Integration of palliative and supportive care in the management of advanced liver disease: development and evaluation of a prognostic screening tool and supportive care intervention
Integration of palliative and supportive care in the management of advanced liver disease: development and evaluation of a prognostic screening tool and supportive care intervention
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DOI：
10.1136/flgastro-2016-100734
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发表时间：
2017-01-01
影响因子：
2.6
通讯作者：
McCune, C. Anne
中科院分区：
文献类型：
--
作者：
Hudson, Benjamin E.;Ameneshoa, Kelly;McCune, C. Anne
背景与目的
失代偿性肝硬化患者很少接受姑息治疗和支持性护理干预，而这些干预措施在其他危及生命的疾病中是常规的。我们旨在设计并评估一种预后筛查工具，以便常规识别在未来一年有高死亡风险的失代偿性肝硬化住院患者，同时开发一种支持性护理干预措施。
设计
对布里斯托大学医院在两个不同的90天期间因肝硬化急诊入院的连续患者的临床记录进行回顾性审查，以确定是否存在与不良预后相关的五个基于证据的因素。根据这些因素预测1年死亡率的能力进行分析。采用“计划 - 实施 - 研究 - 行动”（PDSA）方法将不良预后筛查纳入肝硬化入院患者的常规评估中，并开发一种支持性护理干预措施。
结果
对73例入院患者进行了审查（79.5%为男性，63%为酒精相关性肝病，中位年龄54岁）。入院时存在三个或更多不良预后标准可预测1年死亡率，其敏感性、特异性和阳性预测值分别为72.2%、83.8%和81.3%，并被用作实施支持性护理干预的触发因素。经过六个PDSA循环的改进，预后筛查被纳入所有失代偿性肝硬化入院患者的评估中，同时对合适的患者启动了（同时开发的）支持性护理干预措施。
结论
我们描述了一种护理模式，该模式可识别在未来一年有显著死亡风险的肝硬化住院患者，并描述了一种支持性护理干预措施的开发，该措施可在持续积极治疗的同时提供给合适的患者。
Background and objectives Patients with decompensated cirrhosis rarely receive palliative and supportive care interventions, which are routine in other life-limiting diseases. We aimed to design and evaluate a prognostic screening tool to routinely identify inpatients with decompensated cirrhosis at high risk of dying over the coming year, alongside the development of a supportive care intervention.Design Clinical notes from consecutive patients admitted as an emergency to University Hospitals Bristol with a diagnosis of cirrhosis over two distinct 90-day periods were scrutinised retrospectively for the presence or absence of five evidence-based factors associated with poor prognosis. These were analysed against their ability to predict mortality at 1 year. 'Plan-Do-Study-Act' (PDSA) methodology was used to incorporate poor-prognosis screening into the routine assessment of patients admitted with cirrhosis, and develop a supportive care intervention.Results 73 admissions were scrutinised (79.5% male, 63% alcohol-related liver disease, median age 54). The presence of three or more poor-prognosis criteria at admission predicted 1-year mortality with sensitivity, specificity and positive predictive value of 72.2%, 83.8% and 81.3%, respectively, and was used as a trigger for implementing the supportive care intervention. Following modification from six PDSA cycles, prognostic screening was integrated into the assessment of all patients admitted with decompensated cirrhosis, with the supportive care intervention (developed simultaneously) instigated for appropriate patients.Conclusions We describe a model of care which identifies inpatients with cirrhosis at significant risk of dying over the coming year, and describe development of a supportive care intervention, which can be offered to suitable patients in parallel to ongoing active management.