加拿大多伦多大学Kieran L Quinn团队研究了成人晚期非癌症疾病姑息治疗的效果。该成果发表在2020年7月6日出版的《英国医学杂志》上。

为了评估在非癌症疾病死亡的成年人中，生命最后6个月内新开始的姑息治疗、医疗保健使用和死亡住所之间的关联，并在人口水平上将这些关联与死于癌症的成年人进行比较，2010年至2015年间，研究组在加拿大安大略省进行了一项基于人群的配对队列研究。

研究组招募了113540名死于癌症或非癌症疾病的患者，在所有医疗机构中，这些患者在生命的最后六个月，均新接受了姑息治疗。主要结局指标为急诊就诊率、入院率和被收入重症监护室率，以及首次姑息治疗就诊后在家与医院的死亡几率，并根据患者特征（例如年龄，性别和合并症）进行校正。

死于慢性器官衰竭（如心力衰竭、肝硬化和中风）相关的非癌症疾病的患者中，与那些没有得到姑息治疗的人相比，采用姑息治疗可显著降低急诊就诊率、入院率和重症监护率。此外，这些患者在家或疗养院死亡的几率为49.5%，显著高于在医院内死亡（39.6%）。

在死于痴呆的患者中，姑息治疗显著增加了急诊就诊率和入院率，但减少了在家中或疗养院中死亡的几率。但这些比率的差异取决于死于痴呆症的患者是住在社区还是疗养院。对于居住在社区的痴呆症患者，在医疗保健和姑息治疗之间没有发现关联，且这些患者在家中死亡的几率增加。

研究结果强调了姑息治疗在一些非癌症疾病中的潜在益处，增加姑息治疗的使用机会可改善生命终止治疗，可能对健康政策产生重要影响。

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