Szilcz Máté, Wastesson Jonas W, Johnell Kristina, Morin Lucas
Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
BMJ Support Palliat Care. 2021 Apr 27. doi: 10.1136/bmjspcare-2020-002778.
Unplanned hospitalisations can be burdensome for older people who approach the end of life. Hospitalisations disrupt the continuity of care and often run against patients' preference for comfort and palliative goals of care. This study aimed to describe the patterns of unplanned hospitalisations across illness trajectories in the last year of life.
Longitudinal, retrospective cohort study of decedents, including all older adults (≥65 years) who died in Sweden in 2015. We used nationwide data from the National Cause of Death Register linked at the individual level with several other administrative and healthcare registers. Illness trajectories were defined based on multiple-cause-of-death data to approximate functional decline near the end of life. Incidence rate ratios (IRR) for unplanned hospitalisations were modelled with zero-inflated Poisson regressions.
In a total of 77 315 older decedents (53% women, median age 85.2 years), the overall incidence rate of unplanned hospitalisations during the last year of life was 175 per 100 patient-years. The adjusted IRR for unplanned hospitalisation was 1.20 (95%CI 1.18 to 1.21) times higher than average among decedents who followed a trajectory of cancer. Conversely, decedents who followed the trajectory of prolonged dwindling had a lower-than-average risk of unplanned hospitalisation (IRR 0.66, 95% CI 0.65 to 0.68). However, these differences between illness trajectories only became evident during the last 3 months of life.
Our study highlights that, during the last 3 months of life, unplanned hospitalisations are increasingly frequent. Policies aiming to reduce burdensome care transitions should consider the underlying illness trajectories.
非计划住院对于接近生命末期的老年人而言可能是沉重的负担。住院会扰乱护理的连续性，并且常常违背患者对舒适和姑息性护理目标的偏好。本研究旨在描述生命最后一年中不同疾病轨迹下的非计划住院模式。
对死者进行纵向、回顾性队列研究，纳入2015年在瑞典死亡的所有老年人（≥65岁）。我们使用了来自全国死因登记处的全国性数据，这些数据在个体层面与其他几个行政和医疗保健登记处相链接。基于多死因数据定义疾病轨迹，以近似生命末期的功能衰退。非计划住院的发病率比（IRR）采用零膨胀泊松回归模型进行建模。
在总共77315名老年死者（53%为女性，中位年龄85.2岁）中，生命最后一年非计划住院的总体发病率为每100患者年175例。遵循癌症轨迹的死者中，非计划住院的调整后IRR比平均水平高1.20倍（95%CI 1.18至1.21）。相反，遵循长期衰弱轨迹的死者非计划住院风险低于平均水平（IRR 0.66，95%CI 0.65至0.68）。然而，这些疾病轨迹之间的差异仅在生命的最后3个月才变得明显。
我们的研究强调，在生命的最后3个月，非计划住院越来越频繁。旨在减少沉重护理过渡负担的政策应考虑潜在的疾病轨迹。
