病患特徵決定臨終開支


  【24drs.com】根據2月15日內科學誌上的一項研究結果,病患特徵可能決定了臨終花費,這些特徵包括功能下降、人種、種族、慢性疾病以及身旁有家人陪伴等,且與地區特性無關。
  
  紐約市密蘇里醫學院的Amy S. Kelley醫師與同事們寫到,臨終醫療開支超過其他時期的照護費用,找出造成花費差異的原因可能讓我們找到降低費用的契機。
  
  這項研究目的在找出影響臨終醫療保險花費的病患相關特徵,並且檢驗這些預測因子在控制地區因子後對花費變異的影響。研究人員的假設是種族或人種、社會支持、功能狀態將會獨立地與治療密集度有關,且與地區特性無關,此外,個人特質將能解釋大部分的花費變異。
  
  他們使用2000年到2006年來自健康與退休研究、健康保險資料以及Dartmouth Altas健康照護的資料,建立花費及地區因素的模式。使用一系列雙層多變項迴歸分析模式,納入患者地區、患者與地區特徵,估計2,394位健康與退休研究中年齡至少65.5歲死者生命最後六個月的醫療保險支出。
  
  與較高醫療支出有關的病患相關因素是功能下降(風險比值[RR]為1.64;95%信賴區間[CI]為1.46-1.83)、西班牙裔(RR為1.50;95% CI為1.22-1.85)、黑人(RR為1.43;95% CI為1.25-1.64),糖尿病或特定慢性疾病(RR為1.16;95% CI為1.06-1.27)。與較低醫療支出有關的因子包括有家人陪伴(RR為0.90;95% CI為0.82-0.98)、癡呆(RR為0.78;95% CI為0.71-0.87),但高等照護計畫並未與支出有關。
  
  與較高醫療支出有關的區域因素包括臨終執業模式(RR為1.09;95% CI為1.06-1.14)、每個區域的醫院床數(RR為1.01;95% CI為1.00-1.02)。病患特徵可以解釋10%的整體變異性,即使在控制區域特徵後,仍然達到統計上顯著地與支出有關。
  
  這項研究的限制包括,僅分析死者而非存活者、來自加護照護的資料;依賴近親的資訊;以及一大部分變異性無法解釋。
  
  研究作者們寫到,這項研究指出,特定特徵讓患者們處於高支出、高密集度治療更高的風險:包括功能下降、慢性疾病、以及沒有家人陪伴。這代表我們有找出或針對處於高密度治療風險患者,決定什麼時候、或高花費臨終維持性治療是否與病患偏好一致?或代表不適當、低品質的醫療照護介入機會。這些知識對於發展降低群眾層次健康差異、過度花費、以及病患痛苦的政策與指引來說,是很重要的。
  
  在隨後的主編評論中,來自西雅圖華盛頓大學港景醫學中心的J. Randall Curtis醫師和Ruth A. Engelberg博士建議鼓勵臨床醫師及健康照護系統發展常規高等照護計畫。
  
  Curtis醫師與Engelberg博士寫到,如果我們要在每位病患臨終照護適當治療上達到顯著進展,我們必須建立這些成功的計畫,並且讓所有臨床醫師、患者、以及家人有充分討論。
  
  布魯克代爾基金會贊助這項研究。研究中部分作者接受布魯克代爾領導老年化研究計畫,國家緩和醫療研究中心、以及/或是退休事務大洛杉磯健康照護系統老年研究教育臨床中心贊助。Curtis醫師與Endelberg博士接受國家護理研究機構和國家心臟、肺部與血液機構贊助。
  
  資料來源:http://www.24drs.com/Professional/list/content.asp?x_idno=6460&x_classno=1&x_chkdelpoint=Y
  

Patient Characteristics May Determine End-of-Life Expenditures

By Laurie Barclay, MD
Medscape Medical News

February 15, 2011 — Patient characteristics including functional decline, race, ethnicity, chronic disease, and having family nearby may determine end-of-life expenditures independent of regional characteristics, according to the results of a study reported in the February 15 issue of the Annals of Internal Medicine.

"End-of-life medical expenditures exceed costs of care during other years, vary across regions, and are likely to be unsustainable," write Amy S. Kelley, MD, MSHS, from Mount Sinai School of Medicine in New York City, and colleagues. "Identifying determinants of expenditure variation may reveal opportunities for reducing costs."

The study goal was to identify patient-related characteristics that would affect Medicare expenditures at the end of life, and to examine the contributions of these predictors to expenditure variation while controlling for regional factors. The investigators' hypotheses were that race or ethnicity, social support, and functional status would be independently associated with treatment intensity independent of regional characteristics, and that individual characteristics would account for a significant proportion of expenditure variation.

The relationships between expenditures and patient and regional factors were modeled using year 2000 to 2006 data from the Health and Retirement Study, Medicare claims, and the Dartmouth Atlas of Health Care. Using a series of 2-level multivariable regression models that included patient, regional, and both patient and regional characteristics, Medicare expenditures in the last 6 months of life were estimated in 2394 Health and Retirement Study decedents at least 65.5 years of age.

Patient-related factors associated with higher expenditures were decline in function (rate ratio [RR], 1.64; 95% confidence interval [CI], 1.46 - 1.83), Hispanic ethnicity (RR, 1.50; 95% CI, 1.22 - 1.85), black race (RR, 1.43; 95% CI, 1.25 - 1.64), and diabetes or certain chronic diseases (RR, 1.16; 95% CI, 1.06 - 1.27]). Although factors associated with lower expenditures were nearby family (RR, 0.90; 95% CI, 0.82 - 0.98) and dementia (RR, 0.78; 95% CI, 0.71 - 0.87), advance care planning was not associated with expenditures.

Regional factors associated with higher expenditures included end-of-life practice patterns (RR, 1.09; 95% CI, 1.06 - 1.14) and hospital beds per capita (RR, 1.01; 95% CI, 1.00 - 1.02]). Ten percent of the overall variance was explained by patient characteristics, which continued to be statistically significantly associated with expenditures even after controlling for regional characteristics.

Limitations of this study include the analysis only of decedents, and not survivors, of intensive medical care; reliance on proxy informants; and a large proportion of unexplained variation.

"[T]his study indicates that specific characteristics place persons at a greater risk for high-cost, high-intensity treatment: functional decline, chronic medical conditions, and not having family nearby," the study authors write. "This suggests opportunities for interventions that identify and target patients at increased risk for high-intensity treatment in order to determine when and whether high-cost life-sustaining treatment is consistent with patient preferences or indicative of inappropriate, poor-quality medical care. This knowledge will be critical for the development of policies and guidelines to decrease population-level health disparities, excessive expenditures, and patient suffering."

In an accompanying editorial, J. Randall Curtis, MD, MPH, and Ruth A. Engelberg, PhD, from Harborview Medical Center, University of Washington in Seattle, recommend the development of programs urging clinicians and healthcare systems to conduct regular advance care planning.

"If we want to make significant progress in achieving the right intensity of care at the end of life for each individual patient, we need to build on these successful programs and make them available to all clinicians, patients, and families involved in these discussions," Dr. Curtis and Dr. Engelberg write.

The Brookdale Foundation supported this study. Some of the study authors are supported by Brookdale Leadership in Aging Fellowship, Mid-Career Investigator Award in Patient-Oriented Research from the National Institute on Aging, the National Palliative Care Research Center, and/or the Veterans Affairs Greater Los Angeles Healthcare System Geriatric Research Education Clinical Center. Dr. Curtis and Dr. Engelberg are supported by the National Institute of Nursing Research and the National Heart, Lung, and Blood Institute.

Ann Intern Med. 2011;154:235-242, 283-285.

    
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