HIV感染與臨終治療期間安寧照護服務利用率之關聯

Abstract

背景及目的 安寧照護可以改善愛滋病毒感染者在臨終期間的醫療品質、尊重病人自主權、減少非必要的住院服務、緩解病人疼痛，甚至得以延長存活時間，然而，因為愛滋病的汙名標籤，提高了為愛滋病毒感染者提供安寧照護的困難度。在臺灣，全民健保涵蓋了三種安寧照護給付，但在過去研究中，並沒有針對愛滋病毒感染個案的臨終安寧使用情形，予以廣泛性評估，因此，本研究欲探討臺灣愛滋病毒感染者與非感染者在生命末期的安寧照護使用之差異，以及在愛滋病毒感染者中，安寧照護與使用維生醫療之關聯。 研究方法 納入2000至2016年衛福部疾病管制署愛滋病資料庫中32,647名18歲以上愛滋病毒感染者，再從全民健保資料庫中配對年齡與性別，隨機選取愛滋病毒陰性者共326,470名，並利用邏輯式回歸來評估兩組的死亡個案之中，其生命末期最後一年的安寧照護使用情形，以及最後三個月的維生醫療使用，包含心肺復甦術、氣管插管、機械通氣及去顫，所有樣本皆追蹤至死亡或2018年12月31日。 研究結果 共有20,413名死亡個案，其中5,691(27.88%)為愛滋病毒感染者(對照組)，14,722(72.12%)為愛滋病毒陰性者(對照組)，在初步校正人口特徵及共病症之後，相較於對照組，愛滋病毒感染者在生命末期最後一年有較低的安寧照護服務使用(校正後勝算比:0.66; 95%信賴區間:0.57-0.75)。而這20,413名死亡個案中，有癌症共病者為6,225(30.50%)，其中愛滋病毒感染者為1,149(18.46%)，對照組為5,076(81.54%)，校正後發現在這群有癌症共病的死亡個案中，愛滋病毒感染與較低的安寧照護服務使用相關(校正後勝算比:0.55; 95%信賴區間:0.47-0.64)。此外，在這5,691名愛滋病毒感染者死亡個案之中，臨終前曾使用過安寧照護為331(5.82%)，不曾使用為5,360(94.18%)，研究結果發現曾使用安寧照護的愛滋病毒感染者在生命末期三個月內有較低的維生醫療使用情形(校正後勝算比:0.45; 95%信賴區間:0.34-0.59)。 結論：愛滋病毒感染者在臨終治療期間有較低的安寧照護使用情況，然而，緩和醫療在於改善病人生命末期照護品質，同時尊重病人對臨終照護前治療的選擇。本篇研究結果說明為愛滋病毒感染者推動安寧照護的必要性，為愛滋病毒感染者提供安寧照護服務，可降低其臨終前三個月的維生醫療使用，進而改善臨終期間的醫療品質，以達到緩和醫療之目標。

Background and Purpose Hospice care can improve the quality of life, respect the patient's right to choose, reduce unnecessary hospitalization services, relieve pain for patients, and even prolong survival time for people living with HIV (PLWH) during end-of-life (EOL) treatment. However, the stigma attached to AIDS makes it difficult to provide hospice care services for this group. In Taiwan, there are three types of hospice care were covered by national health insurance. Nevertheless, the impact about PLWH and hospice care has not been extensively studied. Therefore, this study aimed to investigate whether there are differences in utilization of hospice care services among PLWH and HIV-negative individuals in Taiwan, and determine the association between hospice care and life-sustaining treatments for PLWH. Methods The cohort study used data from the Taiwan Centers for Disease Control (CDC) HIV Database, identifying 32,647 adult PLWH from 2000 to 2016. And randomly selecting 326,470 subjects by age and gender from Taiwan National Health Insurance Research Database. Multiple logistic regressions were used to assess the utilization of hospice care services during the last year of life and the life-sustaining treatments during the last three months of life in deceased PLWH and deceased people without HIV/AIDS. Life-sustaining treatments included cardiopulmonary resuscitation, intubation, mechanical ventilation support, and defibrillation. All subjects were followed until death or December 31, 2018. Results There were a total of 20,413 deaths, of which 5.691 (27.88%) were PLWH (case group) and 14,722 (72.12%) were without HIV/AIDS (control group). After adjusting for demographics and comorbidities, compared with the control group, PLWH receive lower hospice care services during their last year of life (adjusted odds ratio: 0.66; 95% confidence interval: 0.57-0.75). Among 20,413 deaths, there were 6,225 (30.50%) with cancer comorbidities, of which 1,149 (18.46%) were PLWH and 5,076 (81.54%) were control group. And it was also found that PLWH with cancer comorbidities were associated with lower hospice care services (adjusted odds ratio: 0.55; 95% confidence interval: 0.47-0.64). In addition, of 5,691 deceased PLWAH, 331 (5.82%) had used hospice care during EOL Treatment, and 5,360 (94.18%) had never used hospice care. The data showed that PLWH with hospice care services were less likely to receive life-sustaining treatments during the last three months of life than those without the services (adjusted odds ratio: 0.45; 95% confidence interval: 0.34-0.59). Conclusions PLWH had a significantly lower utilization of hospice care services during the last year of life. And hospice care services reduced utilization of life-sustaining treatments during the last three months of life among PLWH. The goal of hospice care is to improve the quality of patient care at the end of life, while respecting the patient's choice of care. The results support the need to increase optimal hospice care services among PLWH during their EOL treatment.