july 2020 • BMJ
Association between palliative care and healthcare outcomes among adults with terminal non-cancer illness: population based matched cohort study
Haverá correlação entre cuidados paliativos e melhor saúde em adultos com doença terminal não oncológica? Cuidados paliativos em adultos com doenças terminais não oncológicas (insuf. cardíaca, DPOC, DRC, cirrose, AVC ou fragilidade/demência) associam-se a menos episódios de urgência, menos admissões hospitalares e menos admissões em UCI, maior probabilidade de morte em casa ou casa de repouso em vez de no hospital. É razoável admitir que acesso a cuidados paliativos provoque maior qualidade de vida no final da mesma e as políticas de saúde devem promover maior desenvolvimento desta oferta.
Em Ontario, Canada, 113540 adultos que sofriam de doenças não oncológicas (insuf. cardíaca, DPOC, DRC, cirrose, AVC ou fragilidade/demência) a quem foi iniciado de novo cuidados paliativos nos últimos 6 meses de vida.
Estudo coorte com controlo de base populacional. Os dados demográficos e clínicos foram obtidos de bases de dados centrais que permitiram escolher controlos com semelhante causa de morte, risco de fragilidade hospitalar, presença de cancro metastizado, região de residência e um propensity score para probabilidade de receber cuidados paliativos (calculado pela idade e género). Avaliaram: número de episódio de urgência; hospitalizações, admissões noas UCI, probabilidade de morte em casa vs hospitalar após primeira consulta de cuidados paliativos (ajustada a características dos doentes)
Cuidados paliativos foram associados a menos episódios de urgência, menos admissões hospitalares e menos admissões em UCI, maior probabilidade de morte em casa ou casa de repouso em vez de no hospital.
Objective To measure the associations between newly initiated palliative care in the last six months of life, healthcare use, and location of death in adults dying from non-cancer illness, and to compare these associations with those in adults who die from cancer at a population level. Design Population based matched cohort study. Setting Ontario, Canada between 2010 and 2015. Participants 113 540 adults dying from cancer and non-cancer illness who were given newly initiated physician delivered palliative care in the last six months of life administered across all healthcare settings. Linked health administrative data were used to directly match patients on cause of death, hospital frailty risk score, presence of metastatic cancer, residential location (according to 1 of 14 local health integration networks that organise all healthcare services in Ontario), and a propensity score to receive palliative care that was derived by using age and sex. Main outcome measures Rates of emergency department visits, admissions to hospital, and admissions to the intensive care unit, and odds of death at home versus in hospital after first palliative care visit, adjusted for patient characteristics (such as age, sex, and comorbidities). Results In patients dying from non-cancer illness related to chronic organ failure (such as heart failure, cirrhosis, and stroke), palliative care was associated with reduced rates of emergency department visits (crude rate 1.9 (standard deviation 6.2) v 2.9 (8.7) per person year; adjusted rate ratio 0.88, 95% confidence interval 0.85 to 0.91), admissions to hospital (crude rate 6.1 (standard deviation 10.2) v 8.7 (12.6) per person year; adjusted rate ratio 0.88, 95% confidence interval 0.86 to 0.91), and admissions to the intensive care unit (crude rate 1.4 (standard deviation 5.9) v 2.9 (8.7) per person year; adjusted rate ratio 0.59, 95% confidence interval 0.56 to 0.62) compared with those who did not receive palliative care. Additionally increased odds of dying at home or in a nursing home compared with dying in hospital were found in these patients (n=6936 (49.5%) v n=9526 (39.6%); adjusted odds ratio 1.67, 95% confidence interval 1.60 to 1.74). Overall, in patients dying from dementia, palliative care was associated with increased rates of emergency department visits (crude rate 1.2 (standard deviation 4.9) v 1.3 (5.5) per person year; adjusted rate ratio 1.06, 95% confidence interval 1.01 to 1.12) and admissions to hospital (crude rate 3.6 (standard deviation 8.2) v 2.8 (7.8) per person year; adjusted rate ratio 1.33, 95% confidence interval 1.27 to 1.39), and reduced odds of dying at home or in a nursing home (n=6667 (72.1%) v n=13 384 (83.5%); adjusted odds ratio 0.68, 95% confidence interval 0.64 to 0.73). However, these rates differed depending on whether patients dying with dementia lived in the community or in a nursing home. No association was found between healthcare use and palliative care for patients dying from dementia who lived in the community, and these patients had increased odds of dying at home. Conclusions These findings highlight the potential benefits of palliative care in some non-cancer illnesses. Increasing access to palliative care through sustained investment in physician training and current models of collaborative palliative care could improve end-of-life care, which might have important implications for health policy.