Look Hong Nicole J, Liu Ning, Wright Frances C, MacKinnon Marnie, Seung Soo Jin, Earle Craig C, Gradin Sharon, Sati Saurabh, Buchman Sandy, Mittmann Nicole
Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
JCO Oncol Pract. 2020 Aug;16(8):e688-e702. doi: 10.1200/JOP.19.00397. Epub 2020 Mar 20.
This study evaluates whether an intervention to identify Canadian patients eligible for a palliative approach changes the use of health care resources and costs within the final month of life.
Between 2014 and 2017, physicians identified 1,187 patients in family practice units and cancer centers who were likely to die within 1 year based on diagnosis, symptom assessment, and performance status. A multidisciplinary intervention that included activation of community resources and initiation of palliative planning was started. By using propensity-score matching, patients in the intervention group were matched 1:1 with nonintervention controls selected from provincial administrative data. We compared health care use and costs (using 2017 Canadian dollars) for 30 days before death between patients who died within the 1-year follow-up and matched controls.
Groups (n = 629 in each group) were well-balanced in sociodemographic characteristics, comorbidities, and previous health care use. In the last 30 days, there was no differences in proportions between the two groups of patients regarding emergency department visits, intensive care unit admissions, or inpatient hospitalizations. However, patients in the intervention group had greater use of palliative physician encounters, community home care visits, and/or physician home visits (92.8% 88.4%; = .007). In the 507 pairs with cancer, more patients in the intervention group underwent chemotherapy (44% 33%; < .001) and radiation (18.7% 3.2%; = .043) in the last 30 days. Mean cost per patient was similar for the intervention group (mean, $17,231; 95% CI, $16,027 to $18,436) and for the control group (mean, $16,951; 95% CI, $15,899 to $18,004).
Even with the limitations in our observational study design, identification of palliative patients did not significantly change overall costs but may shift resources toward palliative services.
本研究评估一项旨在识别适合姑息治疗的加拿大患者的干预措施是否会在生命的最后一个月内改变医疗资源的使用和成本。
在2014年至2017年期间，医生在家庭医疗单位和癌症中心识别出1187名基于诊断、症状评估和身体状况可能在1年内死亡的患者。启动了一项多学科干预措施，包括激活社区资源和启动姑息治疗计划。通过倾向得分匹配，干预组患者与从省级行政数据中选取的非干预对照组患者进行1:1匹配。我们比较了在1年随访期内死亡的患者与其匹配对照组在死亡前30天的医疗使用情况和成本（以2017年加拿大元计）。
两组（每组n = 629）在社会人口统计学特征、合并症和既往医疗使用情况方面均衡良好。在最后30天内，两组患者在急诊就诊、重症监护病房入院或住院方面的比例没有差异。然而，干预组患者更多地接受了姑息治疗医生会诊、社区家庭护理访视和/或医生家访（92.8%对88.4%；P = 0.007）。在507对癌症患者中，干预组更多患者在最后30天内接受了化疗（44%对33%；P < 0.001）和放疗（18.7%对3.2%；P = 0.043）。干预组患者的人均成本（平均，17231加元；95%可信区间，16027加元至18436加元）与对照组（平均，16951加元；95%可信区间，15899加元至18004加元）相似。
即使我们的观察性研究设计存在局限性，但识别姑息治疗患者并未显著改变总体成本，但可能会将资源转向姑息治疗服务。
