老年患者在急诊大腹部手术期间的姑息治疗需求负担高。
High Burden of Palliative Care Needs of Older Adults During Emergency Major Abdominal Surgery.
机构信息
The Center for Surgery and Public Health, Boston, Massachusetts.
Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
出版信息
J Am Geriatr Soc. 2018 Nov;66(11):2072-2078. doi: 10.1111/jgs.15516. Epub 2018 Sep 24.
OBJECTIVES
To quantify preoperative illness burden in older adults undergoing emergency major abdominal surgery (EMAS), to examine the association between illness burden and postoperative outcomes, and to describe end-of-life care in the year after discharge.
DESIGN
Retrospective study using data from Health and Retirement Study interviews linked to Medicare claims (2000-2012).
SETTING
National population-based dataset.
PARTICIPANTS
Medicare beneficiaries who underwent EMAS.
MEASUREMENTS
High illness burden, defined as ≥2 of the following vulnerabilities: functional dependence, dementia, use of helpers, multimorbidity, poor prognosis, high healthcare utilization. In-hospital outcomes were complications and mortality. Postdischarge outcomes included emergency department (ED) visits, hospitalization, intensive care unit (ICU) stay, and 365-day mortality. For individuals discharged alive who died within 365 days of surgery, outcomes included hospice use, hospitalization, ICU use, and ED use in the last 30 days of life. Multivariable regression was used to determine the association between illness burden and outcomes.
RESULTS
Of 411 participants, 57% had high illness burden. More individuals with high illness burden had complications (45% vs 28% p=0.00) and in-hospital death (20% vs 9%, p=0.00) than those without. After discharge (n=349), individuals with high illness burden experienced more ED visits (57% vs 46%, P=.04) and were more likely to die (35% vs 13%, p=0.00). Of those who died after discharge (n=86), 75% had high illness burden, median survival was 67 days (range 21-141 days), 48% enrolled in hospice, 32% died in the hospital, 23% were in the ICU in the last 30 days of life and 37% had an ED visit in the last 30 days of life.
CONCLUSION
Most older adults undergoing EMAS have preexisting high illness burden and experience high mortality and healthcare use in the year after surgery, particularly near the end of life. Concurrent surgical and palliative care may improve quality of life and end-of-life care in these people. J Am Geriatr Soc 66:2072-2078, 2018.
目的
定量评估行急诊大腹部手术（EMAS）的老年患者术前疾病负担，探讨疾病负担与术后结局的关系，并描述出院后 1 年内的临终关怀情况。
设计
使用健康与退休研究访谈数据（2000-2012 年）与医疗保险索赔相关联的回顾性研究。
设置
全国人群为基础的数据集。
参与者
接受 EMAS 的 Medicare 受益人。
测量方法
高疾病负担，定义为以下 2 种或以上脆弱性：功能依赖、痴呆、需要帮助者、多种合并症、预后不良、高医疗保健利用率。院内结局包括并发症和死亡率。出院后结局包括急诊就诊、住院、重症监护病房（ICU）入住和 365 天死亡率。对于存活出院后 365 天内死亡的患者，结局包括临终关怀使用、住院、ICU 使用和生命最后 30 天内的急诊就诊。采用多变量回归确定疾病负担与结局之间的关系。
结果
在 411 名参与者中，57%有高疾病负担。高疾病负担者的并发症（45%比 28%，p=0.00）和院内死亡（20%比 9%，p=0.00）更多。出院后（n=349），高疾病负担者急诊就诊更多（57%比 46%，p=0.04），更有可能死亡（35%比 13%，p=0.00）。出院后死亡的患者（n=86）中，75%有高疾病负担，中位生存期为 67 天（范围 21-141 天），48%入组临终关怀，32%在医院死亡，23%在生命最后 30 天入住 ICU，37%在生命最后 30 天内急诊就诊。
结论
大多数接受 EMAS 的老年患者术前即存在高疾病负担，术后 1 年内死亡率和医疗保健使用率高，特别是接近生命终点时。同期进行手术和姑息治疗可能会改善这些患者的生活质量和临终关怀。美国老年学会杂志 66:2072-2078,2018。
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