The Permanente Federation, Oakland, California, USA.
Kaiser Permanente Colorado, Institute for Health Research, Denver, Colorado, USA.
J Palliat Med. 2024 May;27(5):602-613. doi: 10.1089/jpm.2023.0407. Epub 2024 Mar 13.
Gaps remain in our understanding of the intensity and timing of specialty palliative care (SPC) exposure on end-of-life (EOL) outcomes. Examine the association between intensity and timing of SPC and hospice (HO) exposure on EOL care outcomes. Data for this cohort study were drawn from 2021 adult decedents from Kaiser Permanente Southern California and Colorado ( = 26,251). Caregivers of a decedent subgroup completed a postdeath care experience survey from July to August 2022 ( = 424). SPC intensity (inpatient, outpatient, and home-based) and HO exposure in the five years before death were categorized as: (1) No SPC or HO; (2) SPC-only; (3) HO-only; and (4) SPC-HO. Timing of SPC exposure (<90 or 90+ days) before death was stratified by HO enrollment. Death in the hospital and potentially burdensome treatments in the last 14 days of life were extracted from electronic medical records (EMRs) and claims. EOL care experience was obtained from the caregiver survey. Among the EMR cohort, exposure to SPC and HO were: No SPC or HO (38%), SPC-only (14%; of whom, 55% received inpatient SPC only), HO-only (20%), and SPC-HO (28%). For decedents who did not enroll in HO, exposure to SPC 90+ days versus <90 days before death was associated with lower risk of receiving potentially burdensome treatments (adjusted relative risk, aRR: 0.69 [95% confidence interval, CI: 0.62-0.76], < 0.001) and 23% lower risk of dying in the hospital (aRR: 0.77 [95% CI: 0.73-0.81], < 0.001). Caregivers of patients in the HO-only (aRR: 1.27 [95% CI: 0.98-1.63], = 0.07) and SPC-HO cohorts (aRR: 1.19 [95% CI: 0.93-1.52], = 0.18) tended to report more positive care experience compared to the no SPC or HO cohort. Earlier exposure to SPC was important in reducing potentially burdensome treatments and death in the hospital for decedents who did not enroll in HO. Increasing availability and access to community-based SPC is needed.
我们对临终结局方面的专业姑息治疗（SPC）的强度和时间的理解仍存在差距。本研究旨在探究 SPC 强度和时间与临终期（EOL）照护结局中接受临终关怀（HO）的关联。本队列研究的数据来自 2021 年加利福尼亚州和科罗拉多州 Kaiser Permanente 的 26251 位成年死者（ = 26251）。2022 年 7 月至 8 月，死者的护理人员完成了一项死后护理体验调查（ = 424）。在死亡前五年内，SPC 强度（住院、门诊和家庭为基础）和 HO 暴露被分类为：（1）无 SPC 或 HO；（2）仅 SPC；（3）仅 HO；和（4）SPC-HO。在 HO 入组前，SPC 暴露的时间（<90 或 90+天）被分层。从电子病历（EMR）和索赔中提取最后 14 天内的住院和潜在负担性治疗。EOL 护理体验来自护理人员的调查。在 EMR 队列中，SPC 和 HO 的暴露情况为：无 SPC 或 HO（38%）、仅 SPC（14%；其中 55%仅接受住院 SPC）、仅 HO（20%）和 SPC-HO（28%）。对于未入组 HO 的死者，与 SPC 90 天相比，SPC 暴露时间<90 天与接受潜在负担性治疗的风险较低相关（调整后的相对风险，aRR：0.69 [95%置信区间，CI：0.62-0.76]， < 0.001），且在医院死亡的风险降低 23%（aRR：0.77 [95% CI：0.73-0.81]， < 0.001）。仅 HO 队列（aRR：1.27 [95% CI：0.98-1.63]， = 0.07）和 SPC-HO 队列（aRR：1.19 [95% CI：0.93-1.52]， = 0.18）的患者护理人员报告的护理体验往往比无 SPC 或 HO 队列更积极。对于未入组 HO 的死者，早期接受 SPC 治疗对于减少潜在负担性治疗和医院死亡至关重要。需要增加社区为基础的 SPC 的可及性。
