晚期肺癌患者姑息治疗的使用和设置与临终医疗保健利用和护理质量的关联。
Association of Palliative Care Use and Setting With Health-care Utilization and Quality of Care at the End of Life Among Patients With Advanced Lung Cancer.
机构信息
Division of Pulmonary and Critical Care, Oregon Health & Science University, Portland, OR; Health Services Research & Development, VA Portland Health Care System, Portland, OR; Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA; Section of Pulmonary and Critical Care Medicine, Veterans Affairs Portland Health Care System, Portland, OR.
Department of Biostatistics, School of Public Health, Oregon Health & Science University, Portland, OR.
出版信息
Chest. 2020 Dec;158(6):2667-2674. doi: 10.1016/j.chest.2020.06.018. Epub 2020 Jun 23.
BACKGROUND
Palliative care is associated with improved survival and quality of life among patients with lung cancer; however, its influence on health-care utilization and quality of care is unclear.
RESEARCH QUESTION
Is palliative care, and the setting in which it occurs, associated with health-care resource utilization and quality of care among patients with advanced lung cancer?
STUDY DESIGN AND METHODS
This was a retrospective cohort study of 23,142 patients with stage IIIB/IV lung cancer in the Veterans Affairs HealthCare System between 2007 and 2013. Exposures included the receipt of specialist-delivered palliative care, and the setting of the initial palliative care encounter (inpatient or outpatient) received after cancer diagnosis. Primary outcomes included rates of ED visits, along with rates of hospitalization and odds of ICU admission within the last 30 days of life. Secondary outcomes included any health-care utilization (ED, hospital, or ICU) related to chemotherapy toxicity. We used propensity score methods to perform Poisson and logistic regression modeling.
RESULTS
Among the 23,142 patients, 57% received palliative care, and 36% of initial palliative care encounters were outpatient. Compared with no palliative care, initial palliative care encounter in the outpatient setting was associated with reduced rates of ED visits (adjusted incidence rate ratio [aIRR], 0.86; 95% CI, 0.77-0.96) and hospitalizations in the last 30 days of life (aIRR, 0.64; 95% CI, 0.59-0.70). Initial palliative care encounters in both inpatient (adjusted OR [aOR], 0.63; 95% CI, 0.53-0.75) and outpatient (aOR, 0.42; 95% CI, 0.35-0.52) settings were associated with reduced odds of ICU admission in the last 30 days of life. Palliative care was also associated with reduced health-care utilization related to chemotherapy toxicity (aOR, 0.88; 95% CI, 0.82-0.95).
INTERPRETATION
Palliative care (particularly in outpatient settings) is associated with reduced health-care utilization at the end of life and may improve the quality of care among patients with advanced lung cancer. These findings support the role of palliative care as an important component of comprehensive cancer care and highlight the potential benefits of outpatient palliative care services.
背景
姑息治疗可改善肺癌患者的生存和生活质量；然而，其对医疗资源利用和护理质量的影响尚不清楚。
研究问题
姑息治疗及其发生的环境是否与晚期肺癌患者的医疗资源利用和护理质量相关？
研究设计和方法
这是一项回顾性队列研究，纳入了 2007 年至 2013 年期间退伍军人事务部医疗保健系统中 23142 例 IIIB/IV 期肺癌患者。暴露因素包括接受专科医生提供的姑息治疗，以及癌症诊断后首次姑息治疗的环境（住院或门诊）。主要结局包括急诊就诊率，以及临终前 30 天内住院和入住 ICU 的几率。次要结局包括与化疗毒性相关的任何医疗保健利用（急诊、住院或 ICU）。我们使用倾向评分方法进行泊松和逻辑回归建模。
结果
在 23142 例患者中，57%接受了姑息治疗，36%的首次姑息治疗是在门诊进行的。与未接受姑息治疗相比，门诊环境下的初始姑息治疗与急诊就诊率降低相关（校正发病率比 [aIRR]，0.86；95%CI，0.77-0.96）和临终前 30 天内的住院率（aIRR，0.64；95%CI，0.59-0.70）。住院（校正 OR [aOR]，0.63；95%CI，0.53-0.75）和门诊（aOR，0.42；95%CI，0.35-0.52）环境下的初始姑息治疗都与临终前 30 天内 ICU 入院几率降低相关。姑息治疗也与化疗毒性相关的医疗保健利用减少相关（aOR，0.88；95%CI，0.82-0.95）。
结论
姑息治疗（尤其是门诊环境下）与临终时的医疗资源利用减少相关，并可能改善晚期肺癌患者的护理质量。这些发现支持姑息治疗作为综合癌症护理重要组成部分的作用，并强调了门诊姑息治疗服务的潜在益处。
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