使用基于日本指南的诊断方法对临终状态进行识别与预后评估：一项诊断准确性研究
Identification and Prognostication of End-of-Life State Using a Japanese Guideline-Based Diagnostic Method: A Diagnostic Accuracy Study.
作者信息
Arahata Masahisa, Asakura Hidesaku, Morishita Eriko, Minami Shinji, Shimizu Yukihiro
机构信息
Department of General Medicine, Nanto Municipal Hospital, Nanto, Toyama, Japan.
Department of Internal Medicine, Nanto Municipal Hospital, Nanto, Toyama, Japan.
出版信息
Int J Gen Med. 2023 Jan 5;16:23-36. doi: 10.2147/IJGM.S392963. eCollection 2023.
PURPOSE
Prognostic uncertainty can be a barrier to providing palliative care. Accurate prognostic estimation for patients at the end of life is challenging. This study aimed to evaluate the accuracy of end-of-life diagnosis using our unique diagnostic method.
PATIENTS AND METHODS
A retrospective longitudinal observational study was conducted through collaboration among three medical facilities in a rural super-aged community in Japan. In 2007, we established a unique end-of-life diagnostic process comprising (1) physicians' judgement, (2) disclosure to patients, and (3) discussion at an end-of-life case conference (EOL-CC), based on Japanese end-of-life-related guidelines. Research subjects were consecutive patients discussed in EOL-CC between January 1, 2010, and September 30, 2017. The primary outcome was mortality within 6 months after the initial EOL-CC decision. Sensitivity, specificity, and diagnostic odds ratio were calculated using EOL-CC diagnosis (end-of-life or non-end-of-life) as an index test and overall survival (<6 months or ≥6 months) as a reference standard.
RESULTS
In total, 315 patients were eligible for survival analysis (median age 89, range 54-107). The study population was limited to patients with severe conditions such as advanced cancer, organ failures, advanced dementia with severe deterioration in functioning. EOL-diagnosis by our methods was associated with much lower survival rate at 6 months after EOL-CC than non-EOL-diagnosis (6.9% vs 43.5%; P < 0.001). Of the patients, 297 were eligible for diagnostic accuracy analysis (median age 89, range 54-107). The EOL-diagnosis showed high sensitivity (0.95; 95% confidence interval [CI] 0.92-0.97) but low specificity (0.35; 95% CI 0.20-0.53) against the outcomes. It also showed a high diagnostic odds ratio (10.32; 95% CI 4.08-26.13).
CONCLUSION
The diagnostic process using the Japanese end-of-life guidelines had tolerable accuracy in identification and prognostication of end of life.
目的
预后的不确定性可能成为提供姑息治疗的障碍。对临终患者进行准确的预后评估具有挑战性。本研究旨在使用我们独特的诊断方法评估临终诊断的准确性。
患者与方法
通过日本一个农村高龄社区的三个医疗机构合作开展了一项回顾性纵向观察研究。2007年，我们根据日本临终相关指南建立了一个独特的临终诊断流程，包括（1）医生判断，（2）向患者告知，以及（3）在临终病例讨论会上进行讨论（EOL-CC）。研究对象为2010年1月1日至2017年9月30日期间在EOL-CC中讨论的连续患者。主要结局是首次EOL-CC决定后6个月内的死亡率。以EOL-CC诊断（临终或非临终）作为指标测试，以总生存期（<6个月或≥6个月）作为参考标准，计算敏感性、特异性和诊断比值比。
结果
共有315例患者符合生存分析条件（中位年龄89岁，范围54 - 107岁）。研究人群仅限于患有严重疾病的患者，如晚期癌症、器官衰竭、功能严重衰退的晚期痴呆。通过我们的方法进行的EOL诊断与EOL-CC后6个月的生存率相比，非EOL诊断的生存率要低得多（6.9%对43.5%；P < 0.001）。其中，297例患者符合诊断准确性分析条件（中位年龄89岁，范围54 - 107岁）。EOL诊断对结局显示出高敏感性（0.95；95%置信区间[CI] 0.92 - 0.97）但低特异性（0.35；95% CI 0.20 - 0.53）。它还显示出高诊断比值比（10.32；95% CI 4.08 - 26.13）。
结论
使用日本临终指南的诊断流程在识别和预测临终方面具有可接受的准确性。
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