Department of Surgery, University of California, San Francisco.
JAMA Netw Open. 2022 Jul 1;5(7):e2220379. doi: 10.1001/jamanetworkopen.2022.20379.
Hospice care is associated with improved quality of life and goal-concordant care. Limited data suggest that provision of hospice services after surgery is suboptimal; however, literature in this domain is in its nascency, leaving gaps in our understanding of patients who enroll in hospice after surgery.
To characterize the transition to hospice after gastrointestinal tract surgery and identify areas that warrant further attention and intervention.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study included patients discharged to hospice after a surgical hospitalization for a digestive disorder in California-licensed hospitals between January 1, 2015, and December 31, 2019. Data were analyzed from August 1 to November 30, 2021.
Patient age, race and ethnicity, principal language, payer, and Distressed Community Index (DCI).
Admission type and most common diagnoses and procedures for surgical hospitalizations that resulted in discharge to hospice, annual hospitalization trend for 3 years preceding hospice enrollment, and most common diagnoses for patients who were readmitted after hospice enrollment were summarized. Age, race and ethnicity, principal language, payer, and DCI were compared between patients who were readmitted after hospice enrollment and those who were not.
Of 2688 patients with surgical hospitalizations resulting in discharge to hospice (mean [SD] age, 73.2 [14.7] years; 1459 women [54.3%]), 2389 (88.9%) had urgent or emergent discharges. The most common diagnoses were cancer (primary and metastatic; 1541 [57.3%]) and bowel obstruction (563 [20.9%]). The most common procedures were bowel resection, fecal diversion, inferior vena cava filter, gastric bypass, and paracentesis. In the 3 years preceding hospice enrollment, this cohort had a mean (SD) of 2.21 (2.77) hospitalizations per patient (1537 of 5953 surgical [25.8%]). Of these, 3594 of 5953 total (60.4%) and 840 of 1537 surgical (54.7%) hospitalizations were within 1 year of hospice enrollment. Three hundred and sixty-eight patients (13.7%) were readmitted after hospice enrollment, with infection being the most common readmission diagnosis. Readmitted patients were more likely to be younger (mean [SD] age, 69.7 [16.4] vs 73.8 [14.3] years; P < .001), to speak a principal language other than English (62 of 368 [16.8%] vs 292 of 2320 [12.6%]; P = .02), to be insured through Medicaid (70 of 368 [19.0%] vs 223 of 2320 [9.6%]; P < .001), and to be from a community with higher DCI (198 of 360 [55.0%] vs 1117 of 2269 [49.2%]; P = .04) and were less likely to be White (195 of 368 [53.0%] vs 1479 of 2320 [63.8%]; P < .001).
These findings suggest multiple opportunities for advance care planning in this surgical cohort, with a particular focus on emergent care. Further study is needed to understand the reasons for rehospitalization after hospice discharge and identify ways to improve communication and decision-making support for patients who choose to enroll in hospice care. Given the frequent antecedent interactions with the health care system among this population, longitudinal and tailored approaches may be beneficial to promote equitable end-of-life care; however, further research is needed to clarify barriers and understand differing patient needs.
临终关怀与改善生活质量和目标一致的护理相关。有限的数据表明，手术后提供临终关怀服务并不理想；然而，这一领域的文献还处于起步阶段，我们对手术后选择加入临终关怀的患者了解有限。
描述胃肠道手术后过渡到临终关怀的情况，并确定需要进一步关注和干预的领域。
设计、设置和参与者：这项回顾性队列研究包括在加利福尼亚州授权医院进行胃肠道疾病手术住院治疗后出院到临终关怀的患者。数据于 2021 年 8 月 1 日至 11 月 30 日进行分析。
患者年龄、种族和民族、主要语言、支付方和贫困社区指数（DCI）。
总结导致出院到临终关怀的手术住院的入院类型和最常见诊断和手术程序，在临终关怀登记前 3 年的年度住院趋势，以及临终关怀登记后再次入院的患者最常见的诊断。比较临终关怀登记后再次入院和未再次入院的患者的年龄、种族和民族、主要语言、支付方和 DCI。
在 2688 例因手术住院治疗后出院到临终关怀的患者中（平均[SD]年龄 73.2[14.7]岁；1459 名女性[54.3%]），2389 例（88.9%）为紧急或紧急出院。最常见的诊断是癌症（原发性和转移性；1541 例[57.3%]）和肠梗阻（563 例[20.9%]）。最常见的手术是肠切除术、粪便转流术、下腔静脉滤器、胃旁路术和腹腔穿刺术。在临终关怀登记前的 3 年中，该队列的每位患者平均（SD）有 2.21（2.77）次住院（5953 例手术中有 1537 例[25.8%]）。其中，5953 例总住院中有 3594 例（60.4%），1537 例手术中有 840 例（54.7%）在临终关怀登记后的 1 年内。368 例（13.7%）患者在临终关怀登记后再次入院，感染是最常见的再入院诊断。再次入院的患者更年轻（平均[SD]年龄，69.7[16.4]岁比 73.8[14.3]岁；P< .001），更可能说英语以外的主要语言（62/368[16.8%]比 292/2320[12.6%]；P= .02），通过医疗补助保险（70/368[19.0%]比 223/2320[9.6%]；P< .001），来自贫困社区指数更高的社区（360 例中的 198 例[55.0%]比 2269 例中的 1117 例[49.2%]；P= .04），并且不太可能是白人（368 例中的 195 例[53.0%]比 2320 例中的 1479 例[63.8%]；P< .001）。
这些发现表明在这个手术队列中，有多个预先护理计划的机会，特别关注紧急护理。需要进一步研究以了解临终关怀出院后再住院的原因，并确定如何改善选择参加临终关怀护理的患者的沟通和决策支持。鉴于该人群与医疗保健系统的频繁交互，纵向和量身定制的方法可能有助于促进公平的临终关怀；然而，需要进一步的研究来澄清障碍并了解不同患者的需求。
