de Avila Victor, Paik James M, de Avila Leyla, Henry Linda, Mohess Denise, Roche-Green Alva, Younossi Zobair M
Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, USA.
Center for Liver Disease and Department of Medicine, Inova Fairfax Medical Campus, Falls Church, VA, USA.
JHEP Rep. 2021 Jan 27;3(2):100236. doi: 10.1016/j.jhepr.2021.100236. eCollection 2021 Apr.
BACKGROUND & AIMS: The benefits of hospice care in Medicare recipients with hepatocellular carcinoma (HCC) have not been fully evaluated, which we aimed to study.
We used nationally representative samples of the Medicare beneficiaries in the USA (2011-2016) to assess the impact of hospice care on the outcomes of patients with HCC. Hospice care benefits on the survival time, length of stay (LOS), 30-day readmissions, and daily charges during the last year and month of life were assessed by logistic regression and generalised linear regression.
Among 2,230 Medicare beneficiaries with HCC (mean age, 74.9 years; non-Hispanic White 79.1%; male 66.6%), median survival from HCC diagnosis was 68 days; 556 (24.9%) received hospice services; median hospice LOS was 12 days (4-35 days). Hospice users increased from 20.1% to 31.1% over time, driven by enrolment ≤15 days (45.1-59.2%, respectively). In the last year of life, hospice users ( no hospice care) had longer median survival time (76.5 66 days), lower in-hospital mortality (1.1% 25.5%) and lower median daily charges ($951 $1,004) despite more inpatient admissions and higher comorbid diseases. Hospice enrolment was associated with 48.6% reduction in daily charges (95% CI: -54.9% to -41.5%). Longer hospice LOS was associated with lower rates of healthcare utilisation. Patients with chronic liver disease were less likely to enrol in hospice care (odds ratio = 0.18, 95% CI: 0.14-0.24).
Although hospice provides a significant decrease in healthcare utilisation and some benefit in survival, most care is given in the last 2 weeks of life. Efforts to encourage earlier use of hospice services must continue.
The purpose of hospice care is to provide comfort and lessen suffering at the end of life. Hospice care allows one to die outside the hospital environment which is the wish of most people. However, we found that among persons aged 65 years and older who were diagnosed with liver cancer (which has a poor prognosis), only 25% were enrolled in hospice care and the majority used a hospice only in the last weeks of life. This is a disheartening finding as liver cancer patients with longer hospice enrolment had lower costs and improved survival. We suggest that healthcare practitioners consider discussion of palliative and hospice care routinely with patients suffering from liver cancer.
临终关怀对医疗保险覆盖的肝细胞癌（HCC）患者的益处尚未得到充分评估，我们旨在对此进行研究。
我们使用了美国医疗保险受益人的全国代表性样本（2011 - 2016年）来评估临终关怀对HCC患者结局的影响。通过逻辑回归和广义线性回归评估临终关怀在生存时间、住院时长（LOS）、30天再入院率以及生命最后一年和一个月的每日费用方面的益处。
在2230名医疗保险覆盖的HCC患者中（平均年龄74.9岁；非西班牙裔白人占79.1%；男性占66.6%），自HCC诊断后的中位生存期为68天；556名（24.9%）接受了临终关怀服务；中位临终关怀住院时长为12天（4 - 35天）。随着时间推移，临终关怀使用者从20.1%增至31.1%，这是由登记时间≤15天的人数增加所驱动（分别从45.1%增至59.2%）。在生命的最后一年，临终关怀使用者（与未接受临终关怀者相比）有更长的中位生存时间（76.5天对66天）、更低的院内死亡率（1.1%对25.5%）以及更低的中位每日费用（951美元对1004美元），尽管住院次数更多且合并症更多。临终关怀登记与每日费用降低48.6%相关（95%置信区间：-54.9%至-41.5%）。更长的临终关怀住院时长与更低的医疗保健利用率相关。慢性肝病患者接受临终关怀服务的可能性较小（优势比 = 0.18，95%置信区间：0.14 - 0.24）。
尽管临终关怀显著降低了医疗保健利用率并在生存方面有一定益处，但大多数护理是在生命的最后两周提供的。必须继续努力鼓励更早使用临终关怀服务。
临终关怀的目的是在生命末期提供舒适并减轻痛苦。临终关怀使人们能够在医院环境之外离世，这是大多数人的愿望。然而，我们发现，在65岁及以上被诊断患有肝癌（预后较差）的人群中，只有25%的人接受了临终关怀服务，且大多数人仅在生命的最后几周使用临终关怀服务。这是一个令人沮丧的发现，因为临终关怀登记时间更长的肝癌患者成本更低且生存期更长。我们建议医疗从业者常规性地与肝癌患者讨论姑息治疗和临终关怀。
