Takemi Program in International Health, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.
Department of Public Health, Graduate School of Medicine, University of Tokyo, Tokyo, Japan.
JAMA Netw Open. 2021 Nov 1;4(11):e2132787. doi: 10.1001/jamanetworkopen.2021.32787.
The provision of end-of-life care is an important policy issue associated with population aging around the world. Yet it is unclear whether the provision of in-home care services can allow patients the option of in-home death at end of life.
To assess whether the frequent use of in-home care services can assist recipients to stay at home at the end of life.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study of older adults in Japan's long-term care insurance system used national claims data. Participants were long-term care insurance beneficiaries aged 65 years or over who died in 2015, excluding those who died due to external causes such as accidents. Data analyses were conducted from October to December 2020.
Mean days of in-home care service used per week from the first day of the month before the month of death to the date of death.
Primary outcome was whether the older person died at home (or not). To address lack of information on individual preference for place of death, we used an instrumental variable estimation with the full-time equivalent number of care workers providing in-home care services per older population at the municipality level in 2014.
Of the 572 059 decedents included in the study, 314 743 (55.0%) were women (median [IQR] age, 87 [81-91] years). The proportion of in-home deaths was 10.5% (60 175 decedents), and 81 675 decedents (14.3%) used in-home care services at least once prior to their death. Ordinary least squares and 2-stage least squares analyses both indicated that more frequent use of in-home care was associated with a higher probability of in-home deaths (ordinary least squares estimate, 5.0 percentage points; 95% CI, 4.9-5.1 points vs 2-stage least squares estimate, 3.6 percentage points; 95% CI, 2.3-4.9 points).
This retrospective cohort study using an instrumental variable approach demonstrated that more frequent use of in-home care services at the end of life was associated with a higher probability of in-home death. One policy implication of these results is that in order to meet the end-of-life preferences of patients, it is not only necessary to promote the provision of medical services at home but also to ensure an adequate supply of care workers.
临终关怀的提供是与全球人口老龄化相关的一个重要政策问题。然而，目前尚不清楚家庭护理服务的提供是否可以让患者在临终时有选择在家中死亡的机会。
评估家庭护理服务的频繁使用是否可以帮助接受者在生命末期留在家中。
设计、设置和参与者：本研究使用全国索赔数据，对日本长期护理保险制度中的老年人进行了队列研究。参与者为年龄在 65 岁及以上的长期护理保险受益人，他们在 2015 年去世，不包括因意外等外部原因去世的人。数据分析于 2020 年 10 月至 12 月进行。
从死亡当月的月初前一个月的第一天到死亡日期为止，每周使用家庭护理服务的平均天数。
主要结果是老年人是否在家中死亡（或未死亡）。为了解决缺乏个人对死亡地点偏好的信息，我们使用了工具变量估计，以 2014 年市一级每 10 万老年人提供的全职等效护理人员数量作为自变量。
在研究的 572059 名死者中，314743 名（55.0%）为女性（中位数[IQR]年龄，87 [81-91]岁）。在家中死亡的比例为 10.5%（60175 名死者），81675 名死者（14.3%）在死前至少使用过一次家庭护理服务。普通最小二乘法和两阶段最小二乘法分析均表明，家庭护理服务使用越频繁，在家中死亡的可能性越高（普通最小二乘法估计值为 5.0 个百分点；95%CI，4.9-5.1 个百分点；两阶段最小二乘法估计值为 3.6 个百分点；95%CI，2.3-4.9 个百分点）。
本研究使用工具变量方法进行了回顾性队列研究，结果表明，临终时更频繁地使用家庭护理服务与在家中死亡的可能性更高相关。这些结果的一个政策含义是，为了满足患者的临终偏好，不仅有必要促进家庭医疗服务的提供，还需要确保有足够数量的护理人员。
