Jain Snigdha, Long Jessica B, Rao Vinay, Law Anica C, Walkey Allan J, Prsic Elizabeth, Lindenauer Peter K, Krumholz Harlan M, Gross Cary P
Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA.
Cancer Outcomes, Public Policy and Effectiveness Research Center, Yale School of Medicine, New Haven, Connecticut, USA.
J Am Geriatr Soc. 2024 Dec;72(12):3840-3848. doi: 10.1111/jgs.19119. Epub 2024 Aug 1.
High-intensity end-of-life (EOL) care, marked by admission to intensive care units (ICUs) or in-hospital death, can be costly and burdensome. Recent trends in use of ICUs, life-sustaining treatments (LSTs), and noninvasive ventilation (NIV) during EOL hospitalizations among older adults with advanced cancer and patterns of in-hospital death are unknown.
We used SEER-Medicare data (2003-2017) to identify beneficiaries with advanced solid cancer (summary stage 7) who died within 3 years of diagnosis. We identified EOL hospitalizations (within 30 days of death), classifying them by increasing intensity of care into: (1) without ICU; (2) with ICU but without LST (invasive mechanical ventilation, tracheostomy, gastrostomy, acute dialysis) or NIV; (3) with ICU and NIV but without LST; and (4) with ICU and LST use. We constructed a multinomial regression model to evaluate trends in risk-adjusted hospitalization, overall and across hospitalization categories, adjusting for sociodemographics, cancer characteristics, comorbidities, and frailty. We evaluated trends in in-hospital death across categories.
Of 226,263 Medicare beneficiaries with advanced cancer, 138,305 (61.1%) were hospitalized at EOL [Age, Mean (SD):77.9(7.1) years; 45.5% female]. Overall, EOL hospitalizations remained high throughout, from 78.1% (95% CI: 77.4, 78.7) in 2004 to 75.5% (95% CI: 74.5, 76.2) in 2017. Hospitalizations without ICU use decreased from 49.3% (95% CI: 48.5, 50.2) to 35.0% (95% CI: 34.2, 35.9) while hospitalizations with more intensive care increased, from 23.7% (95% CI: 23.0, 24.4) to 28.7% (95% CI: 27.9, 29.5) for ICU without LST or NIV, 0.8% (95% CI: 0.6, 0.9) to 3.8% (95% CI: 3.4, 4.1) for ICU with NIV but without LST, and 4.3% (95% CI: 4.0, 4.7) to 8.0% (95% CI: 7.5, 8.5) for ICU with LST use. Among those who experienced in-hospital death, the proportion receiving ICU care increased from 46.5% to 65.0%.
Among older adults with advanced cancer, EOL hospitalization rates remained stable from 2004-2017. However, intensity of care during EOL hospitalizations increased as evidenced by increasing use of ICUs, LSTs, and NIV.
以入住重症监护病房（ICU）或院内死亡为特征的高强度临终关怀可能成本高昂且负担沉重。在患有晚期癌症的老年人临终住院期间，ICU、维持生命治疗（LST）和无创通气（NIV）的使用趋势以及院内死亡模式尚不清楚。
我们使用监测、流行病学和最终结果（SEER）医保数据（2003 - 2017年）来确定诊断后3年内死亡的晚期实体癌（总结分期7期）受益患者。我们确定了临终住院（死亡前30天内），并根据护理强度增加将其分类为：（1）未入住ICU；（2）入住ICU但未接受LST（有创机械通气、气管切开术、胃造口术、急性透析）或NIV；（3）入住ICU且接受NIV但未接受LST；以及（4）入住ICU且使用LST。我们构建了一个多项回归模型，以评估风险调整后的住院趋势，包括总体趋势以及各住院类别趋势，并对社会人口统计学、癌症特征、合并症和虚弱情况进行了调整。我们评估了各类别中的院内死亡趋势。
在226,263名患有晚期癌症的医保受益患者中，138,305名（61.1%）在临终时住院[年龄，均值（标准差）：77.9（7.1）岁；45.5%为女性]。总体而言，临终住院率一直居高不下，从2004年的78.1%（95%置信区间：77.4, 78.7）降至2017年的75.5%（95%置信区间：74.5, 76.2）。未使用ICU的住院比例从49.3%（95%置信区间：48.5, 50.2）降至35.0%（95%置信区间：34.2, 35.9），而接受更强化护理的住院比例增加，未使用LST或NIV的ICU住院比例从23.7%（95%置信区间：23.0, 24.4）增至28.7%（95%置信区间：27.9, 29.5），使用NIV但未使用LST的ICU住院比例从0.8%（95%置信区间：0.6, 0.9）增至3.8%（95%置信区间：3.4, 4.1），使用LST的ICU住院比例从4.3%（95%置信区间：4.0, 4.7）增至8.0%（95%置信区间：7.5, 8.5）。在院内死亡的患者中，接受ICU护理的比例从46.5%增至65.0%。
在患有晚期癌症的老年人中，2004 - 2017年临终住院率保持稳定。然而，临终住院期间的护理强度增加，这表现为ICU、LST和NIV的使用增加。
