Associations between physician home visits for the dying and place of death: A population-based retrospective cohort study

BackgroundWhile most individuals wish to die at home, the reality is that most will die in hospital.AimTo determine whether receiving a physician home visit near the end-of-life is associated with lower odds of death in a hospital.DesignObservational retrospective cohort study, examining location of death and health care in the last year of life.Setting/ParticipantsPopulation-level study of Ontarians, a Canadian province with over 13 million residents. All decedents from April 1, 2010 to March 31, 2013 (n = 264,754)ResultsMore than half of 264,754 decedents died in hospital: 45.7% died in an acute care hospital and 7.7% in complex continuing care. After adjustment for multiple factors–including patient illness, home care services, and days of being at home–receiving at least one physician home visit from a non-palliative care physician was associated with a 47% decreased odds (odds-ratio, 0.53; 95%CI: 0.51–0.55) of dying in a hospital. When a palliative care physician specialist was involved, the overall odds declined by 59% (odds ratio, 0.41; 95%CI: 0.39–0.43). The same model, adjusting for physician home visits, showed that receiving palliative home care was associated with a similar reduction (odds ratio, 0.49; 95%CI: 0.47–0.51).ConclusionLocation of death is strongly associated with end-of-life health care in the home. Less than one-third of the population, however, received end-of-life home care or a physician visit in their last year of life, revealing large room for improvement.

研究背景：尽管多数民众期望在家中走完人生最后一程，但现实情况是，绝大多数人仍在医院离世。
研究目的：明确临终前接受医师上门出诊是否与更低的医院内死亡风险相关。
研究设计：本研究为观察性回顾性队列研究，聚焦生命最后一年的死亡地点与医疗服务情况。
研究场景与对象：本研究为加拿大安大略省（人口超1300万）的人群水平研究，纳入2010年4月1日至2013年3月31日期间的所有死亡个体（n=264,754）。
研究结果：264,754名死亡个体中，超过半数于医院离世：其中45.7%死于急性护理医院，7.7%于复杂持续护理机构去世。在校正患者基础疾病、居家护理服务、居家天数等多项混杂因素后，接受至少1次非姑息治疗（palliative care）专科医师上门出诊的个体，其医院内死亡风险降低47%（优势比[OR]=0.53；95%置信区间[CI]：0.51~0.55）。若有姑息治疗专科医师参与，则总体死亡风险降低59%（OR=0.41；95%CI：0.39~0.43）。在校正医师上门出诊因素的同一模型中，接受姑息性居家护理的个体也呈现出相似的风险降低效果（OR=0.49；95%CI：0.47~0.51）。
研究结论：死亡地点与临终居家医疗服务存在显著关联。然而，在生命最后一年中，仅有不到三分之一的人群接受了临终居家护理或医师上门出诊服务，这表明该领域仍存在较大的改进空间。