Determinants of Initiating Palliative Care in COPD- Continuity of Care and Initiating Criteria

• Main Authors: Pin-Kuei Fu, 傅彬貴
• Other Authors: 董鈺琪
• Format: Others
• Language: zh-TW
• Published: 2019
• Online Access: http://ndltd.ncl.edu.tw/handle/8q6f52

博士 === 國立臺灣大學 === 健康政策與管理研究所 === 107 === Background Taiwan is entering an aging society, therefore the continuity of care for chronic diseases and the decision-making for palliative care in non-cancer stages have become important issues. Chronic obstructive pulmonary disease (COPD) is a chronic respiratory tract disease that causes decreased lung function, repeated hospitalization, and increased mortality. According to the World Health Organization, COPD will jump into the 3rd leading cause of death in the world in 2030. Increasing care continuity for COPD patients can reduce patient re-hospitalization and mortality. Poor care continuity may cause COPD patients delay to receive palliative care that caused these patients eventually being repeated intubation and progress to ventilator dependent status. However, the initiate of palliative care in late stage COPD patients is often too late. It may due to lackeness of consensus or criteria to initiate palliative care for COPD patients. The current study will firstly explore the association among the care continuity, the medical resources utilizations and the use of palliative care in patients died in COPD. Secondly, we will develop the consensus and criteria of initiate the palliative care in COPD by Taiwan expertis. Finally, we will validate these criteria to predict the 1-year mortality of COPD after hospitalization. We want to establish the useful clinical criteria to be the reference for promoting the palliatve care treatment of chronic lung disease. Material and Method (1) To explore the association of care continuity among COPD patients for their medical resources and palliative care utilizations, and the timing of “Do not resuscitate” (DNR) decisions. This study used clinical data from a medical center in central Taiwan. We use three indexs of care continuity to conduct the current study. These indexs include continuity of Care Index (COCI), modified modified continuity index (MMCI), and usual provider of care index (UPC index). (2) To develop the expert consensus of palliative care intervention for late stage COPD patients by using modified Delphi method. The expert consensus adopts the RAND/UCLA Appropriateness Method developed by the American RAND Corporation and the University of Los Angeles. We enrolled the experts from public medical center, private medical center and regional hospital located in the north, central, south and easten of Taiwan. Through the three rounds of Delphi methos of 14 experts, the feedback and consensus meeting results are used to assess the appropriateness of those indicators. (3) To validate the power of modified Delphi criteria in the prediction of 1-year mortality in COPD This study used clinical data from a medical center in central Taiwan. Patients hospitalized due to acute exacerbation of COPD were enrolled. We validated the power of modified Delphi criteria in the prediction of 1-year mortality in COPD. Results The first part of the results showed that high care continuity (MMCI) did reduce the number of hospitalizations and emergency visits in the year before the death of COPD patients, but in terms of medical expenses, it showed an increase. There is no correlation between care continuity and palliatve care utilization. The most relevant factor for medical expenses is the time when the DNR is signed at the end of the COPD. Patients who had DNR requested in their last admission is defined as late DNR, and those who had a DNR directive prior to their last (terminal) admission to the hospital were classified as Early DNR. The total annual medical expenditure of Late DNR group was 1.42 times higher than the early DNR group. We suggested this phenomenon is related to the lackness of consensus for when to start the palliative care in COPD patients in Tawain. In the second part, 9 criteria of initiating palliative care in COPD were developed by modified Delphi method. Nine indicators were selected as follows: (1) age > 80 years; (2) Modified Medical Research Council (mMRC) Dyspnea Scale ≧3; (3) pulmonary function Parameters: Forced Expiratory Volume in one second (FEV1) ≦30% predicted value; (4) Arterial blood oxygen parameters; (5) Body Mass Index (BMI) <20 or unplanned weight (6) severe or multiple comorbidities; (7) Past medical history - hospitalization due to acute exacerbation; (8) Past medical history - use of non-invasive respirators or invasive respirators due to acute exacerbations; (9) Daily life ability: disability requires care, and it is necessary to use a nasogastric catheter to assist others in daily life. ADO (Age, Dyspnea & Obstruction) index was also thought to be a comprehensive indicator to predict COPD mortality. In the third part, we validated the power of modified Delphi criteria in the prediction of 1-year mortality in COPD. The Delphi criteria have statistically significant differences in the prediction of 1-year of death (p = 0.004, C index = 0.558). The higher of the total score, the higher the predictive power of death (p<0.001, C index= 0.630). The ADO index also be confirmed as a good predictor for death in COPD in this study. We found that ADO plus the medical hx of acute exacerbation and BMI (ADO+ AE+ BMI), this model has the highest predictive value of COPD death (p<0.001, C index= 0.662). Conclusions In this study, we evaluated the relationship between the continuity of care and the utilization of medical resources and palliative care in COPD patients. We not only developed the expert consensus of palliative care intervention for late stage COPD patients by using modified Delphi method, but also verified the mortality prediction ability by actual hospital data. Through the serial review of these indicators, we want to provide the physicians, the patient themselves and their family members the guidance that COPD patients may progress to death within one year. The results of this study can provide the indicators to initiate palliative care or non-invasive care for late stage COPD patients. We suggest these indicators can not only be used by physicians and COPD patients, but also as an assessment tool or criteria to reimburse the palliative care in national health care system, thereby improving the quality of COPD terminal care in the future.