Pritchard R S, Fisher E S, Teno J M, Sharp S M, Reding D J, Knaus W A, Wennberg J E, Lynn J
Department of Veterans Affairs Medical Center, White River Junction, VT, USA.
J Am Geriatr Soc. 1998 Oct;46(10):1242-50. doi: 10.1111/j.1532-5415.1998.tb04540.x.
To examine the degree to which variation in place of death is explained by differences in the characteristics of patients, including preferences for dying at home, and by differences in the characteristics of local health systems.
We drew on a clinically rich database to carry out a prospective study using data from the observational phase of the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT component). We used administrative databases for the Medicare program to carry out a national cross-sectional analysis of Medicare enrollees place of death (Medicare component).
Five teaching hospitals (SUPPORT); All U.S. Hospital Referral Regions (Medicare).
Patients dying after the enrollment hospitalization in the observational phase of SUPPORT for whom place of death and preferences were known. Medicare beneficiaries who died in 1992 or 1993.
Place of death (hospital vs non-hospital).
In SUPPORT, most patients expressed a preference for dying at home, yet most died in the hospital. The percent of SUPPORT patients dying in-hospital varied by greater than 2-fold across the five SUPPORT sites (29 to 66%). For Medicare beneficiaries, the percent dying in-hospital varied from 23 to 54% across U.S. Hospital Referral Regions (HRRs). In SUPPORT, variations in place of death across site were not explained by sociodemographic or clinical characteristics or patient preferences. Patient level (SUPPORT) and national cross-sectional (Medicare) multivariate models gave consistent results. The risk of in-hospital death was increased for residents of regions with greater hospital bed availability and use; the risk of in-hospital death was decreased in regions with greater nursing home and hospice availability and use. Measures of hospital bed availability and use were the most powerful predictors of place of death across HRRs.
Whether people die in the hospital or not is powerfully influenced by characteristics of the local health system but not by patient preferences or other patient characteristics. These findings may explain the failure of the SUPPORT intervention to alter care patterns for seriously ill and dying patients. Reforming the care of dying patients may require modification of local resource availability and provider routines.
探讨患者特征差异（包括在家中死亡的偏好）以及当地卫生系统特征差异对死亡地点差异的解释程度。
我们利用一个临床信息丰富的数据库，对“了解治疗结果和风险的预后及偏好研究”（SUPPORT项目）观察阶段的数据进行前瞻性研究。我们使用医疗保险计划的行政数据库，对医疗保险参保者的死亡地点进行全国性横断面分析（医疗保险部分）。
五家教学医院（SUPPORT项目）；美国所有医院转诊地区（医疗保险部分）。
在SUPPORT项目观察阶段入院后死亡且已知死亡地点和偏好的患者。1992年或1993年死亡的医疗保险受益人。
死亡地点（医院与非医院）。
在SUPPORT项目中，大多数患者表示希望在家中死亡，但大多数人却在医院死亡。在五个SUPPORT项目地点，死于医院的SUPPORT患者比例相差超过两倍（29%至66%）。对于医疗保险受益人，在美国医院转诊地区（HRR），死于医院的比例从23%至54%不等。在SUPPORT项目中，各地点死亡地点的差异无法通过社会人口统计学或临床特征或患者偏好来解释。患者层面（SUPPORT项目）和全国横断面（医疗保险）多变量模型得出了一致的结果。医院床位供应和使用较多地区的居民住院死亡风险增加；疗养院和临终关怀机构供应和使用较多地区的住院死亡风险降低。医院床位供应和使用情况是各HRR地区死亡地点最有力的预测指标。
人们是否在医院死亡受到当地卫生系统特征的强烈影响，而不是患者偏好或其他患者特征。这些发现可能解释了SUPPORT干预未能改变重症和临终患者护理模式的原因。改革临终患者的护理可能需要改变当地资源的可及性和医疗服务提供者的常规做法。
