老年急诊手术后患者术前虚弱状况与生命终末期照护强度。
Preoperative Frailty Status and Intensity of End-of-Life Care Among Older Adults After Emergency Surgery.
机构信息
The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA.
The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Surgery, University of California, San Diego, La Jolla, California, USA.
出版信息
J Pain Symptom Manage. 2021 Jul;62(1):66-74.e3. doi: 10.1016/j.jpainsymman.2020.11.013. Epub 2020 Nov 16.
CONTEXT
Emergency general surgery (EGS) is common and highly morbid for older adults, particularly for those who are frail. However, there are little data on the quality of end-of-life care (EOLC) for this population.
OBJECTIVES
We sought to examine the association of frailty with intensity of EOLC for older adults with and without frailty who undergo EGS but die within one year.
METHODS
This retrospective cohort study included 100% Medicare fee-for-service beneficiaries, ≥66 years, who underwent one of five EGS procedures with the highest mortality (partial colectomy, small bowel resection, peptic ulcer disease repair, adhesiolysis, or laparotomy) between 2008 and 2014 and died within one year. A validated claims-based frailty index (CFI) identified patients who were not frail (CFI < 0.15), prefrail (0.15 ≤ CFI < 0.25), mildly frail (0.25 ≤ CFI < 0.35), and moderately to severe frail (CFI ≥ 0.35). Multivariable adjusted logistic or Poisson regression compared post-discharge and EOL healthcare utilization.
RESULTS
Among 138,916 older EGS adults who died within one year, 32.2% were not frail, 31.7% were prefrail, 29.8% had mild frailty and 6.3% had moderate-to-severe frailty. Decedents with any degree of frailty experienced high-intensity EOLC (P < 0.01), low rates of hospice use (P < 0.01), and fewer days at home. Of those who survived the index hospitalization but died within one year, moderate-to-severely frail decedents had the highest odds of visiting an emergency department (odds ratio [OR] = 1.19, CI = 1.13-1.27), rehospitalization (OR = 1.23, CI = 1.16-1.31), or an intensive care unit admission (OR = 1.22, CI = 1.13-1.30) in the last 30 days of life compared to nonfrail decedents.
CONCLUSION
While all older patients undergoing EGS have poor end-of-life outcomes, frail EGS patients receive the highest intensity EOLC and represent a vulnerable population for whom targeted interventions could limit burdensome treatment.
背景
急诊普通外科（EGS）在老年人中很常见且病死率很高，尤其是身体虚弱的老年人。然而，关于这一人群生命终末期护理（EOLC）质量的数据很少。
目的
我们旨在研究虚弱与接受 EGS 但在一年内死亡的虚弱和非虚弱老年人的 EOLC 强度之间的关联。
方法
这是一项回顾性队列研究，纳入了 2008 年至 2014 年间接受五种最高死亡率的 EGS 手术之一（部分结肠切除术、小肠切除术、消化性溃疡病修复术、粘连松解术或剖腹术）且在一年内死亡的 100%医疗保险按服务付费受益人的数据，年龄≥66 岁。采用经过验证的基于索赔的虚弱指数（CFI）确定非虚弱（CFI<0.15）、虚弱前期（0.15≤CFI<0.25）、轻度虚弱（0.25≤CFI<0.35）和中度至重度虚弱（CFI≥0.35）的患者。多变量调整的逻辑或泊松回归比较了出院后和生命终末期的医疗保健利用情况。
结果
在 138916 名在一年内死亡的老年 EGS 成年人中，32.2%的人没有虚弱，31.7%的人处于虚弱前期，29.8%的人有轻度虚弱，6.3%的人有中度至重度虚弱。任何程度虚弱的死者都经历了高强度的生命终末期护理（P<0.01），接受临终关怀的比例较低（P<0.01），在家的天数较少。在那些从指数住院治疗中存活下来但在一年内死亡的患者中，中度至重度虚弱的死者在生命的最后 30 天内到急诊部就诊（优势比[OR]1.19，95%置信区间[CI]1.13-1.27）、再次住院（OR 1.23，CI 1.16-1.31）或入住重症监护病房（OR 1.22，CI 1.13-1.30）的可能性最高，而非虚弱的死者（OR 1.19，CI 1.13-1.27）。
结论
尽管所有接受 EGS 的老年患者的生命终末期结局都较差，但虚弱的 EGS 患者接受了最高强度的生命终末期护理，他们是一个脆弱的人群，针对他们的干预措施可以限制负担过重的治疗。
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