1 Department of Anesthesiology and.
2 Center for Health Policy and Outcomes in Anesthesia and Critical Care, Columbia University College of Physicians and Surgeons, New York, New York.
Ann Am Thorac Soc. 2018 Sep;15(9):1067-1074. doi: 10.1513/AnnalsATS.201711-872OC.
In the intensive care unit (ICU), studies involving specialized palliative care services have shown decreases in the use of nonbeneficial life-sustaining therapies and ICU length of stay for patients. However, whether widespread availability of hospital-based palliative care is associated with less frequent use of high intensity care is unknown.
To determine whether availability of hospital-based palliative care is associated with decreased markers of treatment intensity for ICU patients.
Retrospective cohort study of adult ICU patients in New York State hospitals, 2008-2014. Multilevel regression was used to assess the relationship between availability of hospital-based palliative care during the year of admission and hospital length of stay, use of mechanical ventilation, dialysis and artificial nutrition, placement of a tracheostomy or gastrostomy tube, days in ICU and discharge to hospice.
Of 1,025,503 ICU patients in 151 hospitals, 814,794 (79.5%) received care in a hospital with a palliative care program. Hospital length of stay was similar for patients in hospitals with and without palliative care programs (6 d [interquartile range, 3-12] vs. 6 d [interquartile range, 3-11]; adjusted rate ratio, 1.04 [95% confidence interval 1.03-1.05]; P < 0.001), as were other healthcare use outcomes. However, patients in hospitals with palliative care programs were 46% more likely to be discharged to hospice than those in hospitals without palliative care programs (1.7% vs. 1.4%; adjusted odds ratio, 1.46 [95% confidence interval 1.30-1.64]; P < 0.001).
The availability of hospital-based palliative care was not associated with differences in in-hospital treatment intensity, but it was associated with significantly increased hospice use for ICU patients. Currently, the measurable benefit of palliative care programs for critically ill patients may be the increased use of hospice facilities, as opposed to decreased healthcare use during an ICU-associated hospitalization.
在重症监护病房（ICU）中，涉及专门的姑息治疗服务的研究表明，非有益的生命维持治疗的使用减少，以及 ICU 患者的住院时间减少。然而，医院内姑息治疗的广泛可及性是否与高强度治疗的使用频率较低有关尚不清楚。
确定医院内姑息治疗的可及性是否与 ICU 患者治疗强度的降低标志物有关。
这是一项针对纽约州医院成年 ICU 患者的回顾性队列研究，时间为 2008 年至 2014 年。使用多水平回归来评估在入院当年是否有医院内姑息治疗与住院时间、机械通气、透析和人工营养、气管造口或胃造口管放置、ICU 天数和临终关怀出院之间的关系。
在 151 家医院的 1025503 名 ICU 患者中，814794 名（79.5%）在有姑息治疗计划的医院接受了治疗。在有和没有姑息治疗计划的医院中，患者的住院时间相似（6 天[四分位间距 3-12] vs. 6 天[四分位间距 3-11]；调整后比率 1.04[95%置信区间 1.03-1.05]；P<0.001），其他医疗保健使用结果也是如此。然而，有姑息治疗计划的医院的患者被送往临终关怀的可能性比没有姑息治疗计划的医院高 46%（1.7%比 1.4%；调整后的优势比 1.46[95%置信区间 1.30-1.64]；P<0.001）。
医院内姑息治疗的可及性与院内治疗强度的差异无关，但与 ICU 患者使用临终关怀的显著增加有关。目前，姑息治疗计划对危重病患者的可衡量益处可能是临终关怀设施的使用增加，而不是 ICU 相关住院期间医疗保健使用的减少。
