美国纽约大学Keith S. Goldfeld团队研究了医院急诊科启动姑息治疗对严重生命限制性疾病老年人的预后影响。这一研究成果发表在2025年1月15日出版的《美国医学会杂志》上。

急诊科（ED）为患有严重生命限制性疾病的老年人提供了启动姑息治疗的机会。

为了评估在急诊室启动姑息治疗的多因素干预对患有严重生命限制性疾病的老年人的住院、随后的医疗保健使用和生存的影响，研究组进行了一项集群随机、阶梯式楔形临床试验，招募2018年5月1日至2022年12月31日在美国29个急诊室中就诊的66岁或以上患者，他们之前有12个月的医疗保险登记，Gagne共病评分大于6，表示短期死亡风险大于30%。疗养院患者被排除在外。

多因素干预（急诊医学初级姑息治疗干预）包括：（1）循证多学科教育；（2） 基于模拟的重症沟通研讨会；（3） 临床决策支持；（4）ED临床工作人员的审计和反馈。主要结局是住院。次要结局包括随后的医疗保健使用和6个月的生存率。

在研究期间，有98922次初次急诊就诊（中位年龄，77岁[IQR，71-84岁]；50%为女性；13%为黑人，78%为白人；Gagne共病评分中位数为8[IQR、7-10]）。干预前住院率为64.4%，干预后住院率为61.3%（绝对差异为-3.1%[95%置信区间，-3.7%至-2.5%]；调整后的比值比[OR]为1.03[95%置信范围，0.93至1.14]）。干预前后的次要结局没有差异。干预前重症监护室的入院率为7.8%，干预后为6.7%（调整后的OR为0.98[95%CI为0.83至1.15]）。

干预前至少一次再次就诊ED的比例为34.2%，干预后为32.2%（调整后的OR为1.00[95%CI为0.91至1.09]）。干预前和干预后的临终关怀使用率分别为17.7%和17.2%（调整后的OR为1.04[95%CI为0.93至1.16]）。干预前家庭健康使用率为42.0%，干预后为38.1%（调整后的OR为1.01[95%CI为0.92至1.10]）。干预前至少1次再次入院的比率为41.0%，干预后为36.6%（调整后的OR为1.01[95%CI为0.92至1.10]）。干预前和干预后的死亡率分别为28.1%和28.7%（调整后的OR为1.07[95%CI为0.98至1.18]）。

研究结果表明，这种在急诊室启动姑息治疗的多因素干预对患有严重生命限制性疾病的老年人的住院、随后的医疗保健使用或短期死亡率没有影响。

附：英文原文

Title: Palliative Care Initiated in the Emergency Department: A Cluster Randomized Clinical Trial

Author: Corita R. Grudzen, Nina Siman, Allison M. Cuthel, Oluwaseun Adeyemi, Rebecca Liddicoat Yamarik, Keith S. Goldfeld, PRIM-ER Investigators, Benjamin S. Abella, Fernanda Bellolio, Sorayah Bourenane, Abraham A. Brody, Lauren Cameron-Comasco, Joshua Chodosh, Julie J. Cooper, Ashley L. Deutsch, Marie Carmelle Elie, Ahmed Elsayem, Rosemarie Fernandez, Jessica Fleischer-Black, Mauren Gang, Nicholas Genes, Rebecca Goett, Heather Heaton, Jacob Hill, Leora Horwitz, Eric Isaacs, Karen Jubanyik, Sangeeta Lamba, Katharine Lawrence, Michelle Lin, Caitlin Loprinzi-Brauer, Troy Madsen, Joseph Miller, Ada Modrek, Ronny Otero, Kei Ouchi, Christopher Richardson, Lynne D. Richardson, Matthew Ryan, Elizabeth Schoenfeld, Matthew Shaw, Ashley Shreves, Lauren T. Southerland, Audrey Tan, Julie Uspal, Arvind Venkat, Laura Walker, Ian Wittman, Erin Zimny

Issue&Volume: 2025-01-15

Abstract:

Importance  The emergency department (ED) offers an opportunity to initiate palliative care for older adults with serious, life-limiting illness.

Objective  To assess the effect of a multicomponent intervention to initiate palliative care in the ED on hospital admission, subsequent health care use, and survival in older adults with serious, life-limiting illness.

Design, Setting, and Participants  Cluster randomized, stepped-wedge, clinical trial including patients aged 66 years or older who visited 1 of 29 EDs across the US between May 1, 2018, and December 31, 2022, had 12 months of prior Medicare enrollment, and a Gagne comorbidity score greater than 6, representing a risk of short-term mortality greater than 30%. Nursing home patients were excluded.

Intervention  A multicomponent intervention (the Primary Palliative Care for Emergency Medicine intervention) included (1) evidence-based multidisciplinary education; (2) simulation-based workshops on serious illness communication; (3) clinical decision support; and (4) audit and feedback for ED clinical staff.

Main Outcome and Measures  The primary outcome was hospital admission. The secondary outcomes included subsequent health care use and survival at 6 months.

Results  There were 98922 initial ED visits during the study period (median age, 77 years [IQR, 71-84 years]; 50% were female; 13% were Black and 78% were White; and the median Gagne comorbidity score was 8 [IQR, 7-10]). The rate of hospital admission was 64.4% during the preintervention period vs 61.3% during the postintervention period (absolute difference, 3.1% [95% CI, 3.7% to 2.5%]; adjusted odds ratio [OR], 1.03 [95% CI, 0.93 to 1.14]). There was no difference in the secondary outcomes before vs after the intervention. The rate of admission to an intensive care unit was 7.8% during the preintervention period vs 6.7% during the postintervention period (adjusted OR, 0.98 [95% CI, 0.83 to 1.15]). The rate of at least 1 revisit to the ED was 34.2% during the preintervention period vs 32.2% during the postintervention period (adjusted OR, 1.00 [95% CI, 0.91 to 1.09]). The rate of hospice use was 17.7% during the preintervention period vs 17.2% during the postintervention period (adjusted OR, 1.04 [95% CI, 0.93 to 1.16]). The rate of home health use was 42.0% during the preintervention period vs 38.1% during the postintervention period (adjusted OR, 1.01 [95% CI, 0.92 to 1.10]). The rate of at least 1 hospital readmission was 41.0% during the preintervention period vs 36.6% during the postintervention period (adjusted OR, 1.01 [95% CI, 0.92 to 1.10]). The rate of death was 28.1% during the preintervention period vs 28.7% during the postintervention period (adjusted OR, 1.07 [95% CI, 0.98 to 1.18]).

Conclusions and Relevance  This multicomponent intervention to initiate palliative care in the ED did not have an effect on hospital admission, subsequent health care use, or short-term mortality in older adults with serious, life-limiting illness.

DOI: 10.1001/jama.2024.23696

Source: https://jamanetwork.com/journals/jama/fullarticle/2829286