成人晚期非癌症疾病姑息治療可臨床獲益
作者：
小柯機器人發布時間：2020/7/7 15:04:49
加拿大多倫多大學Kieran L Quinn團隊研究了成人晚期非癌症疾病姑息治療的效果。該成果發表在2020年7月6日出版的《英國醫學雜誌》上。
為了評估在非癌症疾病死亡的成年人中，生命最後6個月內新開始的姑息治療、醫療保健使用和死亡住所之間的關聯，並在人口水平上將這些關聯與死於癌症的成年人進行比較，2010年至2015年間，研究組在加拿大安大略省進行了一項基於人群的配對隊列研究。
研究組招募了113540名死於癌症或非癌症疾病的患者，在所有醫療機構中，這些患者在生命的最後六個月，均新接受了姑息治療。主要結局指標為急診就診率、入院率和被收入重症監護室率，以及首次姑息治療就診後在家與醫院的死亡機率，並根據患者特徵（例如年齡，性別和合併症）進行校正。
死於慢性器官衰竭（如心力衰竭、肝硬化和中風）相關的非癌症疾病的患者中，與那些沒有得到姑息治療的人相比，採用姑息治療可顯著降低急診就診率、入院率和重症監護率。此外，這些患者在家或療養院死亡的機率為49.5%，顯著高於在醫院內死亡（39.6%）。
在死於痴呆的患者中，姑息治療顯著增加了急診就診率和入院率，但減少了在家中或療養院中死亡的機率。但這些比率的差異取決於死於痴呆症的患者是住在社區還是療養院。對於居住在社區的痴呆症患者，在醫療保健和姑息治療之間沒有發現關聯，且這些患者在家中死亡的機率增加。
研究結果強調了姑息治療在一些非癌症疾病中的潛在益處，增加姑息治療的使用機會可改善生命終止治療，可能對健康政策產生重要影響。
附：英文原文
Title: Association between palliative care and healthcare outcomes among adults with terminal non-cancer illness: population based matched cohort study
Author: Kieran L Quinn, Therese Stukel, Nathan M Stall, Anjie Huang, Sarina Isenberg, Peter Tanuseputro, Russell Goldman, Peter Cram, Dio Kavalieratos, Allan S Detsky, Chaim M Bell
Issue&Volume: 2020/07/06
Abstract: Objective To measure the associations between newly initiated palliative care in the last six months of life, healthcare use, and location of death in adults dying from non-cancer illness, and to compare these associations with those in adults who die from cancer at a population level.
Design Population based matched cohort study.
Setting Ontario, Canada between 2010 and 2015.
Participants 113540 adults dying from cancer and non-cancer illness who were given newly initiated physician delivered palliative care in the last six months of life administered across all healthcare settings. Linked health administrative data were used to directly match patients on cause of death, hospital frailty risk score, presence of metastatic cancer, residential location (according to 1 of 14 local health integration networks that organise all healthcare services in Ontario), and a propensity score to receive palliative care that was derived by using age and sex.
Main outcome measures Rates of emergency department visits, admissions to hospital, and admissions to the intensive care unit, and odds of death at home versus in hospital after first palliative care visit, adjusted for patient characteristics (such as age, sex, and comorbidities).
Results In patients dying from non-cancer illness related to chronic organ failure (such as heart failure, cirrhosis, and stroke), palliative care was associated with reduced rates of emergency department visits (crude rate 1.9 (standard deviation 6.2) v 2.9 (8.7) per person year; adjusted rate ratio 0.88, 95% confidence interval 0.85 to 0.91), admissions to hospital (crude rate 6.1 (standard deviation 10.2) v 8.7 (12.6) per person year; adjusted rate ratio 0.88, 95% confidence interval 0.86 to 0.91), and admissions to the intensive care unit (crude rate 1.4 (standard deviation 5.9) v 2.9 (8.7) per person year; adjusted rate ratio 0.59, 95% confidence interval 0.56 to 0.62) compared with those who did not receive palliative care. Additionally increased odds of dying at home or in a nursing home compared with dying in hospital were found in these patients (n=6936 (49.5%) v n=9526 (39.6%); adjusted odds ratio 1.67, 95% confidence interval 1.60 to 1.74). Overall, in patients dying from dementia, palliative care was associated with increased rates of emergency department visits (crude rate 1.2 (standard deviation 4.9) v 1.3 (5.5) per person year; adjusted rate ratio 1.06, 95% confidence interval 1.01 to 1.12) and admissions to hospital (crude rate 3.6 (standard deviation 8.2) v 2.8 (7.8) per person year; adjusted rate ratio 1.33, 95% confidence interval 1.27 to 1.39), and reduced odds of dying at home or in a nursing home (n=6667 (72.1%) v n=13384 (83.5%); adjusted odds ratio 0.68, 95% confidence interval 0.64 to 0.73). However, these rates differed depending on whether patients dying with dementia lived in the community or in a nursing home. No association was found between healthcare use and palliative care for patients dying from dementia who lived in the community, and these patients had increased odds of dying at home.
Conclusions These findings highlight the potential benefits of palliative care in some non-cancer illnesses. Increasing access to palliative care through sustained investment in physician training and current models of collaborative palliative care could improve end-of-life care, which might have important implications for health policy.
DOI: 10.1136/bmj.m2257
Source: https://www.bmj.com/content/370/bmj.m2257