Disparities in Care Management During Terminal Hospitalization Among Adults With Metastatic Cancer From 2010 to 2017.
Disparities in Care Management During Terminal Hospitalization Among Adults With Metastatic Cancer From 2010 to 2017.
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DOI：
10.1001/jamanetworkopen.2021.25328
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发表时间：
2021-09-01
影响因子：
13.8
通讯作者：
Tsai CJ
中科院分区：
文献类型：
--
作者：
Deeb S;Chino FL;Diamond LC;Tao A;Aragones A;Shahrokni A;Yerramilli D;Gillespie EF;Tsai CJ
患有转移性癌症的成人在终末住院期间护理管理的变化是否与社会人口状况相关？在这项对 21–335 名在医院死亡的转移性癌症患者进行的横断面研究中，少数民族患者以及拥有医疗保险或医疗补助覆盖的患者更有可能在生命结束时接受低价值、高成本的积极医疗干预措施。这项研究的结果表明，识别和理解与观察到的差异相关的因素将有助于与转移性癌症患者就临终关怀进行沟通。许多转移性癌症患者在临终时接受高成本、低价值的护理。识别很有可能接受低价值护理的患者是改善适当的临终护理的重要一步。分析晚期住院期间的护理和干预模式，并检查护理管理是否与生命末期患有转移性癌症的成年患者的社会人口状况相关。这项基于人群的回顾性横断面研究使用来自医疗保健成本和利用项目的数据来分析来自美国多个住院中心的所有付款人的就诊信息。筛选了2010年1月1日至2017年12月31日期间全国住院患者样本数据集中的所有使用和医院收费记录（n = 58 761 097）。最终队列包括 21–335 名入院时 18 岁及以上的患者，他们主要诊断为转移性癌症，并在住院期间死亡。本研究的数据分析时间为2010年1月1日至2017年12月31日。患者人口特征、患者保险状况、医院位置和医院教学状况。全身治疗（包括化疗和免疫治疗）的接受情况、有创机械通气的接受情况、急诊科 (ED) 入院情况、从入院到死亡的时间以及末期住院期间的总费用。 2010年至2017年间，21-335名晚期住院的转移性癌症患者中，中位年龄为65岁（四分位数范围，56-75岁）； 54.0%的患者为女性； 0.5% 为美洲印第安人，3.3% 为亚裔或太平洋岛民，14.1% 为黑人，7.5% 为西班牙裔，65.9% 为白人，3.1% 为其他族裔； 58.2% 的人有医疗保险或医疗补助保险，33.2% 的人有私人保险。总体而言，63.2%的患者从急诊室入院，4.6%接受全身治疗，19.2%在住院期间接受有创机械通气。种族和族裔少数患者从急诊室入院的可能性较高（亚洲或太平洋岛民患者：比值比 [OR]，1.43 [95% CI，1.20-1.72]；P < .001；黑人患者：OR，1.39 [95% CI，1.27-1.52]；P < .001；西班牙裔患者： OR，1.45 [95% CI，1.28-1.64]；P < .001），接受有创机械通气（黑人患者：OR，1.59 [95% CI，1.44-1.75]；P < .001），并产生更高的总费用（亚洲或太平洋岛民患者：OR，1.35 [95% CI， 1.13-1.60]；P = .001；与白人患者相比，黑人患者：OR，1.23 [95% CI，1.13-1.34]；P < .001；西班牙裔患者：OR，1.50 [95% CI，1.34-1.69]；有私人保险的患者从急诊室入院（OR，0.47 [95% CI，0.44-0.51]；P < .001）、接受有创机械通气（OR，0.75 [95% CI，0.69-0.82]；P < .001）以及产生较高总费用（OR，0.64）的可能性较低[95% CI, 0.59-0.68]；与 Medicare 和 Medicaid 受益人相比，P < .001。在这项研究中，来自种族和族裔群体的转移性癌症患者以及拥有医疗保险或医疗补助覆盖的患者更有可能在生命结束时接受低价值、积极的干预措施。需要进一步研究来评估与临终差异相关的潜在因素，以实施前瞻性干预措施。这项横断面研究使用 2010 年至 2017 年间医疗保健成本和利用项目全国住院患者样本的数据来检查成年转移性癌症患者在终末住院期间的护理管理模式。
Is variation in care management during terminal hospitalization among adults with metastatic cancer associated with sociodemographic status? In this cross-sectional study of 21 335 patients with metastatic cancer who died in the hospital, racial and ethnic minority patients and those with Medicare or Medicaid coverage were more likely to receive low-value, high-cost aggressive medical interventions at the end of life. This study’s findings suggest that identifying and understanding factors associated with the observed disparities will be helpful to inform communications with patients with metastatic cancer about end-of-life care. Many patients with metastatic cancer receive high-cost, low-value care near the end of life. Identifying patients with a high likelihood of receiving low-value care is an important step to improve appropriate end-of-life care. To analyze patterns of care and interventions during terminal hospitalizations and examine whether care management is associated with sociodemographic status among adult patients with metastatic cancer at the end of life. This retrospective, population-based cross-sectional study used data from the Healthcare Cost and Utilization Project to analyze all-payer, encounter-level information from multiple inpatient centers in the US. All utilization and hospital charge records from national inpatient sample data sets between January 1, 2010, and December 31, 2017 (n = 58 761 097), were screened. The final cohort included 21 335 patients 18 years and older at inpatient admission who had a principal diagnosis of metastatic cancer and died during hospitalization. Data for the current study were analyzed from January 1, 2010, to December 31, 2017. Patient demographic characteristics, patient insurance status, hospital location, and hospital teaching status. Receipt of systemic therapy (including chemotherapy and immunotherapy), receipt of invasive mechanical ventilation, emergency department (ED) admission, time from hospital admission to death, and total charges during a terminal hospitalization. Among 21 335 patients with metastatic cancer who had terminal hospitalizations between 2010 and 2017, the median age was 65 years (interquartile range, 56-75 years); 54.0% of patients were female; 0.5% were American Indian, 3.3% were Asian or Pacific Islander, 14.1% were Black, 7.5% were Hispanic, 65.9% were White, and 3.1% were identified as other; 58.2% were insured by Medicare or Medicaid, and 33.2% were privately insured. Overall, 63.2% of patients were admitted from the ED, 4.6% received systemic therapy, and 19.2% received invasive mechanical ventilation during hospitalization. Racial and ethnic minority patients had a higher likelihood of being admitted from the ED (Asian or Pacific Islander patients: odds ratio [OR], 1.43 [95% CI, 1.20-1.72]; P < .001; Black patients: OR, 1.39 [95% CI, 1.27-1.52]; P < .001; and Hispanic patients: OR, 1.45 [95% CI, 1.28-1.64]; P < .001), receiving invasive mechanical ventilation (Black patients: OR, 1.59 [95% CI, 1.44-1.75]; P < .001), and incurring higher total charges (Asian or Pacific Islander patients: OR, 1.35 [95% CI, 1.13-1.60]; P = .001; Black patients: OR, 1.23 [95% CI, 1.13-1.34]; P < .001; and Hispanic patients: OR, 1.50 [95% CI, 1.34-1.69]; P < .001) compared with White patients. Privately insured patients had a lower likelihood of being admitted from the ED (OR, 0.47 [95% CI, 0.44-0.51]; P < .001), receiving invasive mechanical ventilation (OR, 0.75 [95% CI, 0.69-0.82]; P < .001), and incurring higher total charges (OR, 0.64 [95% CI, 0.59-0.68]; P < .001) compared with Medicare and Medicaid beneficiaries. In this study, patients with metastatic cancer from racial and ethnic minority groups and those with Medicare or Medicaid coverage were more likely to receive low-value, aggressive interventions at the end of life. Further studies are needed to evaluate the underlying factors associated with disparities at the end of life to implement prospective interventions. This cross-sectional study uses data from the Healthcare Cost and Utilization Project national inpatient sample between 2010 and 2017 to examine care management patterns during terminal hospitalization among adult patients with metastatic cancer.
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