Division of General Internal Medicine (G.P., R.A., Y.S.), Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Palliative Research Center (G.P., R.A., Y.S.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
Butler Memorial Hospital (D.S.), Butler, Pennsylvania, USA.
J Pain Symptom Manage. 2023 Nov;66(5):578-586. doi: 10.1016/j.jpainsymman.2023.07.020. Epub 2023 Aug 6.
Goals of care conversations for seriously ill hospitalized patients are associated with high-quality patient-centered care.
We aimed to assess the prevalence of documented goals of care conversations for rural hospitalized patients compared to nonrural hospitalized patients.
We retrospectively assessed goals of care documentation using a template note for adult patients with predicted 90-day mortality greater than 30% admitted to eight rural and nine nonrural community hospitals between July 2021 and April 2023. We compared predictors and prevalence of goals of care documentation among rural and nonrural hospitals.
Of the 31,098 patients admitted during the study period, 21% were admitted to a rural hospital. Rural patients were more likely than nonrural patients to be >65 years old (89% vs. 86%, P = <.0001), more likely to live in a neighborhood classified in the highest quintile of socioeconomic disadvantage (40% vs. 16%, P = <.0001), and less likely to receive a palliative care consult (8% vs. 18%, P = <.0001). Goals of care documentation occurred less often for patients admitted to rural vs. nonrural community hospitals (2% vs. 7%, P < .0001). In the base multivariable logistic regression model adjusting for patient characteristics, the odds of goals care documentation were lower in rural vs. nonrural community hospitals (aOR 0.4, P = .0232). In a second multivariable logistic regression model including both patient characteristics and severity of illness, the odds of goals of care documentation in rural community hospitals were no longer statistically different than nonrural community hospitals (aOR 0.5, P = .1080). Patients who received a palliative care consult had a lower prevalence of goals of care documentation in rural vs. nonrural hospitals (16% vs. 37%, P = <.0001).
In this study of 17 rural and nonrural community hospitals, we found low overall prevalence of goals of care documentation with particularly infrequent documentation occurring within rural hospitals. Future study is needed to assess barriers to goals of care documentation contributing to low prevalence of goals of care conversations in rural hospital settings.
为重病住院患者进行的治疗目标沟通与高质量以患者为中心的护理密切相关。
我们旨在评估与非农村住院患者相比，农村住院患者接受记录的治疗目标沟通的比例。
我们回顾性地使用成人患者模板记录评估了治疗目标的记录，该模板适用于预测 90 天死亡率大于 30%的患者，这些患者在 2021 年 7 月至 2023 年 4 月期间入住了 8 家农村和 9 家非农村社区医院。我们比较了农村和非农村医院的治疗目标记录的预测因素和比例。
在研究期间，31098 名患者中有 21%入住了农村医院。与非农村患者相比，农村患者年龄大于 65 岁的可能性更高（89% vs. 86%，P<0.0001），居住在社会经济劣势程度最高五分位数的邻里的可能性更高（40% vs. 16%，P<0.0001），接受姑息治疗咨询的可能性更低（8% vs. 18%，P<0.0001）。与入住非农村社区医院的患者相比，入住农村社区医院的患者接受治疗目标记录的情况较少（2% vs. 7%，P<0.0001）。在调整患者特征的基础多变量逻辑回归模型中，农村社区医院与非农村社区医院相比，接受治疗目标记录的可能性较低（优势比 0.4，P=0.0232）。在包括患者特征和疾病严重程度的第二个多变量逻辑回归模型中，农村社区医院接受治疗目标记录的可能性与非农村社区医院相比不再具有统计学差异（优势比 0.5，P=0.1080）。接受姑息治疗咨询的患者在农村社区医院和非农村社区医院接受治疗目标记录的比例均较低（16% vs. 37%，P<0.0001）。
在这项对 17 家农村和非农村社区医院的研究中，我们发现治疗目标记录的总体比例较低，农村医院尤其不常进行记录。需要进一步研究以评估导致农村医院治疗目标沟通比例较低的治疗目标记录障碍。
