Characteristics and Trends Among Patients With Cardiovascular Disease Referred to Palliative Care
Characteristics and Trends Among Patients With Cardiovascular Disease Referred to Palliative Care
复制标题
DOI：
10.1001/jamanetworkopen.2019.2375
复制
发表时间：
2019-05-01
影响因子：
13.8
通讯作者：
Kamal, Arif H.
中科院分区：
文献类型：
--
作者：
Warraich, Haider J.;Wolf, Steven P.;Kamal, Arif H.
近年来，姑息治疗(PC)对心血管疾病(CVD)患者的重要性有所增加。然而，尚不清楚患者是否收到了更早转诊至PCC.OBJECTIVE，以评估参考PC的CVD患者的特征和趋势。设计、设置和参与者队列研究中，对2015年1月2日至2017年12月29日期间来自姑息治疗登记的多中心质量数据收集工具的数据进行分析，包括18岁或18岁以上的CVD患者，参考具有记录的姑息表现评分(PPS)的初始PC会诊。EXPOSURE CVD患者首次PC访问。MAIN结果和测量主要结果为PPS。结果来自16个地点的1801名患者(平均年龄77.7[13.7]岁)中，875名(48.6%)为女性，1339名(74.3%)为白人。521名患者(28.9%)的PPS评分较低(0%-30%)，与卧床状态一致，且没有随时间的变化。最常见的中到重度症状是幸福感差、疲倦、食欲不振和呼吸困难。相遇的年份与疼痛症状的改善(优势比，1.25；95%可信区间，1.05-1.50)和便秘(优势比，1.32；95%可信区间，1.03-1.69)有关。在其他症状或生命终结文件中，没有随着时间的推移而变化。虽然来自全科医学的转诊比例从2015年的43.2%(387例中的167例)上升到2017年的52.9%(775例中的410例)，但来自心脏病医生的转诊比例从2015年的16.5%(387例中的)下降到2017年的10.5%(775例中的81例)。转诊为PC的黑人患者比例从2015年的11.9%(387人中的46人)下降到2017年的6.3%(775人中的49人)。虽然69.5%的CVD患者(1801年的1252例)有心力衰竭的初诊，但非心力衰竭的CVD诊断比例，如冠状动脉疾病和瓣膜心脏病，从2015年的25.6%(99/387)上升到2017年的30.1%(233/775)。结论与CVD相关的患者表现出明显的症状负担，随着时间的推移，转诊至PC的CVD患者的PPS没有变化的证据。心脏病专家为心血管疾病患者提供的PC转诊相对较少，而且这一比例随着时间的推移而下降。提交PC的种族和少数民族的比例很小，并随着时间的推移而下降。这些发现加强了心脏病专家更多地接触PC的必要性，并考虑更早地转介适当的CVD患者。
IMPORTANCE Use of palliative care (PC) for patients with cardiovascular disease (CVD) has increased recently. However, it is unknown if patients are receiving earlier referrals to PC.OBJECTIVE To assess characteristics and trends of patients with CVD referred to PC.DESIGN, SETTING, AND PARTICIPANTS Cohort study in which analysis of data from the multicenter Quality Data Collection Tool for Palliative Care registry from January 2, 2015, through December 29, 2017, included patients with CVD 18 years or older referred to initial PC consultation who had a documented palliative performance score (PPS).EXPOSURES Patients with CVD who presented for an initial PC visit.MAIN OUTCOMES AND MEASURES The primary outcome was PPS. Secondary outcomes included symptoms and end-of-life documentation.RESULTS Among 1801 patients (mean [SD] age, 77.7 [13.7] years) from 16 sites in the analysis, 875 (48.6%) were women and 1339 (74.3%) were white. A low PPS score (0%-30%), consistent with bedbound status, was recorded for 521 patients (28.9%), with no change through time. The most common moderate to severe symptoms were poor well-being, tiredness, anorexia, and dyspnea. Year of encounter was associated with improved symptoms of pain (odds ratio, 1.25; 95% CI, 1.05-1.50) and with constipation (odds ratio, 1.32; 95% CI, 1.03-1.69). No change through time was noted in other symptoms or end-of-life documentation. Although the proportion of referrals from general medicine increased from 43.2%(167 of 387) in 2015 to 52.9% (410 of 775) in 2017, the proportion of referrals from cardiologists decreased from 16.5%(64 of 387) in 2015 to 10.5%(81 of 775) in 2017. The proportion of patients referred to PC who were black decreased from 11.9%(46 of 387) in 2015 to 6.3%(49 of 775) in 2017. While 69.5% of all patients with CVD (1252 of 1801) had a primary diagnosis of heart failure, the proportion of non-heart failure CVD diagnoses, such as coronary artery disease and valvular heart disease, increased from 25.6%(99 of 387) in 2015 to 30.1%(233 of 775) in 2017.CONCLUSIONS AND RELEVANCE Patients with CVD demonstrated significant symptom burden, and there was no evidence in the registry of change in the PPSs of patients with CVD referred to PC through time. Cardiologists provided comparatively fewer referrals to PC for patients with CVD, and this proportion decreased through time. The proportion of racial and ethnic minorities referred to PC was small and decreased through time. These findings reinforce the need for cardiologists to be more engaged with PC and consider referring appropriate patients with CVD sooner.