Does receipt of hospice care in nursing homes improve the management of pain at the end of life?
Does receipt of hospice care in nursing homes improve the management of pain at the end of life?
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DOI：
10.1046/j.1532-5415.2002.50118.x
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发表时间：
2002-03-01
影响因子：
6.3
通讯作者：
Lapane, K
中科院分区：
文献类型：
--
作者：
Miller, SC;Mor, V;Lapane, K
目的：比较参加和未参加联邦医疗保险临终关怀的临终疗养院居民对日常疼痛的止痛处理。设计：回顾、比较队列研究。集合：堪萨斯州、缅因州、密西西比州、纽约和南达科他州的800多家疗养院。研究对象：来自临终关怀(2644)和非临终关怀(7929)的匹配队列的临终疼痛的疗养院居民，他们至少完成了两次居民评估(最小数据集(MDS))，最后一次是在1992年至1996年之间，并且在1997年4月之前死亡。每日疼痛亚组包括709名临终关怀和1,326名非临终关怀住院患者。测量：使用死亡前最后一次MDS的详细药物使用数据来检查日常疼痛的止痛管理。美国医学主任协会(AMDA)的指南被用来确定在长期护理环境中不推荐用于控制慢性疼痛的止痛药。结果：15%的临终关怀住院患者和23%的非临终关怀住院患者没有使用止痛药(优势比(OR)=0.57，95%可信区间(CI)=0.45-0.74)。临终关怀住院患者(21%)接受AMDA不推荐的止痛药的比例(21%)低于非临终关怀住院患者(29%)(OR=0.65，9s%CI=0.52-0.80)。总体而言，对乙酰氨基酚(不与其他药物联合使用)最常用于非临终关怀居民(1673张处方中的25%)，而吗啡衍生物最常用于临终关怀居民(1058张处方中的30%)。51%的临终关怀居民和33%的非临终关怀居民接受了日常疼痛的定期治疗。在控制临床混杂因素的情况下，临终关怀住院病人因日常疼痛接受常规治疗的可能性是非临终关怀住院病人的两倍(调整后的优势比=2.08，95%CI=1.68-2.56)。结论：研究结果表明，入住临终关怀的疗养院住院病人比未登记临终关怀的疗养院住院病人对日常疼痛的止痛管理更好。这项研究描述的处方实践表明，许多日常疼痛的疗养院临终居民没有接受止痛治疗，或者正在接受与AMDA和其他疼痛管理指南不一致的止痛治疗。如果要在疗养院实现高质量的临终关怀，改善疗养院疼痛的止痛管理至关重要。
OBJECTIVES: To compare analgesic management of daily pain for dying nursing home residents enrolled and not enrolled in Medicare hospice.DESIGN: Retrospective, comparative cohort study.SETTING: Over 800 nursing homes in Kansas, Maine, Mississippi, New York, and South Dakota.PARTICIPANTS: A subset of residents with daily pain near the end of life taken from a matched cohort of hospice (2,644) and nonhospice (7,929) nursing home residents who had at least two resident assessments (Minimum Data Sets (MDSs)) completed, their last between 1992 and 1996, and who died before April 1997. The daily pain subset consisted of 709 hospice and 1,326 nonhospice residents.MEASUREMENTS: Detailed drug use data contained on the last MDS before death were used to examine analgesic management of daily pain. Guidelines from the American Medical Directors Association (AMDA) were used to identify analgesics not recommended for use in managing chronic pain in long-term care settings. The stud), outcome, regular treatment of daily pain, examined whether patients received any analgesic, other than those not recommended by AMDA, at least twice a day for each day of documented daily pain (i.e., 7 days before date of last MDS).RESULTS: Fifteen percent of hospice residents and 23% of nonhospice residents in daily pain received no analgesics (odds ratio (OR) = 0.57, 95% confidence interval (CI) = 0.45-0.74). A lower proportion of hospice residents (21%) than of nonhospice residents (29%) received analgesics not recommended by AMDA (OR = 0.65, 9S% CI = 0.52-0.80). Overall, acetaminophen (not in combination with other drugs) was used most frequently for nonhospice residents (25% of 1,673 prescriptions), whereas morphine derivatives were used most frequently for hospice residents (30% of 1,058 prescriptions). Fifty-one percent of hospice residents and 33% of nonhospice residents received regular treatment for daily pain. Controlling for clinical confounders, hospice residents were twice as likely as nonhospice residents to receive regular treatment for daily pain (adjusted odds ratio = 2.08, 95% CI = 1.68-2.56).CONCLUSION: Findings suggest that analgesic management of daily pain is better for nursing home residents enrolled in hospice than for those not enrolled in hospice. The prescribing practices portrayed by this study reveal that many dying nursing home residents in daily pain are receiving no analgesic treatment or are receiving analgesic treatment inconsistent with AMDA and other pain management guidelines. Improving the analgesic management of pain in nursing homes is essential if high-quality end-of-life care in nursing homes is to be achieved.