Trends in Noninvasive and Invasive Mechanical Ventilation Among Medicare Beneficiaries at the End of Life
Trends in Noninvasive and Invasive Mechanical Ventilation Among Medicare Beneficiaries at the End of Life
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DOI：
10.1001/jamainternmed.2020.5640
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发表时间：
2020-10-19
影响因子：
39
通讯作者：
Teno, Joan M.
中科院分区：
文献类型：
--
作者：
Sullivan, Donald R.;Kim, Hyosin;Teno, Joan M.
重要性临终关怀是昂贵的，死者往往经历过度治疗或低质量的护理。无创通气（NIV）可能是一种姑息性的方法，以避免有创机械通气（IMV）的选择患者谁是住院在生命的最后30天。这项以人群为基础的队列研究使用了20%的随机样本，在生命的最后30天内接受过急性护理住院治疗，并在2000年1月1日至2017年12月31日期间死亡的服务受益人。社会人口学、诊断和合并症数据来自医疗保险索赔数据。数据分析从2019年9月至2020年7月进行。主要结果和指标：对经验证的国际疾病分类，第九次修订，临床修改或国际疾病统计分类，第十次修订，临床修改程序代码进行审查，以确定使用NIV，IMV，NIV和IMV，或不使用。使用主要入院诊断代码（慢性阻塞性肺疾病[COPD]、充血性心力衰竭[CHF]、癌症和痴呆）确定了四个医疗保险受益人亚组。临终关怀的措施包括院内死亡（急性护理环境），临终关怀登记死亡，临终关怀登记在生命的最后3天。随机效应logistic回归分析NIV和IMV使用调整社会人口学特征，入院诊断，和comorbidity.RESULTS共2 470435医疗保险受益人（1 353 798妇女[54.8%]，平均[SD]年龄，82.2 [8.2]岁）住院死亡后30天内。与2000年相比，2005年NIV使用增加的调整后比值比（AOR）为2.63（95% CI，2.46-2.82;%接收：0.8% vs 2.0%），2017年为11.84（95% CI，11.11-12.61;%接收：0.8% vs 7.1%）。与2000年相比，2005年IMV使用增加的AOR为1.04（95% CI，1.02-1.06;接受百分比：15.0% vs 15.2%），2017年为1.63（95% CI，1.59-1.66;接受百分比：15.0% vs 18.2%）。在比较2017年与2000年的子分析中，CHF患者的NIV增加趋势相似（接受治疗百分比：1.4% vs 14.2%; AOR，14.14 [95% CI，11.77-16.98]）和COPD（接受%：2.7% vs 14.5%; AOR，8.22 [95% CI，6.42-10.52]），CHF患者中IMV使用的相互稳定（接受治疗百分比：11.1% vs 7.8%; AOR，1.07 [95% CI，0.95-1.19]）和COPD（接受治疗百分比：17.4% vs 13.2%; AOR，1.03 [95% CI，0.88-1.21]）。癌症死亡者增加NIV使用的AOR为10.82（95%CI，8.16-14.34;%接收：0.4% vs 3.5%），痴呆死亡者为9.62（95%CI，7.61-12.15; %接收：0.6% vs 5.2%）。癌症死亡者增加IMV使用的AOR为1.40（95% CI，1.26-1.55;%接收：6.2% vs 7.6%），痴呆死亡者为1.28（95% CI，1.17-1.41;%接收：5.7% vs 6.2%）。在使用NIV与IMV的死亡者中，（50.3%[95% CI，49.3%-51.3%] vs 76.7%[95% CI，75.9%-77.5%]）和生命最后3天的临终关怀登记（57.7%[95% CI，56.2%-59.3%] vs 63.0%[95% CI，60.9%-65.1%]），沿着较高的临终关怀登记率（41.3%[95% CI，40.4%-42.3%] vs 20.0%[95% CI，19.2%-20.7%]）结论和相关性这项研究发现，从2000年到2017年，医疗保险受益人在生命结束时使用NIV的人数迅速增加，尤其是在癌症和痴呆症患者中。研究结果表明，评估NIV结果的试验有必要为临床医生和患者及其医疗保健代理人之间关于这种治疗目标的讨论提供信息。
IMPORTANCE End-of-life care is costly, and decedents often experience overtreatment or low-quality care. Noninvasive ventilation (NIV) may be a palliative approach to avoid invasive mechanical ventilation (IMV) among select patients who are hospitalized at the end of life.OBJECTIVE To examine the trends in NIV and IMV use among decedents with a hospitalization in the last 30 days of life.DESIGN, SETTING, AND PARTICIPANTS This population-based cohort study used a 20% random sample of Medicare fee-for-service beneficiaries who had an acute care hospitalization in the last 30 days of life and died between January 1, 2000, and December 31, 2017. Sociodemographic, diagnosis, and comorbidity data were obtained from Medicare claims data. Data analysis was performed from September 2019 to July 2020.EXPOSURES Use of NIV or IMV. MAIN OUTCOMES AND MEASURES Validated International Classification of Diseases, Ninth Revision, Clinical Modification or International Statistical Classification of Diseases, Tenth Revision, Clinical Modification procedure codes were reviewed to identify use of NIV, IMV, both NIV and IMV, or none. Four subcohorts of Medicare beneficiaries were identified using primary admitting diagnosis codes (chronic obstructive pulmonary disease [COPD], congested heart failure [CHF], cancer, and dementia). Measures of end-of-life care included in-hospital death (acute care setting), hospice enrollment at death, and hospice enrollment in the last 3 days of life. Random-effects logistic regression examined NIV and IMV use adjusted for sociodemographic characteristics, admitting diagnosis, and comorbidities.RESULTS A total of 2 470435 Medicare beneficiaries (1 353 798women [54.8%]; mean [SD] age, 82.2 [8.2] years) were hospitalized within 30 days of death. Compared with 2000, the adjusted odds ratio (AOR) for the increase in NIV usewas 2.63 (95% CI, 2.46-2.82;% receipt: 0.8% vs 2.0%) for 2005 and 11.84 (95% CI, 11.11-12.61;% receipt: 0.8% vs 7.1%) for 2017. Compared with 2000, the AOR for the increase in IMV usewas 1.04 (95% CI, 1.02-1.06;% receipt: 15.0% vs 15.2%) for 2005 and 1.63 (95% CI, 1.59-1.66;% receipt: 15.0% vs 18.2%) for 2017. In subanalyses comparing 2017 with 2000, similar trends found increased NIV among patients with CHF (% receipt: 1.4% vs 14.2%; AOR, 14.14 [95% CI, 11.77-16.98]) and COPD (% receipt: 2.7% vs 14.5%; AOR, 8.22 [95% CI, 6.42-10.52]), with reciprocal stabilization in IMV use among patients with CHF (% receipt: 11.1% vs 7.8%; AOR, 1.07 [95% CI, 0.95-1.19]) and COPD (% receipt: 17.4% vs 13.2%; AOR, 1.03 [95% CI, 0.88-1.21]). The AOR for increased NIV usewas 10.82 (95% CI, 8.16-14.34;% receipt: 0.4% vs 3.5%) among decedents with cancer and 9.62 (95% CI, 7.61-12.15; % receipt: 0.6% vs 5.2%) among decedents with dementia. The AOR for increased IMV usewas 1.40 (95% CI, 1.26-1.55;% receipt: 6.2% vs 7.6%) among decedents with cancer and 1.28 (95% CI, 1.17-1.41;% receipt: 5.7% vs 6.2%) among decedents with dementia. Among decedents with NIV vs IMV use, lower rates of in-hospital death (50.3%[95% CI, 49.3%-51.3%] vs 76.7%[95% CI, 75.9%-77.5%]) and hospice enrollment in the last 3 days of life (57.7%[95% CI, 56.2%-59.3%] vs 63.0%[95% CI, 60.9%-65.1%]) were observed along with higher rates of hospice enrollment (41.3%[95% CI, 40.4%-42.3%] vs 20.0%[95% CI, 19.2%-20.7%]).CONCLUSIONS AND RELEVANCE This study found that the use of NIV rapidly increased from 2000 through 2017 among Medicare beneficiaries at the end of life, especially among persons with cancer and dementia. The findings suggest that trials to evaluate the outcomes of NIV are warranted to inform discussions about the goals of this therapy between clinicians and patients and their health care proxies.