手术气道对头颈癌患者死亡地点、医疗资源利用及费用的影响：一项基于人群的研究

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中文摘要

背景： 拥有手术气道的患者在获得高质量临终（EOL）照护方面面临障碍。识别手术气道患者在医疗资源利用和死亡地点方面的差异，可能有助于改善临终照护服务的提供。本研究旨在比较有和无手术气道的头颈癌（HNC）患者在生命最后90天内的死亡地点及选定的医疗照护方面。
方法： 一项回顾性死者队列研究，使用加拿大安大略省临床评估科学研究所的健康行政数据，纳入2008年1月1日至2018年12月31日期间死亡的头颈癌患者。暴露组包括在死亡前任何时间接受全喉切除术或在死亡前90天内接受急诊气管造口术的患者。主要结局包括死亡地点、住院时间、姑息治疗就诊次数以及生命最后90天内负担沉重的照护转换。次要结局包括生命最后90天内的医疗费用。
结果： 有手术气道的患者（n=1280，7.8%）比无手术气道的患者更可能在亚急性照护中心死亡（OR=1.51 [95% CI: 1.26-1.81]，p<0.001）。两组在急性照护机构死亡（OR=1.11 [95% CI: 0.97-1.27]，p=0.14）或长期照护机构死亡（OR=0.85 [95% CI: 0.62-1.16]，p=0.30）方面无显著差异。在生命最后90天内，他们在急性照护医院停留的时间更长（6.37天 [95% CI: 5.40-7.39]，p<0.001），经历负担沉重照护转换的几率更高（OR=1.46 [95% CI: 1.29-1.67]，p<0.001），且其照护相关费用更高（平均费用比=1.43 [95% CI: 1.36-1.51]，p<0.001）。然而，在调整协变量后，有和无手术气道的患者在姑息治疗参与方面无统计学显著差异（OR=1.14 [95% CI: 0.98-1.31]，p=0.09）。
结论： 有手术气道的患者更可能在亚急性照护中心死亡，并且在生命最后90天内经历了更高的医疗资源利用，包括更长的住院时间、更高的负担沉重照护转换率以及更高的费用。调整后，两组在姑息治疗参与方面无统计学显著差异。这些发现应谨慎解读，因为由于数据缺失，无法对疾病分期和肿瘤部位进行调整。需要进一步研究以更好地理解这些差异的潜在驱动因素及其对临终照护的影响。

英文摘要

BACKGROUND: Patients with surgical airways experience barriers to high quality end-of-life (EOL) care. Recognizing differences in healthcare utilization and location of death among patients with surgical airways may inform improvements in EOL care delivery. This study aimed to compare location of death and selected aspects of healthcare in the last 90 days of life between head and neck cancer (HNC) patients with and without a surgical airway.
METHODS: Retrospective decedent cohort study of health administrative data from the Institute of Clinical Evaluative Sciences in Ontario, Canada of individuals with HNC who died between January 1, 2008, and December 31, 2018. The exposure group included those with a total laryngectomy any time prior to death or emergency tracheostomy within 90 days prior to death. Primary outcomes included location of death and length of stay in hospital, palliative care encounters, and burdensome transitions of care in the last 90 days of life. Secondary outcomes included healthcare costs during the last 90 days of life.
RESULTS: Patients with surgical airways (n = 1280, 7.8%) were more likely to die in a subacute care center (OR = 1.51 [95% CI: 1.26-1.81], p < 0.001) than those without surgical airways. There were no significant differences between the groups for deaths occurring in acute care (OR = 1.11 [95% CI: 0.97-1.27], p = 0.14) or long-term care settings (OR = 0.85 [95% CI: 0.62-1.16], p = 0.30). In the last 90 days of life, they spent more time in acute care hospitals (6.37 days [95% CI: 5.40-7.39], p < 0.001), had higher odds of experiencing burdensome transitions (OR = 1.46 [95% CI: 1.29-1.67], p < 0.001) and had greater costs associated with their care (mean cost ratio = 1.43 [95% CI: 1.36-1.51], p < 0.001). However, after adjusting for covariates, there was no statistically significant difference in palliative care involvement between patients with and without surgical airways (OR = 1.14 [95% CI: 0.98-1.31], p = 0.09).
CONCLUSIONS: Patients with surgical airways were more likely to die in subacute care centers and experienced increased healthcare utilization, including longer hospital stays, higher rates of burdensome transitions, and greater costs in the last 90 days of life. There was no statistically significant difference in palliative care involvement between groups after adjustment. These findings should be interpreted with caution, as adjustment for disease stage and tumor site was not possible due to missing data. Further research is needed to better understand the underlying drivers of these differences and their implications for EOL care.