可能危及生命，73%的患者接受了住院治疗。16 名患者（84%）共记录了 74 次 IPA；14%发生在周末或公共假日。中位住院时间为 3 天（范围为 1-29 天）。每位患者的 EDP 和 IPA 中位数分别为 1 和 2（范围为 0-12 和 0-20）。导致 EDP（30%）和 IPA（15%）的最常见原因是呼吸窘迫。研究结束时，37%的患者死亡，63%的患者已知接受了 PCS，11%的患者拒绝了 PCS 的转诊。所有危急事件均被认为是不可避免的。
在 12 个月的时间内，很少有患者避免使用急性卫生保健服务，这突出表明在 CKD 漫长而缓慢的衰退过程中，这一人群的服务需求很高。通过整合肾脏和姑息治疗团队，在疾病进程的早期就采取积极的临终关怀措施，通过更好的症状管理和规划的护理途径，可能避免因急性发作而到医院就诊。
