Li Ka Shing Knowledge Institute of St Michaels Hospital, Toronto, Ontario, Canada.
Division of Vascular Surgery, University of Toronto, Toronto, Ontario, Canada.
Br J Surg. 2020 Jan;107(1):64-72. doi: 10.1002/bjs.11367. Epub 2019 Oct 14.
The aim was to characterize end-of-life care in patients who have had a leg amputated for peripheral artery disease (PAD) or diabetes.
This was a population-based retrospective cohort study of patients with PAD or diabetes who died in Ontario, Canada, between 2011 and 2017. Those who had a leg amputation within 3 years of death were compared with a control cohort of deceased patients with PAD or diabetes, but without leg amputation. The patients were identified from linked health records within the single-payer healthcare system. Place and cause of death, as well as health services and costs within 90 days of death, were compared between the amputee and control cohorts. Among amputees, multivariable regression models were used to characterize the association between receipt of home palliative care and in-hospital death, as well as time spent in hospital at the end of life.
Compared with 213 300 controls, 3113 amputees were less likely to die at home (15·5 versus 24·9 per cent; P < 0·001) and spent a greater number of their last 90 days of life in hospital (median 19 versus 8 days; P < 0·001). Amputees also had higher end-of-life healthcare costs across all sectors. However, receipt of palliative care was less frequent among amputees than controls (inpatient: 13·4 versus 16·8 per cent, P < 0·001; home: 14·5 versus 23·8 per cent, P < 0·001). Among amputees, receipt of home palliative care was associated with a lower likelihood of in-hospital death (odds ratio 0·49, 95 per cent c.i. 0·40 to 0·60) and fewer days in hospital (rate ratio 0·84, 0·76 to 0·93).
Palliative care is underused after amputation in patients with PAD or diabetes, and could contribute to reducing in-hospital death and time spent in hospital at the end of life.
本研究旨在描述因外周动脉疾病（PAD）或糖尿病而截肢的患者的临终关怀情况。
这是一项基于人群的回顾性队列研究，纳入了 2011 年至 2017 年期间在加拿大安大略省死亡的 PAD 或糖尿病患者。将在死亡前 3 年内接受过截肢手术的患者与因 PAD 或糖尿病而死亡但未接受过截肢手术的患者进行比较。通过单一支付方医疗保健系统中的关联健康记录识别患者。比较截肢组和对照组患者在死亡后 90 天内的死亡地点和原因以及卫生服务和费用。在截肢患者中，使用多变量回归模型来描述接受家庭姑息治疗与院内死亡以及临终时住院时间之间的关联。
与 213300 名对照相比，3113 名截肢患者更不可能在家中死亡（15.5%比 24.9%；P<0.001），并且在生命的最后 90 天中在医院度过的时间更多（中位数 19 比 8 天；P<0.001）。截肢患者在所有部门的临终医疗保健费用也更高。然而，与对照组相比，截肢患者接受姑息治疗的比例较低（住院：13.4%比 16.8%，P<0.001；家庭：14.5%比 23.8%，P<0.001）。在截肢患者中，家庭姑息治疗的使用与院内死亡的可能性降低相关（比值比 0.49，95%置信区间 0.40 至 0.60），并且住院时间减少（比率比 0.84，0.76 至 0.93）。
PAD 或糖尿病截肢患者的姑息治疗使用率较低，姑息治疗的使用可能有助于降低院内死亡和临终时的住院时间。
