Functional outcomes after critical illness in the elderly.
Functional outcomes after critical illness in the elderly.
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老年人危重疾病后的功能结果。
DOI：
10.1097/ccm.0000000000001026
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发表时间：
2015
影响因子：
8.8
通讯作者：
Eckenhoff,RodericG
中科院分区：
文献类型：
--
作者：
Neuman,MarkD;Eckenhoff,RodericG
老年人危重疾病后的功能结果住房状况与健康之间的关系，倾向匹配的独特使用表明，无家可归的病人没有额外的后遗症，特别是他们的无家可归，确实受益于同样的照顾。事实上，这一发现本身就非常有趣，值得注意，毫无疑问将成为讨论和进一步研究的动力。围绕这一领域的文献和普遍的口头禅表明，无家可归的病人医疗保健差，慢性病负担更重，结果更糟（2,4）。这种“贫穷之病”已被广泛报道，可以肯定地说，人们普遍认为这种病做得不好。这到底是因为这些病人的某些固有因素，还是因为他们的健康状况与总体人口相比普遍较差，迄今为止还没有得到评估。倾向匹配表明，病人本身并没有无家可归的痛苦，但他们与同样住得不好的病人相似。因此，作者得出结论，无家可归是有问题的，因为它阻碍了获得医疗保健的机会，并导致慢性疾病的队列，但这些患者或他们应该在ICU接受的护理本质上没有什么不同。尽管这些发现令人感兴趣，但这些患者的匹配仍然存在一些问题。事实上，匹配病人的疾病严重程度，然后暗示这些病人同样受益于ICU护理，这在很大程度上是基于治疗这种严重程度，可能构成一个循环论证。当然，没有办法评估这一点，因为这些病人是适合他们的匹配。对于我们这些经常照顾无家可归和贫穷病人的人来说，他们缺乏事先的照顾，而且合并症的增加导致病人“病情加重”，结果也很困难。也许通过诊断匹配或前瞻性地将患者纳入观察性试验是有必要的，只有跨多个中心的更大队列才能评估文章的主要发现是固有的真理还是匹配方法的结果。最后也是值得大量讨论的是归因风险问题。事实上，可改变风险（可能是由于住房状况和社会经济地位）和不可改变风险（到达ICU时的疾病严重程度）的差异以及这种风险的动态（例如，一旦患者进入ICU，无家可归的后遗症是否可以得到解决）是这篇重要文章阐明的关键问题。我希望这篇文章开始对人口统计和社会经济对类似严重程度的疾病的影响进行更大的讨论和分析，而不是培养一种信念，即所有患者在进入ICU时都是一样的，只是根据他们的疾病和严重程度进行区分。
Functional Outcomes After Critical Illness in the Elderly* associations between housing status and health, the unique use of propensity matching suggests that homeless patients have no additional sequelae specifically from their homelessness and indeed benefit from the same care. Indeed, this finding alone is extremely interesting and worthy of note and will no doubt be an impetus for discussion and additional study. The literature surrounding this area and general mantra suggests that homeless patients have poor medical care, a greater burden of chronic disease, and worsened outcomes (2, 4). This “disease of poverty” has been widely reported, and it is safe to say generally believed to do poorly. Whether this was because of something inherent in these patients or because of a generally worse health compared with the overall population has something that has not been evaluated until now. Propensity matching suggests that patients do not indeed suffer inherently from being homeless but are similar to equally ill-housed patients. Hence, the authors conclude that homelessness is problematic in that it prevents access to health care and results in a chronically ill cohort but that there is nothing inherently different about these patients or the care they should get in the ICU. Although these findings are of interest, there remain some questions about the matching of these patients. Indeed, matching patients’ illness severity and then suggesting that these patients benefit similarly from ICU care, which is based on a large part on treating that severity, could constitute a circular argument. Of course, there is no way to assess this because these patients are fit on their matching. For those of us who regularly care for homeless and poor patients, it does seem anecdotally as they lack prior care, and increased comorbidities result in a “sicker” patient and difficult outcomes. Perhaps matching via diagnosis or prospectively enrolling patients into an observational trial is warranted Only a larger cohort across multiple centers can assess whether the main finding of the article is an inherent truth or is a result of the matching methodology. Finally and worthy of considerable discussion is the issue of attributable risk. Indeed, the difference of modifiable risk (potentially due to housing status and socieoeconomic status) and non–modifiable risk (disease severity upon arrival in the ICU) and the dynamics of this risk (eg, whether the sequelae of homelessness can be addressed once the patient is in the ICU) are the crucial question illuminated by this important article. I hope that rather than fostering the belief that all patients are the same when they enter the ICU to be differentiated only upon their illness and severity, this article begins a larger discussion and analysis of the demographics and socieoeconomic impact on illness of similar severity.