Race, Ethnicity, and Other Risks for Live Discharge Among Hospice Patients with Dementia
Race, Ethnicity, and Other Risks for Live Discharge Among Hospice Patients with Dementia
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DOI：
10.1111/jgs.16242
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发表时间：
2019-11-21
影响因子：
6.3
通讯作者：
Prigerson, Holly G.
中科院分区：
文献类型：
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作者：
Luth, Elizabeth A.;Russell, David J.;Prigerson, Holly G.
目的痴呆症患者的生命终结轨迹通常是漫长且难以预测的，将这些人置于临终关怀的高风险中。痴呆症患者因病情稳定或未能下降而住院出院的风险尚未得到很好的确定。我们的目的是确定人口统计学、健康和安宁疗护服务因素与安宁疗护痴呆患者因病情稳定或未能下降而出院相关。设计回顾性队列研究。在纽约市设立了一家大型非营利机构。参与者共2629名年龄在65岁及以上的老年痴呆症临终关怀患者。主要结局是由于病情稳定或未能好转而从安宁疗护院活出院（vs .死亡）。措施包括人口统计因素（种族/民族、医疗补助、性别、年龄、婚姻状况、父母状况）、健康特征（原发性痴呆诊断、合并症、功能状况、先前住院）和临终关怀服务（地点、服务时间、护士就诊次数和时间）。结果Logistic回归模型显示，与白人痴呆临终关怀患者相比，非裔美国人和西班牙裔痴呆临终关怀患者的活出院风险增加（非裔美国：调整优势比[aOR] = 2.42； 95%可信区间[CI] = 1.34-4.38；西班牙裔：aOR = 2.99; 95% CI = 1.81-4.94）。居家安宁疗护（aOR = 7.57; 95% CI = 4.04-14.18）、服务时间较长（aOR = 1.04; 95% CI = 1.04-1.05）、护士探视与出院间隔时间较长（aOR = 1.86; 95% CI = 1.56-2.21）也与活出院相关。结论为避免痴呆患者退出安宁疗护带来的负担和破坏性转变，应针对非裔美国人、西班牙裔美国人和家庭安宁疗护患者的需求，量身定制干预措施，以减少因病情稳定或未能下降而活出院的人数。有关持续安宁疗护资格的政策，应考虑到失智症患者生命终结轨迹的变数与延长期。
OBJECTIVES The end-of-life trajectory for persons with dementia is often protracted and difficult to predict, placing these individuals at heightened risk of live discharge from hospice. Risks for live discharge due to condition stabilization or failure to decline among patients with dementia are not well established. Our aim was to identify demographic, health, and hospice service factors associated with live discharge due to condition stabilization or failure to decline among hospice patients with dementia. DESIGN Retrospective cohort study. SETTING A large not-for-profit agency in New York City. PARTICIPANTS A total of 2629 hospice patients with dementia age 65 years and older. MEASUREMENTS Primary outcome was live discharge from hospice due to condition stabilization or failure to decline (vs death). Measures include demographic factors (race/ethnicity, Medicaid, sex, age, marital status, parental status), health characteristics (primary dementia diagnosis, comorbidities, functional status, prior hospitalization), and hospice service (location, length of service, number and timing of nurse visits). RESULTS Logistic regression models indicated that compared with white hospice patients with dementia, African American and Hispanic hospice patients with dementia experienced increased risk of live discharge (African American: adjusted odds ratio [aOR] = 2.42; 95% confidence interval [CI] = 1.34-4.38; Hispanic: aOR = 2.99; 95% CI = 1.81-4.94). Home hospice (aOR = 7.57; 95% CI = 4.04-14.18), longer length of service (aOR = 1.04; 95% CI = 1.04-1.05), and more days between nurse visits and discharge (aOR = 1.86; 95% CI = 1.56-2.21) were also associated with live discharge. CONCLUSION To avoid burdensome and disruptive transitions out of hospice in patients with dementia, interventions to reduce live discharge due to condition stabilization or failure to decline should be tailored to meet the needs of African American, Hispanic, and home hospice patients. Policies regarding sustained hospice eligibility should account for the variable and protracted end-of-life trajectory of patients with dementia.