Division of Palliative Medicine, Department of Medicine (K.E.B., G.V., D.L.O-R., B.S., J.L., C.Z., M.W.R., S.Z.P.), University of California, San Francisco, California, USA.
Division of Palliative Medicine, Department of Medicine (K.E.B., G.V., D.L.O-R., B.S., J.L., C.Z., M.W.R., S.Z.P.), University of California, San Francisco, California, USA.
J Pain Symptom Manage. 2023 Sep;66(3):270-280.e8. doi: 10.1016/j.jpainsymman.2023.06.024. Epub 2023 Jun 27.
CONTEXT/OBJECTIVES: A critical frontier for palliative medicine is to develop systems to routinely and equitably address the palliative care (PC) needs of seriously ill populations.
An automated screen identified Medicare primary care patients who had serious illness based on diagnosis codes and utilization patterns. A stepped-wedge design was used to evaluate a six-month intervention through which a healthcare navigator assessed these seriously ill patients and their care partners for PC needs in the domains of 1) physical symptoms, 2) emotional distress, 3) practical concerns, and 4) advance care planning (ACP) via telephone surveys. Identified needs were addressed with tailored PC interventions.
A total of 292/2175 (13.4%) patients screened positive for serious illness. A total of 145 completed an intervention phase; 83 completed a control phase. Severe physical symptoms were identified in 27.6%, emotional distress in 57.2%, practical concerns in 37.2%, and ACP needs in 56.6%. Twenty-five intervention patients (17.2%) were referred to specialty PC compared to six control patients (7.2%). Prevalence of ACP notes increased 45.5%-71.7% (p = 0.001) during the intervention and remained stable during the control phase. Quality of life remained stable during the intervention and declined 7.4/10-6.5/10 (P =0.04) during the control phase.
Through an innovative program, patients with serious illness were identified from a primary care population, assessed for PC needs, and offered specific services to meet those needs. While some patients were appropriate for specialty PC, even more needs were addressed without specialty PC. The program resulted in increased ACP and preserved quality of life.
背景/目的：缓和医学的一个关键领域是开发系统，以常规和公平的方式满足重病患者的缓和医疗（PC）需求。
通过自动筛查，根据诊断代码和使用模式，确定医疗保险初级保健患者患有严重疾病。采用逐步楔形设计来评估为期六个月的干预措施，在此期间，医疗保健导航员通过电话调查评估这些重病患者及其护理伙伴在以下领域的 PC 需求：1）身体症状，2）情绪困扰，3）实际问题，以及 4） 预先护理计划（ACP）。通过量身定制的 PC 干预措施来解决确定的需求。
共有 292/2175（13.4%）名筛查阳性的患者患有严重疾病。共有 145 名患者完成了干预阶段；145 名患者完成了控制阶段。27.6%的患者存在严重的身体症状，57.2%的患者存在情绪困扰，37.2%的患者存在实际问题，56.6%的患者存在 ACP 需求。与六名对照组患者（7.2%）相比，25 名干预组患者（17.2%）被转诊至专科 PC。在干预期间，ACP 记录的比例增加了 45.5%-71.7%（p=0.001），在控制阶段保持稳定。在干预期间，生活质量保持稳定，在控制阶段下降了 7.4/10-6.5/10（P=0.04）。
通过一项创新计划，从初级保健人群中识别出患有严重疾病的患者，评估他们的 PC 需求，并提供具体服务以满足这些需求。虽然有些患者适合专科 PC，但更多的需求在没有专科 PC 的情况下得到了满足。该计划增加了 ACP，并维持了生活质量。
