病症严重度及死亡风险是转至安宁照护的预测因子


  Jan. 24, 2005 (纽奥良) - 一项发表于美国安宁照护缓和医学学会暨安宁照护护士协会年会上的研究指出,癌症患者在症状严重时,或在死亡风险升高时,很容易被转移到安宁照护机构。
  
  Gregory R. Harper医师在与Medscape的访谈中提到,该项研究的结果并不令人惊讶,因为该研究可以加速提供予临终癌症患者较好的照顾。
  
  Lehigh Valley医院癌症科总医师Harper医师表示,通常癌症患者转至安宁照护的时机都嫌过晚,而这项研究可以帮助我们,确认何种患者会较适合接受安宁照护,而不是居家照护。
  
  监于癌症住院患者的治疗方式有著某些缺陷,例如患者与医师及护士间沟通不良、住院期过长、延迟转送至安宁照护,或延迟转送至其它的临终照护等种种因素,Harper的研究小组于是启动本项调查;该项研究计画整合了肿瘤科护士及专业医师,针对医疗成本、临床医疗变量、安宁照护的转移等因素进行分析。
  
  2002年7月到2004年7月间,在该医院的纪录中,研究人员分析了858位癌症患者的病历纪录;目的在建立初期的治疗成本及临床治疗法型态;患者中有671位在出院后选择居家照护,或为自行照顾,或为聘用家庭护士等方式;剩下的117位,不是在院死亡,就是转移至安宁照护。
  
  患者纪录的分类是以症状严重程度及死亡风险为基础,各归类为次要、中等、主要及极端等等级;相较于居家照护的患者,症状程度及死亡风险,都是主要及极端严重的患者较容易转至安宁照护。
  
  两组之间,在总治疗成本及住院期方面,都没有显著的差异;但是,高治疗成本及长住院期却显见于重度症状及高死亡风险的族群;有趣的是,高治疗成本及较长住院期的患者所接受的治疗方式比较多样。
  
  Harper医师警告,病症严重度及死亡风险这两项指标,是在事后才确立的,至于是否可以作为适时的指标,还需要更进一步的分析才能看出。
  
  Harper医师向Medscape表示,重症患者的治疗方式还需要作更多的努力来予以标准化,我们希望正在进行中的研究,可以帮助我们做更精确的预后判断,藉此能将合适的患者及时的转至安宁照护。

Illness Severity, Mortality Ri

By Paula Moyer
Medscape Medical News

Jan. 24, 2005 (New Orleans) — Hospitalized patients with cancer are more likely to be discharged to hospice services when they are more severely ill or have a higher risk of mortality, according to investigators who presented their findings here at the joint annual meeting of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association.

While these findings may not be surprising, the study may help expedite such services for cancer patients who would be better served by end-of-life care, principal investigator Gregory R. Harper, MD, PhD, said in an interview with Medscape.

"Too often cancer patients' referrals to hospice are delayed," said Dr. Harper, physician-in-chief of cancer services at the John & Dorothy Morgan Cancer Center of Lehigh Valley Hospital and Health Network in Allentown, Pennsylvania. "These findings may help us identify which patients would be more appropriately served by hospice rather than home care."

Dr. Harper and colleagues conducted the study because of their concern about the pattern of care for hospitalized cancer patients, with characteristic poor communication among such patients' nurses and physicians, long stays, and delayed referrals to hospice or other end-of-life services. Therefore, the researchers developed a project that integrates an oncology nurse practitioner with attending oncologists in their practice. The study that their team undertook analyzed costs of care, variances in clinical practice, and referrals to hospice care for such patients.

The investigators analyzed the records of 858 cancer patients admitted to their facility between July 2002 and June 2004. The goal was to establish a baseline of costs and clinical practice patterns. Among the patients whose records were complete, 671 were discharged to home care, either as self care or with visiting nurses. The remaining 117 patients either died in the hospital or were discharged to hospice care.

The records characterized all patients by severity of illness and risk of mortality, each of which was rated as minor, moderate, major, or extreme. Patients with major or extreme illness, and those with major and extreme risk of mortality, were significantly more likely to be in the hospice group than in the home care group (P < .001).

The investigators detected no significant differences in either total variable costs or length of stay between the two groups. However, the costs and length of stay were significantly greater in those severely ill and at high risk of mortality (P < .001). Of interest, higher costs and increased length of stay for such patients were also associated with significantly more types of care received (P < .001).

Dr. Harper cautioned that both indicators, illness severity and mortality risk, were assigned retrospectively, and that he and his investigative team are analyzing the data further to see if they can identify real-time predictors for these markers.

"We have more work to do regarding standardizing care for severely ill patients," Dr. Harper told Medscape. "We hope that ongoing research will help us make more accurate prognoses so that we can make hospice referrals sooner for patients for whom such care is appropriate."

AAHPN-HPNA 2005 Annual Assembly: Abstract 762. Presented Jan. 21, 2005.

Reviewed by Gary D. Vogin, MD

    
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