乌鸦传媒

Palliative care and hospice for ischemic stoke patients has been rising over the past decade, with their outcomes improving nationally over time as well, researchers found.

Comfort care interventions for patients hospitalized with ischemic stroke rose 4.8-fold by 2014-2015 compared with 2006-2007, although the overall rate was still just 3.8% across that entire study period.

This significant increase was progressive, reported Farhaan Vahidy, PhD, MBBS, MPH, of the Houston Methodist Neurological Institute, and colleagues . Adjusted odds compared with 2006-2007 were:

• 1.87 for 2008-2009
• 3.07 for 2010-2011
• 4.15 for 2012-2013
• 4.80 for 2014-2015

"Comfort care is becoming an increasingly important component of stroke care, and further studies are warranted to reduce disparities and optimize access, outcomes, and costs for those who need it," the researchers concluded.

That increase in use was despite increased acute care treatment options emerging during the study period. In fact, after full adjustment for other factors, patients receiving thrombolytic therapy and endovascular thrombectomy were 6% and 10%, respectively, more likely to get palliative or hospice care than those who didn't get those acute treatments.

The study included 4,249,201 adults with ischemic stroke in the National Inpatient Sample from 2006 to 2015. Among them, 3.8% had administrative data coded for comfort care intervention use.

While in-hospital mortality was about 15-fold more likely for comfort care recipients, in-hospital mortality dropped in this group over time relative to other discharge dispositions (aOR 0.46 over the 10-year period, 95% CI 0.38-0.56). Comfort care patients instead increasingly went to long-term care and home healthcare.

"The shifting trend in place of death indicates that while fewer patients with stroke are dying in the hospital (in-hospital mortality is decreasing because of improved acute treatment and management), there may still be a significant number of patients with stroke who die in the postacute, long-term care, or community setting following discharge," Vahidy's group wrote.

"This may be in line with the wishes and preferences of patients and their families, with the preferred setting for death being at home in the presence of loved ones," they added. "The provision of and access to postdischarge care options are essential to comfort care's impact on in-hospital outcomes as well as patient-centered goals of care."

Palliative and hospice interventions were linked with modestly longer hospital stays, but with a significant 16% lower cost for the hospitalization after adjustment for length of stay, death, age, and disease severity ($8,724 vs $10,405).

The researchers drew attention to "considerable sex, race, and geographic disparities" in comfort care use. Women were 56% more likely than men to get these interventions after adjustment for other factors; white patients were about 40% more likely than Black patients, and about 28% more likely than other racial and ethnic groups, to get comfort care.

Cultural preferences and practices could be at play, the researchers noted. However, they added, "Racism also plays a complex role in the risk factors that lead to poor outcomes as well as in the allocation of healthcare resources. Mechanisms of such disparities need to be further evaluated."

Palliative care is actually most common in New England hospitals, so the fact that hospitals in the West were 27% more likely to use these interventions than those in the Northeast "suggests a possible gap in the use of available comfort care services in Northeast hospitals for certain conditions such as stroke," Vahidy's group added.

Study limitations included lack of data on patients' baseline level of function and on advance directives, both important influences on comfort care use.

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