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[JAMA在线发表]:系统性收入ICU不能改善老年危重病患者远期病死率
2017年09月29日 时讯速递, 进展交流 暂无评论

Original Investigation

Caring for the Critically Ill Patient

September 27, 2017

Effect of Systematic Intensive Care Unit Triage on Long-term Mortality Among Critically Ill Elderly Patients in France: A Randomized Clinical Trial

Bertrand Guidet, Guillaume Leblanc, Tabassome Simon, et al

JAMA. Published online September 27, 2017. doi:10.1001/jama.2017.13889

Importance 背景

The high mortality rate in critically ill elderly patients has led to questioning of the beneficial effect of intensive care unit (ICU) admission and to a variable ICU use among this population.

老年危重病患者病死率很高,导致人们对于将这些患者收入ICU是否有益提出质疑,因而这一人群使用ICU资源的情况差异很大。

Objective 目的

To determine whether a recommendation for systematic ICU admission in critically ill elderly patients reduces 6-month mortality compared with usual practice.

确定与常规治疗相比,推荐老年危重病患者系统收入ICU能否降低6个月病死率。

Design, Setting, and Participants 设计,场景和研究人群

Multicenter, cluster-randomized clinical trial of 3037 critically ill patients aged 75 years or older, free of cancer, with preserved functional status (Index of Independence in Activities of Daily Living ≥4) and nutritional status (absence of cachexia) who arrived at the emergency department of one of 24 hospitals in France between January 2012 and April 2015 and were followed up until November 2015.

这项多中心、群组随机临床试验有法国24家医院参加,共入选到急诊科就诊的3037名老年危重病患者(年龄≥75岁,未罹患肿瘤,保留一定的功能状态(日常生活独立性指数≥4)及营养状态(无恶液质))。研究从2012年1月至2015年4月,随访截止到2015年11月。

Interventions 干预措施

Centers were randomly assigned either to use a program to promote systematic ICU admission of patients (n=1519 participants) or to follow standard practice (n=1518 participants).

各参研中心被随机分为实施计划促进ICU系统收治(n=1519名患者)或遵循标准流程(n=1518名患者)。

Main Outcomes and Measures 主要预后指标

The primary outcome was death at 6 months. Secondary outcomes included ICU admission rate, in-hospital death, functional status, and quality of life (12-Item Short Form Health Survey, ranging from 0 to 100, with higher score representing better self-reported health) at 6 months.

主要预后终点为6个月病死率。次要预后终点包括ICU收治比例,住院死亡,6个月时的功能状态及生活质量(12项健康调查简表,分值从0-100分,分值越高,表明自诉健康状况更佳)。

Results 结果

One patient withdrew consent, leaving 3036 patients included in the trial (median age, 85 [interquartile range, 81-89] years; 1361 [45%] men). Patients in the systematic strategy group had an increased risk of death at 6 months (45% vs 39%; relative risk [RR], 1.16; 95% CI, 1.07-1.26) despite an increased ICU admission rate (61% vs 34%; RR, 1.80; 95% CI, 1.66-1.95). After adjustments for baseline characteristics, patients in the systematic strategy group were more likely to be admitted to an ICU (RR, 1.68; 95% CI, 1.54-1.82) and had a higher risk of in-hospital death (RR, 1.18; 95% CI, 1.03-1.33) but had no significant increase in risk of death at 6 months (RR, 1.05; 95% CI, 0.96-1.14). Functional status and physical quality of life at 6 months were not significantly different between groups.

1名患者撤除知情同意,其余3036名患者纳入试验(中位年龄,85 [四分位区间,81-89] 岁;1361 名 [45%] 男性)。系统策略组患者6个月死亡风险增加(45% vs 39%;相对危险度 [RR],1.16;95% CI,1.07-1.26),尽管这组患者ICU收治比例增加(61% vs 34%; RR, 1.80; 95% CI, 1.66-1.95)。针对基线特征进行校正后,系统策略组患者更多收入ICU (RR, 1.68; 95% CI, 1.54-1.82),住院死亡风险更高 (RR, 1.18; 95% CI, 1.03-1.33),但是6个月死亡风险无显著增加 (RR, 1.05; 95% CI, 0.96-1.14)。两组间6个月时功能状态及生活质量无显著差异。

Conclusions and Relevance 结论和意义

Among critically ill elderly patients in France, a program to promote systematic ICU admission increased ICU use but did not reduce 6-month mortality. Additional research is needed to understand the decision to admit elderly patients to the ICU.

在法国老年危重病患者中,实施促进系统性收入ICU的计划增加ICU的使用,但不降低6个月病死率。需要进行进一步研究以了解将老年患者收入ICU的决策。

Trial Registration

clinicaltrials.gov Identifier: NCT01508819

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