Austin Health, Melbourne, Australia.
Goulburn Valley Health, Shepparton, Australia.
BMC Palliat Care. 2020 Jan 27;19(1):14. doi: 10.1186/s12904-020-0517-3.
The therapeutic landscape in medical oncology continues to expand significantly. Newer therapies, especially immunotherapy, offer the hope of profound and durable responses with more tolerable side effect profiles. Integrating this information into the decision making process is challenging for patients and oncologists. Systemic anticancer treatment within the last thirty days of life is a key quality of care indicator and is one parameter used in the assessment of aggressiveness of care.
A retrospective review of medical records of all patients previously treated at Goulburn Valley Health oncology department who died between 1 January 2015 and 30 June 2018 was conducted. Information collected related to patient demographics, diagnosis, treatment, and hospital care within the last 30 days of life. These results were presented to the cancer services meeting and a quality improvement intervention program was instituted. A second retrospective review of medical records of all patients who died between 1 July 2018 and 31 December 2018 was conducted in order to measure the effect of this intervention.
The initial audit period comprised 440 patients. 120 patients (27%) received treatment within the last 30 days of life. The re-audit period comprised 75 patients. 19 patients (25%) received treatment within the last 30 days of life. Treatment rates of chemotherapy reduced after the intervention in contrast to treatment rates of immunotherapy which increased. A separate analysis calculated the rate of mortality within 30 days of chemotherapy from the total number of patients who received chemotherapy was initially 8% and 2% in the re-audit period. Treatment within the last 30 days of life was associated with higher use of aggressive care such as emergency department presentation, hospitalisation, ICU admission and late hospice referral. Palliative care referral rates improved after the intervention.
This audit demonstrated that a quality improvement intervention can impact quality of care indicators with reductions in the use of chemotherapy within the last 30 days of life. However, immunotherapy use increased which may be explained by increased access and a better risk benefit balance.
医学肿瘤学的治疗领域继续显著扩大。新型疗法，特别是免疫疗法，提供了更持久、更耐受的反应希望，副作用更小。将这些信息纳入决策过程对患者和肿瘤学家来说都是一个挑战。在生命的最后 30 天内进行全身性抗癌治疗是一个关键的护理质量指标，也是评估护理积极性的一个参数。
对 2015 年 1 月 1 日至 2018 年 6 月 30 日期间在古尔本市健康肿瘤科接受治疗的所有死亡患者的病历进行了回顾性审查。收集的信息包括患者人口统计学、诊断、治疗和生命最后 30 天内的住院护理。这些结果被提交给癌症服务会议，并实施了质量改进干预计划。对 2018 年 7 月 1 日至 2018 年 12 月 31 日期间死亡的所有患者的病历进行了第二次回顾性审查，以衡量该干预措施的效果。
初步审核期包括 440 名患者。120 名患者（27%）在生命的最后 30 天内接受了治疗。重新审核期包括 75 名患者。19 名患者（25%）在生命的最后 30 天内接受了治疗。与免疫治疗相比，治疗率在干预后降低了，而化疗的治疗率却有所上升。一项单独的分析计算了从接受化疗的患者总数中计算出的化疗后 30 天内死亡率，初次审核期为 8%，重新审核期为 2%。生命的最后 30 天内的治疗与更积极的护理的使用有关，如急诊就诊、住院、重症监护病房入院和晚期临终关怀转诊。干预后，姑息治疗转诊率有所提高。
本审计表明，质量改进干预可以影响护理质量指标，减少生命最后 30 天内的化疗使用。然而，免疫治疗的使用增加了，这可能是由于获得机会增加和风险效益平衡更好。
