Sheckter Clifford C, Hung Kay S, Rochlin Danielle, Maan Zeshaan, Karanas Yvonne, Curtin Catherine
Division of Plastic & Reconstructive Surgery, Department of Surgery, Stanford University, Stanford, CA, United States; Clinical Excellence Research Center (CERC), Department of Medicine, Stanford University, Stanford, CA, United States.
Division of Plastic & Reconstructive Surgery, Department of Surgery, Stanford University, Stanford, CA, United States.
Burns. 2018 Dec;44(8):1903-1909. doi: 10.1016/j.burns.2018.07.012. Epub 2018 Aug 13.
Despite advances in critical care and the surgical management of major burns, highly moribund patients are unlikely to survive. Little is known regarding the utilization and effects of palliative care services in this population.
All major burn hospitalizations were identified within the Nationwide Inpatient Sample. Patients were characterized by burn, demographic, facility, and diseases factors. Palliative care services were identified with International Classification Disease 9th edition code V6.67. Temporal trends were assessed with Poisson modeling. Inpatient mortality and death without surgical intervention were assessed with logistic regression. Outcomes were stratified by modified Baux scores.
7424 major burns were included; 1.9% received palliative care services. Patients receiving palliation had a mean age of 63.6 years (SD 19.6), mean total body surface area of 62.2% (SD 24.9%), and mean modified Baux score of 127.1 (SD 26.7). Adjusting for covariates, the incidence rate ratio was 1.42 over the 10-year period (95% CI, 1.31-1.54, p<0.001). Independent predictors of palliative consultations included older age, larger burns, deeper burns, and higher Elixhauser comorbidity score. Among patients with modified Baux scores between 100-153, those receiving palliative care services were significantly more likely to die without surgery, OR 3.24 (95% CI 1.13-10.39, p=0.029), with no significant difference in mortality, OR 11.72 (95% CI 0.87-22.57, p=0.051) CONCLUSION AND RELEVANCE: Palliative care services were increasingly used during the study period. Palliative care services in highly moribund burn patients do not impact survival and may decrease the likelihood of surgical intervention in select patients.
尽管重症监护和大面积烧伤的外科治疗取得了进展，但病情极其严重的患者存活的可能性不大。关于这一人群姑息治疗服务的利用情况和效果，人们了解甚少。
在全国住院患者样本中确定所有大面积烧伤住院病例。患者的特征包括烧伤情况、人口统计学特征、医疗机构和疾病因素。通过国际疾病分类第九版代码V6.67确定姑息治疗服务。采用泊松模型评估时间趋势。通过逻辑回归评估住院死亡率和未经手术干预的死亡率。结果按改良博克斯评分进行分层。
纳入7424例大面积烧伤病例；1.9%接受了姑息治疗服务。接受姑息治疗的患者平均年龄为63.6岁（标准差19.6），平均体表面积为62.2%（标准差24.9%），平均改良博克斯评分为127.1（标准差26.7）。在对协变量进行调整后，10年期间的发病率比为1.42（95%置信区间，1.31 - 1.54，p<0.001）。姑息治疗会诊的独立预测因素包括年龄较大、烧伤面积较大、烧伤深度较深以及埃利克斯豪泽合并症评分较高。在改良博克斯评分在100 - 153之间的患者中，接受姑息治疗服务的患者未经手术死亡的可能性显著更高，比值比为3.24（95%置信区间1.13 - 10.39，p = 0.029），死亡率无显著差异，比值比为11.72（95%置信区间0.87 - 22.57，p = 0.051）。结论与意义：在研究期间，姑息治疗服务的使用越来越多。病情极其严重的烧伤患者接受姑息治疗服务不会影响生存率，且可能降低部分患者接受手术干预的可能性。
