Department of Surgery, Massachusetts General Hospital, Boston, MA, USA.
Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA.
Ann Surg Oncol. 2019 Dec;26(13):4204-4212. doi: 10.1245/s10434-019-07757-2. Epub 2019 Aug 28.
Given survival measured in months, metrics, such as 30-day mortality, are poorly suited to measure the quality of palliative procedures for patients with advanced cancer. Nationally endorsed process measures associated with high-quality PC include code-status clarification, goals-of-care discussions, palliative-care referral, and hospice assessment. The impact of the performance of these process measures on subsequent healthcare utilization is unknown.
Administrative data and manual review were used to identify hospital admissions with performance of palliative procedures for advanced pancreatic cancer at two tertiary care hospitals from 2011 to 2016. Natural language processing, a form of computer-assisted abstraction, identified process measures in associated free-text notes. Healthcare utilization was compared using a Cox proportional hazard model.
We identified 823 hospital admissions with performance of a palliative procedure. PC process measures were identified in 68% of admissions. Patients with documented process measures were older (66 vs. 63; p = 0.04) and had a longer length of stay (9 vs. 6 days; p < 0.001). In multivariate analysis, patients treated by surgeons were less likely to have PC process measures performed (odds ratio 0.19; 95% confidence interval 0.10-0.37). Performance of PC process measures was associated with decreased healthcare utilization in a Cox proportional hazard model.
PC process measures were not performed in almost one-third of hospital admissions for palliative procedures in patients with advanced pancreatic cancer. Performance of established high-quality process measures for seriously ill patients undergoing palliative procedures may help patients to avoid burdensome, high-intensity care at the end-of-life.
由于以月为单位进行生存测量，因此诸如 30 天死亡率等指标不适用于衡量晚期癌症患者的姑息治疗质量。与高质量 PC 相关的全国认可的流程指标包括明确患者的医疗状况、进行治疗目标讨论、转介姑息治疗以及进行临终关怀评估。这些流程指标的执行情况对后续医疗保健利用的影响尚不清楚。
利用行政数据和人工审查，从 2011 年至 2016 年，在两家三级护理医院确定接受姑息性治疗的晚期胰腺癌住院患者。自然语言处理（一种计算机辅助提取形式）在相关的自由文本记录中识别出流程指标。使用 Cox 比例风险模型比较医疗保健利用情况。
我们确定了 823 例进行姑息治疗的住院患者。68%的患者记录了姑息治疗流程指标。有记录的流程指标的患者年龄更大（66 岁比 63 岁；p=0.04），住院时间更长（9 天比 6 天；p<0.001）。在多变量分析中，接受外科医生治疗的患者接受姑息治疗流程指标治疗的可能性较小（比值比 0.19；95%置信区间 0.10-0.37）。在 Cox 比例风险模型中，姑息治疗流程指标的执行与医疗保健利用的减少相关。
在接受姑息治疗的晚期胰腺癌患者中，近三分之一的住院患者未进行姑息治疗流程指标的检测。对接受姑息治疗的重病患者执行既定的高质量流程指标可能有助于患者避免在生命末期承受繁重、高强度的医疗护理。
