Leclaire Clement, Georges Alexandre, de Stampa Matthieu, Aegerter Philippe
Paris Public Hospital at Home (HAD AP-HP), Greater Paris University Hospitals, Assistance Publique-Hopitaux de Paris, Paris, France
Paris Public Hospital at Home (HAD AP-HP), Greater Paris University Hospitals, Assistance Publique-Hopitaux de Paris, Paris, France.
BMJ Open. 2025 May 22;15(5):e089835. doi: 10.1136/bmjopen-2024-089835.
To determine whether an invasive approach is associated with favourable long-term outcomes among elderly medical patients in the intensive care unit (ICU), compared with a conservative approach.
Nationwide observational study (OCTO-REVERSE study) using data prospectively collected in the National French Healthcare Database (covering 99% of the population, 66 million people).
Comprehensive multicentre study through the linkage of large-scale national registries (including all public or private facilities) from 2013 to 2018 to avoid ambiguities related to the COVID-19 pandemic.
All non-surgical patients aged 80 years or older admitted to an ICU in France during the period (n=107 014 patients at 822 hospitals).
The main outcome was the 1-year survival rate. The association of the two approaches with 1-year survival was estimated using a time-dependent Cox model and a propensity score (PS) adapted to time-to-event analysis, yielding the average treatment effect in the treated and extended weighted Kaplan-Meier curves.
107 014 patients were categorised into two groups based on the type of care received: invasive (n=51 680 (48%) received invasive ventilation and/or vasopressor support) or conservative (n=55 334 (52%) received neither). 1-year survival rate was significantly lower in the invasive group than in the conservative group (27% vs 59% estimated with extended time-dependent Kaplan-Meier method). The risk of death in the invasive group remained significantly higher after time-dependent PS weighting (HR 1.64; 95% CI 1.60 to 1.69; p<0.001). The loss in restricted mean survival time was 67.7 days (95% CI 65.7 to 69.8) in this group and 31% of deaths occurred the day of initiation of the procedure, or the following day.
Among the whole population of critically ill elderly medical patients in France, the invasive approach was unknowingly associated with end-of-life care in nearly three quarters of cases. Further research is needed to align intensive care with compassionate goals.
与保守治疗方法相比，确定侵入性治疗方法是否与重症监护病房（ICU）老年内科患者的长期良好预后相关。
全国性观察性研究（OCTO-REVERSE研究），使用在法国国家医疗保健数据库（覆盖99%的人口，6600万人）中前瞻性收集的数据。
通过2013年至2018年大规模国家登记处（包括所有公共或私人机构）的链接进行全面的多中心研究，以避免与新冠疫情相关的模糊性。
在此期间，法国所有80岁及以上入住ICU的非手术患者（822家医院的107014名患者）。
主要观察指标为1年生存率。使用时间依赖性Cox模型和适用于事件发生时间分析的倾向评分（PS）估计两种治疗方法与1年生存率的关联，得出治疗组的平均治疗效果和扩展加权Kaplan-Meier曲线。
根据接受的治疗类型，107014名患者被分为两组：侵入性治疗组（n = 51680（48%）接受侵入性通气和/或血管活性药物支持）或保守治疗组（n = 55334（52%）两者均未接受）。侵入性治疗组的1年生存率显著低于保守治疗组（采用扩展时间依赖性Kaplan-Meier方法估计分别为27%和59%）。在进行时间依赖性PS加权后，侵入性治疗组的死亡风险仍然显著更高（风险比1.64；95%置信区间1.60至1.69；p<0.001）。该组受限平均生存时间损失为67.7天（95%置信区间65.7至69.8），31%的死亡发生在手术开始当天或次日。
在法国所有重症老年内科患者中，近四分之三的病例中侵入性治疗方法在不知不觉中与临终关怀相关。需要进一步研究以使重症监护与人文关怀目标相一致。
