The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Surgery, University of California, San Diego, La Jolla, California, USA.
Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California, USA; Greater Los Angeles Veterans Affairs Healthcare System, David Geffen School of Medicine at University of California, Los Angeles, California, USA; Affiliated Adjunct Staff, RAND Health, Los Angeles, California, USA.
J Pain Symptom Manage. 2019 Nov;58(5):844-850.e2. doi: 10.1016/j.jpainsymman.2019.08.003. Epub 2019 Aug 9.
Palliative care (PC) for seriously ill surgical patients, including aligning treatments with patients' goals and managing symptoms, is associated with improved patient-oriented outcomes and decreased health care utilization. However, efforts to integrate PC alongside restorative surgical care are limited by the lack of a consensus definition for serious illness in the perioperative context.
The objectives of this study were to develop a serious illness definition for surgical patients and identify a denominator for quality measurement efforts.
We developed a preliminary definition including a set of criteria for 11 conditions and health states. Using the RAND-UCLA Appropriateness Method, a 12-member expert advisory panel rated the criteria for each condition and health state twice, once after an in-person moderated discussion, for validity (primary outcome) and feasibility of measurement.
All panelists completed both rounds of rating. All 11 conditions and health states defining serious illness for surgical patients were rated as valid. During the in-person discussion, panelists refined and narrowed criteria for two conditions (vulnerable elder, heart failure). The final definition included the following 11 conditions and health states: vulnerable elder, heart failure, advanced cancer, oxygen-dependent pulmonary disease, cirrhosis, end-stage renal disease, dementia, critical trauma, frailty, nursing home residency, and American Society of Anesthesiology Risk Score IV-V.
We identified a consensus definition for serious illness in surgery. Opportunities remain in measuring the prevalence, identifying health trajectories, and developing screening criteria to integrate PC with restorative surgical care.
对重病手术患者进行姑息治疗（PC），包括调整治疗方案以符合患者的目标和管理症状，与改善以患者为导向的结果和减少医疗保健利用有关。然而，由于在围手术期缺乏对严重疾病的共识定义，将 PC 与恢复性手术护理相结合的努力受到限制。
本研究的目的是为手术患者制定严重疾病的定义，并确定质量测量工作的分母。
我们开发了一个初步定义，包括一套 11 种疾病和健康状况的标准。使用 RAND-UCLA 适宜性方法，一个由 12 名专家顾问组成的小组两次对每个疾病和健康状况的标准进行了评估，一次是在现场讨论之后，以评估其有效性（主要结果）和测量的可行性。
所有小组成员都完成了两轮评分。所有 11 种疾病和健康状况都被认为是手术患者严重疾病的有效定义。在现场讨论中，小组成员对两种疾病（脆弱的老年人、心力衰竭）的标准进行了细化和缩小。最终的定义包括以下 11 种疾病和健康状况：脆弱的老年人、心力衰竭、晚期癌症、需要吸氧的肺部疾病、肝硬化、终末期肾病、痴呆、重症创伤、虚弱、疗养院居住和美国麻醉师协会风险评分 IV-V。
我们确定了手术中严重疾病的共识定义。在测量患病率、确定健康轨迹以及开发将姑息治疗与恢复性手术护理相结合的筛查标准方面，仍有机会。
