上海市居家临终关怀服务开展及费用调查分析

<正>临终关怀是指对救治无望、生命即将结束的人实施的综合性照顾,旨在使其尊严、舒适、温暖地走完生命的最后历程[1]。伴随着中国老龄化社会的到来,中国医疗界面临的挑战也越来越突出,不同于一般的医疗问题,老龄化社会面对的医疗挑战不仅仅是疾病的解决或治愈问题。对于老年人而言,死亡更是一个难以回避的问题,其医疗问题的核心绝非类似年轻人的解决疾病、远离死亡[2]。因此,临终关怀的重要性越来越得到社会各界的重视。     

Decisions for hospice care in patients with advanced cancer

OBJECTIVES: To identify factors that may influence the decision of whether to enter a hospice program or to continue with a traditional hospital approach in patients with advanced cancer and to understand their decision-making process. DESIGN: Cross-sectional structured interview. SETTING: One community-based hospice and three university-based teaching hospitals. PARTICIPANTS: Two hundred thirty-four adult patients diagnosed with advanced lung, breast, prostate, or colon cancer with a life expectancy of less than 1 year: 173 hospice patients and 61 nonhospice patients receiving traditional hospital care. MEASUREMENTS: Hospice and nonhospice patients' demographic, clinical, and other patient-related characteristics were compared. Multivariate analysis was then conducted to identify variables associated with the hospice care decision in a logistic regression model. Information sources regarding hospice care and people involved in the hospice decision were identified. RESULTS: Patients receiving hospice care were significantly older (average age 69 vs 65 years, P =.009) and less educated (average 11.9 vs 12.9 years, P =.031) and had more people in their households (average 1.66 vs 1.16 persons, P =.019). Hospice patients had more comorbid conditions (1.30 vs 0.93, P =.035) and worse activities of daily living scores (7.01 vs 6.23, P =.030) than nonhospice patients. Hospice patients were more realistic about their disease course than their nonhospice counterparts. Patients' understanding of their prognoses affected their perceptions of the course of their disease. Hospice patients preferred quality of life to length of life. In the multivariate analysis, lower education level and greater number of people in the household were associated with the decision to enter hospice. A healthcare provider first told most of those who entered hospice about hospice. Families largely made the final decision to enter hospice (42%), followed by patients themselves (28%) and physicians (27%). CONCLUSION: The decision to enter hospice is related to demographic, clinical, and other patient-related characteristics. This study suggests that the decision-making process for hospice care in patients with advanced cancer is multidimensional. The healthcare community may better meet the end-of-life care needs of advanced cancer patients through enhanced communication with patients and families, including providing accurate prognoses and better understanding of patients' preferences and values.     

A normative analysis of home care goals

Home- and community-based services (HCBS) can contribute to full social and economic participation in society by people with disabilities. Of 16 client-level and system-level HCBS goals, three are emphasized; targeting the neediest, individual choice, and strengthening informal systems. Projections are made of how selected goals would play out under two different resource conditions. Efforts to expand and strengthen HCBS involve trade-offs--for example, increasing access and comprehensiveness undermines affordability, increased targeting to the neediest means less access for those below the need threshold, and expanding client choice raises fears about trade-offs with quality and effectiveness. Targeting and choice seem to represent central and compatible goals for the design of an HCBS system. The combination minimizes trade-offs with affordability and enhances political feasibility.     

A specialized home care intervention improves survival among older post-surgical cancer patients

CONTEXT: Changes in the healthcare system have resulted in shortened hospital stays, moving the focus of care from the hospital to the home. Patients are discharged post-operatively with ongoing needs, and whether they receive nursing care post-hospitalization can influence their recovery and survival. Little information is available about the factors that influence outcomes, including the survival of older cancer patients after cancer surgery. OBJECTIVE: To compare the length of survival of older post-surgical cancer patients who received a specialized home care intervention provided by advanced practice nurses (APNs) with that of patients who received usual follow-up care in an ambulatory setting. We also assessed potential predictors of survival in terms of depressive symptoms, symptom distress, functional status, comorbidities, length of hospital stay, age of patient, and stage of disease. DESIGN: A randomized controlled intervention study. SETTING: Discharged older cancer patients after surgery at a Comprehensive Cancer Center in southeastern Pennsylvania. PATIENTS: Three hundred seventy-five patients aged 60 to 92, newly diagnosed with solid cancers, were treated surgically between February 1993 and December 1995. One hundred ninety patients were randomized to the intervention groups and 185 to the usual care group. INTERVENTION: The intervention was a standardized protocol that consisted of standard assessment and management post-surgical guidelines, doses of instructional content, and schedules of contacts. The intervention lasted 4 weeks and consisted of three home visits and five telephone contacts provided by APNs. Both the patients and their family caregivers received comprehensive clinical assessments, monitoring, and teaching, including skills training. MAIN OUTCOME MEASURE: Time from enrollment of patients into the study until death or last date known alive at the end of November 1996. RESULTS: During the 44-month follow-up period, 93 (24.8%) of 375 patients died. Forty-one (22%) of those who died were patients in the specialized home care intervention group, compared with 52 (28%) in the usual care group. Stage of disease at diagnosis differed between the two groups at baseline (38% late stage patients in the intervention group compared with 26% in the control group, P = .01), so stratified analysis was performed. Overall, the specialized home care intervention group was found to have increased survival (P = .002 using stratified log-rank test). Among early stage patients only, there was no difference in survival between the intervention and control groups. Among late stage patients, there was improved survival in the intervention group. For example, 2-year survival among late stage intervention group cases was 67% compared with 40% among control cases. When Cox's proportional hazard model was used to adjust for significant baseline covariates, the relative hazard of death in the usual care group was 2.04 (CI: 1.33 to 3.12; P = .001) after adjusting for stage of disease and surgical hospitalization length of stay. CONCLUSIONS: This is the first empirical study of post-surgical cancer patients to link a specialized home care intervention by advanced practice nurses with improved survival. Additional research is needed to test home care interventions aimed at maintaining quality of life outcomes and their effects on survival of post-surgical cancer patients.     

A cost analysis of outpatient care for patients with Barrett's esophagus in a managed care setting

OBJECTIVES: Although Barrett's esophagus (BE) may be associated with severe gastroesophageal reflux disease (GERD), there are currently no studies that evaluate resource utilization in Barrett's patients. The aims of this study were 1) to determine the cost and number of endoscopies and clinic visits to the GI clinic for GERD or its complications in patients with BE; 2) to determine the pattern and cost of medication use in patients with BE; and 3) to compare medication use by patients with BE to that of patients with insulin-requiring diabetes mellitus (DM). METHODS: Using the cost distribution report data and the pharmacy acquisition costs from the Durham VAMC, we calculated the monthly cost of endoscopies, clinic visits related to GERD, and medication use in 53 patients with BE between 1/1/94 and 1/1/97. We also calculated the average cost of medication use for 55 patients with insulin-requiring DM. RESULTS: All patients with BE were male. Their median age was 64.0 yr (IQR 57-68). Of them, 92% were white; 23% had low-grade dysplasia (LGD). Patients with LGD were more likely to have more than three endoscopies in 3 yr than were those with no LGD (OR 6.3, 95% CI 1.11-35.67). There was no difference in clinic visits in the patients with and without dysplasia (OR 0.335, 95% CI 0.093-1.206). A total of 139 endoscopies and 172 clinic visits were observed. Outpatient care for patients with BE costs approximately $103/month or $1241/yr. Endoscopies and clinic visits accounted for 31.1% and 5.9% of the monthly medical cost, respectively. Medications accounted for 63% of the total cost of care. Prokinetic agents accounted for 0.8% of the total cost of medications, whereas histamine receptor antagonists (H2 blockers) and proton pump inhibitors (PPIs) accounted for 34.6% and 64.6%, respectively. Medication cost per month in patients with BE was approximately $65, similar to that of patients with insulin-requiring DM ($63). CONCLUSIONS: Our conclusions were as follows: 1) Outpatient care for patients with BE costs approximately $1241/yr or ($103/month). 2) Medication use per month accounted for more than half of the total cost; PPIs accounted for 64.6% of total medication cost, suggesting that reflux was severe. 3) Consistent with current surveillance strategies, patients with LGD had more frequent endoscopy than patients with no dysplasia. 4) Medication cost per month in patients with BE is similar to that in patients with DM, another group with a chronic disorder. 5) Those who make health policy can use these results to compare the cost of care of patients with BE to the cost for those with other chronic medical disorders.     

Prognostic factors in patients in the terminal phase of haematological malignancies who are receiving home medical care

Although there are many prognostic models for patients in the terminal phase of solid tumours, a reliable prognostic scoring system in patients in the terminal phase of haematological malignancies (HM) has not been established. We retrospectively evaluated 180 patients in the terminal phase of HM who were receiving home medical care (HMC). Multivariate analyses revealed that clinician's estimate, consciousness, loss of appetite, dyspnoea, neutrophil count, lymphocyte count, and lactate dehydrogenase were associated with overall survival (OS). Based on this result, we developed a novel prognostic scoring system, the Japan palliative haematological oncology prognostic estimates, in which four risk groups were shown to clearly differ in survival (p < 0.001): a low-risk group (n = 41, median OS of 434 days), an intermediate-low-risk group (n = 80, median OS of 112 days), an intermediate-high-risk group (n = 38, median OS of 31.5 days), and a high-risk group (n = 21, median OS of 10 days). This is the first investigation of prognostic factors that influence the OS of patients in the terminal phase of HM who are receiving HMC. Providing patients with reliable information about their prognosis is important for them to consider how to spend their remaining life.     

Patterns and predictors of home health and hospice use by older adults with cancer

OBJECTIVES: To describe patterns of home health and hospice use by older cancer patients and a comparison group of older persons without cancer. To identify predictors of home care and hospice utilization. DESIGN: Retrospective analysis using the Surveillance, Epidemiology and End Results (SEER)-Medicare Database, a linkage of the SEER Program of the National Cancer Institute (an epidemiological surveillance system of population-based tumor registries) and Medicare Claims. SETTING: The SEER data used in this paper cover a service area that includes approximately 14% of the U.S. population, including the states of Connecticut, Hawaii, Iowa, and New Mexico and the metropolitan areas of Detroit, San Francisco-Oakland, Atlanta, Seattle-Puget Sound, Los Angeles County, and San Jose-Monterey. PARTICIPANTS: Five analytical samples were drawn. The first consisted of all cases with a diagnosis of cancer in 1997 to 1999 who were eligible for services in calendar year 1999 (n=120,072). The second and third were subsamples of these and consisted of cases with a new cancer diagnosis in 1999 (n=46,373) and cases who died in 1999 (n=41,483). The fourth consisted of a comparison sample without cancer (n=160,707). The fifth was a subsample of this and consisted of those who died in 1999 (n=6,639). MEASUREMENTS: Utilization rates of home health and hospice services. RESULTS: Twenty-nine percent of cancer patients used home health services, and 10.7% used hospice services, compared with 7.8% of noncancer patients who used home health and less than 1% who used hospice. Half (51.4%) of cancer patients who used home health did not have cancer listed as an admitting diagnosis for the use of those services. Home health utilization was lowest for unmarried men. CONCLUSION: This is the first study to evaluate community-based home health and hospice utilization by older cancer patients. Future studies must begin to address what constitutes appropriate utilization.     

A cost analysis of screening methodology for family members of colorectal cancer patients

First-degree relatives of colorectal cancer patients are at increased risk for this malignancy which, in certain families, has right-sided predilection. For both these reasons, some clinicians recommend colonoscopy as the initial screening examination for these relatives. We used the results of a screening program of families of colon cancer patients to determine whether the tumor yield and costs justified this recommendation. Our study included 468 asymptomatic, first-degree relatives of large bowel neoplasia patients. Of these, 429 had only one relative with colorectal neoplasia and 39 had two or more such relatives. Persons with one affected relative were screened by fecal occult blood and flexible sigmoidoscopy, followed by colonoscopy if either test was positive, whereas colonoscopy was used as the primary screening test for those with two or more relatives with colorectal neoplasia. The comparison group included 452 persons without this family history of large bowel neoplasia. They were screened with fecal occult blood tests and flexible sigmoidoscopy. Based on a range of costs in the United States, and taking into account the hypothetical increased yield of screenees with neoplasia detected if colonoscopy was used as the primary screening examination, calculations of costs indicate that screening asymptomatic adults by colonoscopy is markedly (4-fold) more cost-effective if they have two or more first-degree colon cancer relatives. Otherwise, screening families with only 1 affected relative by flexible sigmoidoscopy, together with fecal occult blood, would seem the most economic method.     

A descriptive evaluation of warfarin use in patients receiving hospice or palliative care services

Purpose To describe and compare warfarin therapy use and outcomes between warfarin-receiving patients in hospice or palliative care (HPC) and not in HPC. Methods This retrospective, matched analysis examined warfarin-receiving patients who did (study cohort) and did not receive (control cohort) HPC services between 2002 and 2005. The matched cohorts were compared on rates of international normalized ratio (INR) measurements, INR control, and warfarin-related adverse events. Results Included were 101 and 484 study and matched control patients, respectively. Study patients had a higher mean rate of INR measurements per 30 days (2.2 ± 1.7 vs. 1.7 ± 1.4, P = 0.001) and were more likely to be above and below target INR range (P < 0.05) than control patients. Differences between the cohorts in incidences of warfarin-related adverse events were not statistically significant (P > 0.05). Conclusions Patients in HPC required more frequent INR monitoring but had similar risks for warfarin-related adverse events. Robin R. Hill, Kerri D. Martinez, Thomas Delate, Daniel M. Witt has no conflicts of interest to disclose.