Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina.
Duke Clinical Research Institute, Durham, North Carolina.
JAMA Cardiol. 2018 Oct 1;3(10):917-926. doi: 10.1001/jamacardio.2018.2678.
While 1 in 10 older patients hospitalized with heart failure (HF) die within 30 days, end-of-life care for this population is not well described.
To assess rates of discharge to hospice, readmission after hospice, and survival in hospice in patients following hospital discharge.
DESIGN, SETTING, AND PARTICIPANTS: In this observational cohort analysis of patients in the multicenter American Heart Association Get With The Guidelines (GWTG)-HF registry linked to Medicare fee-for-service claims data, we analyzed patients 65 years and older discharged alive from the hospital between 2005 and 2014. We compared 4588 patients discharged to hospice with 4357 patients with advanced HF (ejection fraction ≤25% and any of the following: inpatient inotrope use, serum sodium level ≤130 mEq/L, blood urea nitrogen level ≥45 mg/dL [to convert to micromoles per liter, multiply by 0.357], systolic blood pressure ≤90 mm Hg, or comfort measures during hospitalization) not discharged to hospice and with 113 045 other patients with HF in the GWTG-HF registry. Data were analyzed from October 2017 to June 2018.
Discharge to hospice, rehospitalization, and mortality.
Of the 4588 patients discharged to hospice, 2556 (55.7%) were female and 4047 (88.2%) were white, and they had a median (interquartile range) age of 86 (80-90) years. Hospice accounted for 4588 of 121 990 discharges (3.8%), of which 2424 (52.8%) were discharges to home hospice and 2164 (47.2%) were to a hospice facility. Hospice discharges increased from 2.0% (109 of 5528) in 2005 to 4.9% (968 of 19 590) in 2014. Patients discharged to hospice were older, white, and more symptomatic compared with patients with advanced HF (n = 4357) and other patients in the GWTG-HF registry (n = 113 045). The median (interquartile range) postdischarge survival time in patients discharged to hospice was 11 (3-63) days compared with 318 (78-1105) days in patients with advanced HF and 754 (221-1868) days in other patients in the GWTG-HF registry. A total of 739 patients (34.1%) discharged to hospice facilities died in less than 72 hours, while 295 (12.2%) discharged to home hospice died in less than 72 hours; 690 patients (15.0%) discharged from hospice lived for 6 months or more. Among hospitals with more than 25 hospice discharges, the median (interquartile range) hospice discharge rate was 3.5% (2.0%-5.7%). Readmission at 30 days was lower in patients discharged to hospice (189 [4.1%]) compared with patients with advanced HF (1185 [27.2%]) and others in the GWTG-HF registry (25 022 [22.2%]). Nonwhite race and younger age were the strongest predictors of readmission from hospice.
Hospice use has grown to about 4.9% of Medicare HF hospital discharges, with significant hospital-level variation. Almost a quarter of patients discharged to hospice die within 3 days of discharge, and about 4.1% of patients are readmitted to the hospital within 30 days.
尽管 10 名住院心力衰竭（HF）的老年患者中有 1 名在 30 天内死亡，但该人群的临终关怀服务并未得到很好的描述。
评估出院后入住临终关怀病房、出院后再次入院和在临终关怀病房中存活的患者比例。
设计、地点和参与者：在这项对多中心美国心脏协会 Get With The Guidelines（GWTG）-HF 注册中心与医疗保险费用服务索赔数据相关联的患者的观察性队列分析中，我们分析了 2005 年至 2014 年期间从医院出院的 65 岁及以上患者。我们将 4588 名出院后入住临终关怀病房的患者与 4357 名患有晚期 HF（射血分数≤25%，并伴有以下任何一种情况：住院期间使用儿茶酚胺、血清钠水平≤130 mEq/L、血尿素氮水平≥45 mg/dL[换算为微摩尔/升，乘以 0.357]、收缩压≤90 mmHg 或住院期间使用舒适措施）且未出院至临终关怀病房的患者以及 GWTG-HF 注册中心的其他 113045 名 HF 患者进行了比较。数据于 2017 年 10 月至 2018 年 6 月进行分析。
出院至临终关怀病房、再入院和死亡率。
在 4588 名出院至临终关怀病房的患者中，2556 名（55.7%）为女性，4047 名（88.2%）为白人，中位（四分位间距）年龄为 86（80-90）岁。临终关怀占 121990 次出院的 4588 次（3.8%），其中 2424 次（52.8%）为家庭临终关怀出院，2164 次（47.2%）为临终关怀机构出院。临终关怀的出院率从 2005 年的 2.0%（5528 例中的 109 例）上升到 2014 年的 4.9%（19590 例中的 968 例）。与晚期 HF（n=4357）和 GWTG-HF 注册中心的其他患者（n=113045）相比，出院至临终关怀病房的患者年龄更大、更白且症状更严重。出院至临终关怀病房的患者中位（四分位间距）出院后生存时间为 11（3-63）天，晚期 HF 患者为 318（78-1105）天，GWTG-HF 注册中心的其他患者为 754（221-1868）天。共有 739 名（34.1%）出院至临终关怀病房的患者在 72 小时内死亡，295 名（12.2%）出院至家庭临终关怀的患者在 72 小时内死亡；690 名（15.0%）从临终关怀病房出院的患者存活了 6 个月或更长时间。在临终关怀出院人数超过 25 人的医院中，中位（四分位间距）临终关怀出院率为 3.5%（2.0%-5.7%）。与晚期 HF 患者（1185 例[27.2%]）和 GWTG-HF 注册中心的其他患者（25022 例[22.2%]）相比，出院至临终关怀病房的患者在 30 天内再次入院的比例较低（189[4.1%]）。非白人种族和较年轻的年龄是从临终关怀病房再次入院的最强预测因素。
临终关怀的使用已增长到 Medicare HF 住院患者的 4.9%左右，且存在显著的医院水平差异。近四分之一的出院至临终关怀病房的患者在出院后 3 天内死亡，约 4.1%的患者在 30 天内再次入院。
