在急性护理中，有指定医疗照护目标意愿书与重病老年人的医疗资源使用之间的关联：一项多中心前瞻性队列研究。

Association between Goals of Care Designation orders and health care resource use among seriously ill older adults in acute care: a multicentre prospective cohort study.

机构信息

Division of Palliative Medicine, Department of Oncology (Earp), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Covenant Health Palliative Institute (Fassbender), Grey Nuns Community Hospital, St. Marguerite Health Services Centre; Division of Palliative Care Medicine, Department of Oncology (Fassbender), University of Alberta, Edmonton, Alta.; Department of Community Health Sciences (King), Cumming School of Medicine, University of Calgary; Division of Palliative Medicine, Department of Oncology (Douglas), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Covenant Health Palliative Institute (Douglas), Grey Nuns Community Hospital, St. Marguerite Health Services Centre, Edmonton, Alta.; Division of Palliative Medicine, Department of Oncology (Biondo), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Medicine and Oncology (Palliative Care) (Brisebois) and Department of Medicine (Davison, Sia), University of Alberta, Edmonton, Alta.; Division of Palliative Medicine, Department of Oncology (Wasylenko), Cumming School of Medicine, University of Calgary, Calgary, Alta.; John Dossetor Health Ethics Centre, Faculty of Medicine and Dentistry (Wasylenko), University of Alberta, Edmonton, Alta.; Alberta Health Services, South Zone Seniors Health Integrated Home Care/Palliative Care (Esau), Edmonton, Alta.; Departments of Oncology, Medicine and Community Health Sciences (Simon), University of Calgary, Calgary, Alta.

出版信息

CMAJ Open. 2022 Nov 1;10(4):E945-E955. doi: 10.9778/cmajo.20210155. Print 2022 Oct-Dec.

DOI:10.9778/cmajo.20210155

PMID:36319025

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC9633054/

Abstract

BACKGROUND

The Goals of Care Designation (GCD) is a medical order used to communicate the focus of a patient's care in Alberta, Canada. In this study, we aimed to determine the association between GCD type (resuscitative, medical or comfort) and resource use during hospitalization.

METHODS

This was a prospective cohort study of newly hospitalized inpatients in Alberta conducted from January to September 2017. Participants were aged 55 years or older with chronic obstructive pulmonary disease, congestive heart failure, cirrhosis, cancer or renal failure; aged 55-79 years and their provider answered "no" to the "surprise question" (i.e., provider would not be surprised if the patient died in the next 6 months); or aged 80 years or older with any acute condition. The exposure of interest was GCD. The primary outcome was health care resource use during admission, measured by length of stay (LOS), intensive care unit hours, Resource Intensity Weights (RIWs), flagged interventions and palliative care referral. The secondary outcome was 30-day readmission. Adjusted regression analyses were performed (adjusted for age, sex, race and ethnicity, Clinical Frailty Scale score, comorbidities and city).

RESULTS

We included 475 study participants. The median age was 83 (interquartile range 77-87) years, and 93.7% had a GCD at enrolment. Relative to patients with the resuscitative GCD type, patients with the medical GCD type had a longer LOS (1.42 times, 95% confidence interval [CI] 1.10-1.83) and a higher RIW (adjusted ratio 1.14, 95% CI 1.02-1.28). Patients with the comfort and medical GCD types had more palliative care referral (comfort GCD adjusted relative risk (RR) 9.32, 95% CI 4.32-20.08; medical GCD adjusted RR 3.58, 95% CI 1.75-7.33) but not flagged intervention use (comfort GCD adjusted RR 1.06, 95% CI 0.49-2.28; medical GCD adjusted RR 0.98, 95% CI 0.48-2.02) or 30-day readmission (comfort GCD adjusted RR 1.00, 95% CI 0.85-1.19; medical GCD adjusted RR 1.05, 95% CI 0.97-1.20).

INTERPRETATION

Goals of Care Designation type early during admission was associated with LOS, RIW and palliative care referral. This suggests an alignment between health resource use and the focus of care communicated by each GCD.

摘要

背景

目的关怀指定（GCD）是一种用于在加拿大艾伯塔省传达患者护理重点的医疗命令。在这项研究中，我们旨在确定 GCD 类型（复苏、医疗或舒适）与住院期间资源使用之间的关联。

方法

这是一项 2017 年 1 月至 9 月在艾伯塔省新住院的成年患者的前瞻性队列研究。参与者年龄在 55 岁或以上，患有慢性阻塞性肺疾病、充血性心力衰竭、肝硬化、癌症或肾衰竭；年龄在 55-79 岁之间，其提供者对“惊喜问题”回答“否”（即，如果患者在接下来的 6 个月内死亡，提供者不会感到惊讶）；或 80 岁或以上，患有任何急性疾病。感兴趣的暴露是 GCD。主要结局是入院期间的医疗资源使用，通过住院时间（LOS）、重症监护病房时间、资源强度权重（RIWs）、标记干预措施和姑息治疗转介来衡量。次要结局是 30 天再入院。进行了调整后的回归分析（调整了年龄、性别、种族和民族、临床虚弱量表评分、合并症和城市）。

结果

我们纳入了 475 名研究参与者。中位年龄为 83 岁（四分位距 77-87），93.7%在入组时具有 GCD。与复苏 GCD 类型的患者相比，具有医疗 GCD 类型的患者的 LOS 更长（1.42 倍，95%置信区间 [CI] 1.10-1.83）和更高的 RIW（调整比值 1.14，95%CI 1.02-1.28）。具有舒适和医疗 GCD 类型的患者接受更多的姑息治疗转介（舒适 GCD 调整后的相对风险（RR）9.32，95%CI 4.32-20.08；医疗 GCD 调整后的 RR 3.58，95%CI 1.75-7.33），但标记干预措施的使用没有差异（舒适 GCD 调整后的 RR 1.06，95%CI 0.49-2.28；医疗 GCD 调整后的 RR 0.98，95%CI 0.48-2.02）或 30 天再入院（舒适 GCD 调整后的 RR 1.00，95%CI 0.85-1.19；医疗 GCD 调整后的 RR 1.05，95%CI 0.97-1.20）。