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Govier DJ, Bui DP, Hauschildt KE, Eaton TL, McCready H, Smith VA, Osborne TF, Bowling CB, Boyko EJ, Ioannou GN, Maciejewski ML, O'Hare AM, Viglianti EM, Bohnert ASB, Hynes DM, Iwashyna TJ. Financial hardship after COVID-19 infection among US Veterans: a national prospective cohort study. BMC Health Serv Res 2024; 24:943. [PMID: 39160528 PMCID: PMC11331641 DOI: 10.1186/s12913-024-11421-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2024] [Accepted: 08/09/2024] [Indexed: 08/21/2024] Open
Abstract
BACKGROUND Research suggests an association between COVID-19 infection and certain financial hardships in the shorter term and among single-state and privately insured samples. Whether COVID-19 is associated with financial hardship in the longer-term or among socially vulnerable populations is unknown. Therefore, we examined whether COVID-19 was associated with a range of financial hardships 18 months after initial infection among a national cohort of Veterans enrolled in the Veterans Health Administration (VHA)-the largest national integrated health system in the US. We additionally explored the association between Veteran characteristics and financial hardship during the pandemic, irrespective of COVID-19. METHODS We conducted a prospective, telephone-based survey. Out of 600 Veterans with COVID-19 from October 2020 through April 2021 who were invited to participate, 194 Veterans with COVID-19 and 194 matched comparators without a history of infection participated. Financial hardship outcomes included overall health-related financial strain, two behavioral financial hardships (e.g., taking less medication than prescribed due to cost), and seven material financial hardships (e.g., using up most or all savings). Weighted generalized estimating equations were used to estimate risk ratios (RR) and 95% confidence intervals (CI) of financial hardship by COVID-19 status, and to assess the relationship between infection and Veteran age, VHA copay status, and comorbidity score, irrespective of COVID-19 status. RESULTS Among 388 respondents, 67% reported at least one type of financial hardship since March 2020, with 21% reporting behavioral hardships and 64% material hardships; 8% reported severe-to-extreme health-related financial strain. Compared with uninfected matched comparators, Veterans with a history of COVID-19 had greater risks of severe-to-extreme health-related financial strain (RR: 4.0, CI: 1.4-11.2), taking less medication due to cost (RR: 2.9, 95% CI: 1.0-8.6), and having a loved one take time off work to care for them (RR: 1.9, CI: 1.1-3.6). Irrespective of COVID-19 status, Veterans aged < 65 years had a greater risk of most financial hardships compared with Veterans aged ≥ 65 years. CONCLUSIONS Health-related financial hardships such as taking less medication due to cost and severe-to-extreme health-related financial strain were more common among Veterans with a history of COVID-19 than among matched comparators. Strategies are needed to address health-related financial hardship after COVID-19. TRIAL REGISTRATION NCT05394025, registered 05-27-2022.
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Affiliation(s)
- Diana J Govier
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, 3710 SW US Veterans Hospital Rd., Portland, OR, 97239, USA.
- Oregon Health & Science University - Portland State University School of Public Health, Portland, OR, USA.
| | - David P Bui
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, 3710 SW US Veterans Hospital Rd., Portland, OR, 97239, USA
| | - Katrina E Hauschildt
- VA Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, MI, USA
- School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Tammy L Eaton
- VA Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, MI, USA
- University of Michigan Institute for Healthcare Policy & Innovation, Ann Arbor, MI, USA
| | - Holly McCready
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, 3710 SW US Veterans Hospital Rd., Portland, OR, 97239, USA
| | - Valerie A Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation, VA Durham Health Care System, Durham, NC, USA
- Department of Medicine, Duke University, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Thomas F Osborne
- VA Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - C Barrett Bowling
- Center of Innovation to Accelerate Discovery and Practice Transformation, VA Durham Health Care System, Durham, NC, USA
- Department of Medicine, Duke University, Durham, NC, USA
- Durham Veterans Affairs Geriatric Research Education and Clinical Center, VA Durham Health Care System, Durham, NC, USA
| | - Edward J Boyko
- Seattle Epidemiologic Research and Information Center, VA Puget Sound Health Care System, Seattle, WA, USA
| | - George N Ioannou
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Matthew L Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation, VA Durham Health Care System, Durham, NC, USA
- Department of Medicine, Duke University, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Ann M O'Hare
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
- Hospital and Specialty Medicine Service, VA Puget Sound Health Care System, Seattle, WA, USA
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Elizabeth M Viglianti
- VA Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, MI, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Amy S B Bohnert
- VA Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, MI, USA
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Denise M Hynes
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, 3710 SW US Veterans Hospital Rd., Portland, OR, 97239, USA
- College of Health and Center for Quantitative Life Sciences, Oregon State University, Corvallis, OR, USA
- School of Nursing, Oregon Health & Science University, Portland, OR, USA
| | - Theodore J Iwashyna
- VA Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, MI, USA
- School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Department of Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
- School of Public Health, Johns Hopkins University, Baltimore, MD, USA
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2
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Dotolo DG, Pytel CC, Nielsen EL, Im J, Engelberg RA, Khandelwal N. Financial Hardship: A Qualitative Study Exploring Perspectives of Seriously Ill Patients and Their Family. J Pain Symptom Manage 2024:S0885-3924(24)00922-9. [PMID: 39147110 DOI: 10.1016/j.jpainsymman.2024.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2024] [Revised: 08/02/2024] [Accepted: 08/06/2024] [Indexed: 08/17/2024]
Abstract
CONTEXT Seriously ill patients, such as those who experience critical illness, and their families experience a variety of poor outcomes, including financial hardship. However, little is known about the ways in which these seriously ill patients and their families experience financial hardship. OBJECTIVE To examine seriously ill patients' and families' experiences of financial hardship and perspectives on addressing these concerns during and after critical illness. METHODS We conducted a thematic analysis of semi-structured interviews with seriously ill patients who recently experienced a critical care hospitalization (n=15) and family caregivers of these patients (n=18). RESULTS Our analysis revealed three themes: 1) Prioritizing Survival and Recovery; 2) Living with Uncertainty-including experiences of prolonged uncertainty, navigating bureaucratic barriers, and long-term worries; and 3) Preferences for Financial Guidance. Our results suggest patients and families prioritize survival over financial hardship initially, and feelings of uncertainty about finances persist. However, patients and family caregivers are reluctant to have their physicians address financial hardship. CONCLUSIONS Our findings suggest that the acute and time sensitive nature of treatment decisions in critical care settings provides a unique context for experiences of financial hardship. Additional research is needed to better understand these experiences and design context-sensitive interventions to mitigate financial hardship and associated poor patient- and family-centered outcomes.
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Affiliation(s)
- Danae G Dotolo
- Cambia Palliative Care Center of Excellence (D.G.D., E.L.N., R.A.E., N.K.), University of Washington, Harborview Medical Center, Seattle, Washington, USA; Department of Medicine, Division of Pulmonary (D.G.D., E.L.N., R.A.E.), Critical Care, & Sleep Medicine, University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Christina Clare Pytel
- Department of Anesthesiology and Pain Medicine (C.C.P., N.K.), University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Elizabeth L Nielsen
- Cambia Palliative Care Center of Excellence (D.G.D., E.L.N., R.A.E., N.K.), University of Washington, Harborview Medical Center, Seattle, Washington, USA; Department of Medicine, Division of Pulmonary (D.G.D., E.L.N., R.A.E.), Critical Care, & Sleep Medicine, University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Jennifer Im
- Department of Health Systems and Population Health (J.I.), University of Washington, Seattle, Washington, USA
| | - Ruth A Engelberg
- Cambia Palliative Care Center of Excellence (D.G.D., E.L.N., R.A.E., N.K.), University of Washington, Harborview Medical Center, Seattle, Washington, USA; Department of Medicine, Division of Pulmonary (D.G.D., E.L.N., R.A.E.), Critical Care, & Sleep Medicine, University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Nita Khandelwal
- Cambia Palliative Care Center of Excellence (D.G.D., E.L.N., R.A.E., N.K.), University of Washington, Harborview Medical Center, Seattle, Washington, USA; Department of Anesthesiology and Pain Medicine (C.C.P., N.K.), University of Washington, Harborview Medical Center, Seattle, Washington, USA.
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3
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Birkelo BC, Koyner JL, Ostermann M, Bhatraju PK. The Road to Precision Medicine for Acute Kidney Injury. Crit Care Med 2024; 52:1127-1137. [PMID: 38869385 PMCID: PMC11250999 DOI: 10.1097/ccm.0000000000006328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2024]
Abstract
OBJECTIVES Acute kidney injury (AKI) is a common form of organ dysfunction in the ICU. AKI is associated with adverse short- and long-term outcomes, including high mortality rates, which have not measurably improved over the past decade. This review summarizes the available literature examining the evidence of the need for precision medicine in AKI in critical illness, highlights the current evidence for heterogeneity in the field of AKI, discusses the progress made in advancing precision in AKI, and provides a roadmap for studying precision-guided care in AKI. DATA SOURCES Medical literature regarding topics relevant to precision medicine in AKI, including AKI definitions, epidemiology, and outcomes, novel AKI biomarkers, studies of electronic health records (EHRs), clinical trial design, and observational studies of kidney biopsies in patients with AKI. STUDY SELECTION English language observational studies, randomized clinical trials, reviews, professional society recommendations, and guidelines on areas related to precision medicine in AKI. DATA EXTRACTION Relevant study results, statements, and guidelines were qualitatively assessed and narratively synthesized. DATA SYNTHESIS We synthesized relevant study results, professional society recommendations, and guidelines in this discussion. CONCLUSIONS AKI is a syndrome that encompasses a wide range of underlying pathologies, and this heterogeneity has hindered the development of novel therapeutics for AKI. Wide-ranging efforts to improve precision in AKI have included the validation of novel biomarkers of AKI, leveraging EHRs for disease classification, and phenotyping of tubular secretory clearance. Ongoing efforts such as the Kidney Precision Medicine Project, identifying subphenotypes in AKI, and optimizing clinical trials and endpoints all have great promise in advancing precision medicine in AKI.
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Affiliation(s)
- Bethany C Birkelo
- Division of Nephrology, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Jay L Koyner
- Section of Nephrology, Department of Medicine, University of Chicago, Chicago, IL
| | - Marlies Ostermann
- Department of Critical Care and Nephrology, King's College London, Guy's and St. Thomas' Hospital, London, United Kingdom
| | - Pavan K Bhatraju
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
- Kidney Research Institute, University of Washington, Seattle, WA
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4
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Hauschildt KE, Bui DP, Govier DJ, Eaton TL, Viglianti EM, Ettman CK, McCready H, Smith VA, O’Hare AM, Osborne TF, Boyko EJ, Ioannou GN, Maciejewski ML, Bohnert ASB, Hynes DM, Iwashyna TJ. Regional variation in financial hardship among US veterans during the COVID-19 pandemic. HEALTH AFFAIRS SCHOLAR 2024; 2:qxae075. [PMID: 38938272 PMCID: PMC11210296 DOI: 10.1093/haschl/qxae075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Accepted: 06/04/2024] [Indexed: 06/29/2024]
Abstract
Geographic variation in hardship, especially health-related hardship, was identified prior to and during the pandemic, but we do not know whether this variation is consistent among Veterans Health Administration (VHA)-enrolled veterans, who reported markedly high rates of financial hardship during the pandemic, despite general and veteran-specific federal policy efforts aimed at reducing hardship. In a nationwide, regionally stratified sample of VHA-enrolled veterans, we examined whether the prevalence of financial hardship during the pandemic varied by US Census region. We found veterans in the South, compared with those in other census regions, reported higher rates of severe-to-extreme financial strain, using up all or most of their savings, being unable to pay for necessities, being contacted by collections, and changing their employment due to the kind of work they could perform. Regional variation in veteran financial hardship demonstrates a need for further research about the role and interaction of federal and state financial-assistance policies in shaping risks for financial hardship as well as potential opportunities to mitigate risks among veterans and reduce variation across regions.
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Affiliation(s)
- Katrina E Hauschildt
- VA Center for Clinical Management Research, Ann Arbor VA, Ann Arbor, MI 48109, United States
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD 21205, United States
| | - David P Bui
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR 97239, United States
| | - Diana J Govier
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR 97239, United States
- Oregon Health & Science University—Portland State University School of Public Health, Portland, OR 97201, United States
| | - Tammy L Eaton
- VA Center for Clinical Management Research, Ann Arbor VA, Ann Arbor, MI 48109, United States
- University of Michigan Institute for Healthcare Policy & Innovation, Ann Arbor, MI 48109, United States
- Division of Hospital Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, United States
| | - Elizabeth M Viglianti
- VA Center for Clinical Management Research, Ann Arbor VA, Ann Arbor, MI 48109, United States
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, United States
| | - Catherine K Ettman
- School of Public Health, Johns Hopkins University, Baltimore, MD 21205, United States
| | - Holly McCready
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR 97239, United States
| | - Valerie A Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC 27705, United States
- Department of Medicine, Duke University, Durham, NC 27710, United States
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC 27710, United States
| | - Ann M O’Hare
- Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Healthcare System, Seattle, WA 98108, United States
- Hospital and Specialty Medicine Service, Veterans Affairs Puget Sound Health Care System, Seattle, WA 98108, United States
- Department of Medicine, University of Washington, Seattle, WA 98195, United States
| | - Thomas F Osborne
- VA Palo Alto Healthcare System, Palo Alto, CA 94304, United States
- Department of Radiology, Stanford University School of Medicine, Stanford, CA 94305, United States
| | - Edward J Boyko
- Seattle Epidemiologic Research and Information Center, VA Puget Sound Health Care System, Seattle, WA 98108, United States
| | - George N Ioannou
- Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Healthcare System, Seattle, WA 98108, United States
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle, WA 98195, United States
| | - Matthew L Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC 27705, United States
- Department of Medicine, Duke University, Durham, NC 27710, United States
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC 27710, United States
| | - Amy S B Bohnert
- VA Center for Clinical Management Research, Ann Arbor VA, Ann Arbor, MI 48109, United States
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI 48109, United States
| | - Denise M Hynes
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR 97239, United States
- College of Health, and Center for Quantitative Life Sciences, Oregon State University, Corvallis, OR 97331, United States
- School of Nursing, Oregon Health and Science University, Portland, OR 97201, United States
| | - Theodore J Iwashyna
- VA Center for Clinical Management Research, Ann Arbor VA, Ann Arbor, MI 48109, United States
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD 21205, United States
- School of Public Health, Johns Hopkins University, Baltimore, MD 21205, United States
- Department of Medicine, University of Michigan Medical School, Ann Arbor, MI 48109, United States
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5
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Palakshappa JA, Batt JAE, Bodine SC, Connolly BA, Doles J, Falvey JR, Ferrante LE, Files DC, Harhay MO, Harrell K, Hippensteel JA, Iwashyna TJ, Jackson JC, Lane-Fall MB, Monje M, Moss M, Needham DM, Semler MW, Lahiri S, Larsson L, Sevin CM, Sharshar T, Singer B, Stevens T, Taylor SP, Gomez CR, Zhou G, Girard TD, Hough CL. Tackling Brain and Muscle Dysfunction in Acute Respiratory Distress Syndrome Survivors: NHLBI Workshop Report. Am J Respir Crit Care Med 2024; 209:1304-1313. [PMID: 38477657 PMCID: PMC11146564 DOI: 10.1164/rccm.202311-2130ws] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 03/12/2024] [Indexed: 03/14/2024] Open
Abstract
Acute respiratory distress syndrome (ARDS) is associated with long-term impairments in brain and muscle function that significantly impact the quality of life of those who survive the acute illness. The mechanisms underlying these impairments are not yet well understood, and evidence-based interventions to minimize the burden on patients remain unproved. The NHLBI of the NIH assembled a workshop in April 2023 to review the state of the science regarding ARDS-associated brain and muscle dysfunction, to identify gaps in current knowledge, and to determine priorities for future investigation. The workshop included presentations by scientific leaders across the translational science spectrum and was open to the public as well as the scientific community. This report describes the themes discussed at the workshop as well as recommendations to advance the field toward the goal of improving the health and well-being of ARDS survivors.
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Affiliation(s)
| | - Jane A. E. Batt
- University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada
| | - Sue C. Bodine
- Oklahoma Medical Research Foundation, Oklahoma City, Oklahoma
- Oklahoma City Veterans Affairs Medical Center, Oklahoma City, Oklahoma
| | - Bronwen A. Connolly
- Wellcome-Wolfson Institute for Experimental Medicine, Queen’s University, Belfast, United Kingdom
| | - Jason Doles
- Indiana University School of Medicine, Indianapolis, Indiana
| | - Jason R. Falvey
- University of Maryland School of Medicine, Baltimore, Maryland
| | | | - D. Clark Files
- Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Michael O. Harhay
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | | | | | | | | | - Meghan B. Lane-Fall
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Michelle Monje
- Howard Hughes Medical Institute, Stanford University, Stanford, California
| | - Marc Moss
- University of Colorado School of Medicine, Aurora, Colorado
| | - Dale M. Needham
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Shouri Lahiri
- Cedars Sinai Medical Center, Los Angeles, California
| | - Lars Larsson
- Center for Molecular Medicine, Karolinska Institute, Solna, Sweden
- Department of Physiology & Pharmacology, Karolinska Institute and Viron Molecular Medicine Institute, Boston, Massachusetts
| | - Carla M. Sevin
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Tarek Sharshar
- Anesthesia and Intensive Care Department, GHU Paris Psychiatry and Neurosciences, Institute of Psychiatry and Neurosciences of Paris, INSERM U1266, University Paris Cité, Paris, France
| | | | | | | | - Christian R. Gomez
- Division of Lung Diseases, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Guofei Zhou
- Division of Lung Diseases, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Timothy D. Girard
- Center for Research, Investigation, and Systems Modeling of Acute Illness, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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6
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Song A, Auriemma CL. Everything Everywhere All at Once? Identifying Exposures and Outcomes that Matter to Families within and beyond the Intensive Care Unit. Ann Am Thorac Soc 2024; 21:701-703. [PMID: 38691007 PMCID: PMC11109916 DOI: 10.1513/annalsats.202403-256ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2024] Open
Affiliation(s)
- Anne Song
- Palliative and Advanced Illness Research Center
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, and
| | - Catherine L Auriemma
- Palliative and Advanced Illness Research Center
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, and
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
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7
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Legrand M, Bagshaw SM, Bhatraju PK, Bihorac A, Caniglia E, Khanna AK, Kellum JA, Koyner J, Harhay MO, Zampieri FG, Zarbock A, Chung K, Liu K, Mehta R, Pickkers P, Ryan A, Bernholz J, Dember L, Gallagher M, Rossignol P, Ostermann M. Sepsis-associated acute kidney injury: recent advances in enrichment strategies, sub-phenotyping and clinical trials. Crit Care 2024; 28:92. [PMID: 38515121 PMCID: PMC10958912 DOI: 10.1186/s13054-024-04877-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 03/17/2024] [Indexed: 03/23/2024] Open
Abstract
Acute kidney injury (AKI) often complicates sepsis and is associated with high morbidity and mortality. In recent years, several important clinical trials have improved our understanding of sepsis-associated AKI (SA-AKI) and impacted clinical care. Advances in sub-phenotyping of sepsis and AKI and clinical trial design offer unprecedented opportunities to fill gaps in knowledge and generate better evidence for improving the outcome of critically ill patients with SA-AKI. In this manuscript, we review the recent literature of clinical trials in sepsis with focus on studies that explore SA-AKI as a primary or secondary outcome. We discuss lessons learned and potential opportunities to improve the design of clinical trials and generate actionable evidence in future research. We specifically discuss the role of enrichment strategies to target populations that are most likely to derive benefit and the importance of patient-centered clinical trial endpoints and appropriate trial designs with the aim to provide guidance in designing future trials.
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Affiliation(s)
- Matthieu Legrand
- Division of Critical Care Medicine, Department of Anesthesia and Perioperative Care, UCSF, 521 Parnassus Avenue, San Francisco, CA, 94143, USA.
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, Canada
| | - Pavan K Bhatraju
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, USA
- Kidney Research Institute, University of Washington, Seattle, USA
| | - Azra Bihorac
- Department of Medicine, University of Florida, Gainesville, FL, USA
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, USA
| | - Ellen Caniglia
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
| | - Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
- Outcomes Research Consortium, Cleveland, OH, USA
- Perioperative Outcomes and Informatics Collaborative, Winston-Salem, NC, USA
| | - John A Kellum
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jay Koyner
- University Section of Nephrology, Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Michael O Harhay
- Clinical Trials Methods and Outcomes Lab, Department of Biostatistics, Epidemiology, and Informatics, PAIR (Palliative and Advanced Illness Research) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Fernando G Zampieri
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, Canada
| | | | | | - Kathleen Liu
- Divisions of Nephrology and Critical Care Medicine, Departments of Medicine and Anesthesia, University of California San Francisco, San Francisco, CA, USA
| | - Ravindra Mehta
- Department of Medicine, University of California, San Diego, USA
| | - Peter Pickkers
- Intensive Care Medicine, Radboudumc, Nijmegen, The Netherlands
| | - Abigail Ryan
- Chronic Care Policy Group, Division of Chronic Care Management, Center for Medicare and Medicaid Services, Center for Medicare, Baltimore, MD, USA
| | | | - Laura Dember
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Department of Biostatistics, Epidemiology and Informatics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Martin Gallagher
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Patrick Rossignol
- FCRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
- INSERM CIC-P 1433, CHRU de Nancy, INSERM U1116, Université de Lorraine, Nancy, France
- Medicine and Nephrology-Hemodialysis Departments, Monaco Private Hemodialysis Centre, Princess Grace Hospital, Monaco, Monaco
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's & St Thomas' Hospital, London, UK
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8
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McPeake J, Iwashyna TJ, MacTavish P, Devine H, Henderson P, Quasim T, Shaw M. Could an integrated model of health and social care after critical illness reduce socioeconomic disparities in outcomes? A Bayesian analysis. BJA OPEN 2024; 9:100259. [PMID: 38322488 PMCID: PMC10844938 DOI: 10.1016/j.bjao.2024.100259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 01/09/2024] [Indexed: 02/08/2024]
Abstract
Background There is limited evidence to understand what impact, if any, recovery services might have for patients across the socioeconomic spectrum after critical illness. We analysed data from a multicentre critical care recovery programme to understand the impact of this programme across the socioeconomic spectrum. Methods The setting for this pre-planned secondary analysis was a critical care rehabilitation programme-Intensive Care Syndrome: Promoting Independence and Return to Employment. Data were collected from five hospital sites running this programme. We utilised a Bayesian approach to analysis and explore any possible effect of the InS:PIRE intervention on Health-Related Quality of Life (HRQoL) across the socioeconomic gradient. A Bayesian quantile, non-linear mixed effects regression model, using a compound symmetry covariance structure, accounting for multiple timepoints was utilised. The Scottish Index of Multiple Deprivation (SIMD) was used to measure socioeconomic status and HRQoL was measured using the EQ-5D-5L. Results In the initial baseline cohort of 182 patients, 55% of patients were male, the median age was 58 yr (inter-quartile range: 50-66 yr) and 129 (79%) patients had two or more comorbidities at ICU admission. Using the neutral prior, there was an overall probability of intervention benefit of 100% (β=0.71, 95% credible interval: 0.34-1.09) over 12 months to those in the SIMD≤3 cohort, and an 98.6% (β=-1.38, 95% credible interval: -2.62 to -0.16) probability of greater benefit (i.e. a steeper increase in improvement) at 12 months in the SIMD≤3 vs SIMD≥4 cohort in the EQ-visual analogue scale. Conclusions Using multicentre data, this re-analysis suggests, but does not prove, that an integrated health and social care intervention is likely to improve outcomes across the socioeconomic gradient after critical illness, with a potentially greater benefit for those from deprived communities. Future research designed to prospectively analyse how critical care recovery programmes could potentially improve outcomes across the socioeconomic gradient is warranted.
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Affiliation(s)
- Joanne McPeake
- The Healthcare Improvement Studies Institute, University of Cambridge, Cambridge, UK
| | | | - Pamela MacTavish
- Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Helen Devine
- Crosshouse University Teaching Hospital, NHS Ayrshire and Arran, Kilmarnock, UK
| | - Phil Henderson
- Royal Alexandria Hospital, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Tara Quasim
- Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, UK
- University of Glasgow, School of Medicine, Dentistry and Nursing, Glasgow, UK
| | - Martin Shaw
- University of Glasgow, School of Medicine, Dentistry and Nursing, Glasgow, UK
- Clinical Physics, NHS Greater Glasgow and Clyde, Glasgow, UK
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9
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Eaton TL, Taylor SP. Health system approaches to providing posthospital care for survivors of sepsis and critical illness. Curr Opin Crit Care 2023; 29:513-518. [PMID: 37641522 DOI: 10.1097/mcc.0000000000001076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
PURPOSE OF REVIEW In the current review, we highlight developing strategies taken by healthcare systems to improve posthospital outcomes for sepsis and critical illness. RECENT FINDINGS Multiple studies conducted in the adult population over the last 18 months have advanced current knowledge on postdischarge care after sepsis and critical illness. Effective interventions are complex and multicomponent, targeting the multilevel challenges that survivors face. Health systems can leverage existing care models such as primary care or invest in specialty programs to deliver postdischarge care. Qualitative and implementation science studies provide insights into important contextual factors for program success. Several studies demonstrate successful application of telehealth to improve reach of postdischarge support. Research is beginning to identify subtypes of survivors that may respond to tailored intervention strategies. SUMMARY Several successful critical illness survivor models of care have been implemented and knowledge about effectiveness, cost, and implementation factors of these strategies is growing. Further innovation is needed in intervention development and evaluation to advance the field.
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Affiliation(s)
- Tammy L Eaton
- National Clinician Scholars Program (NCSP); VA HSR&D Center for the Study of Healthcare Innovation, Implementation, & Policy, University of Michigan Department of Systems, Populations and Leadership, University of Michigan School of Nursing
| | - Stephanie Parks Taylor
- Division of Hospital Medicine, Michigan Medicine; & Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
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10
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Blank JA, Armstrong-Hough M, Valley TS. Disparities among patients with respiratory failure. Curr Opin Crit Care 2023; 29:493-504. [PMID: 37641499 PMCID: PMC10599128 DOI: 10.1097/mcc.0000000000001079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
PURPOSE OF REVIEW Disparities are common within healthcare, and critical illness is no exception. This review summarizes recent literature on health disparities within respiratory failure, focusing on race, ethnicity, socioeconomic status, and sex. RECENT FINDINGS Current evidence indicates that Black patients have higher incidence of respiratory failure, while the relationships among race, ethnicity, and mortality remains unclear. There has been renewed interest in medical device bias, specifically pulse oximetry, for which data demonstrate patients with darker skin tones may be at risk for undetected hypoxemia and worse outcomes. Lower socioeconomic status is associated with higher mortality, and respiratory failure can potentiate socioeconomic inequities via illness-related financial toxicity. Literature on sex-based disparities is limited; however, evidence suggests males receive more invasive care, including mechanical ventilation. SUMMARY Most studies focused on disparities in incidence and mortality associated with respiratory failure, but few relied on granular clinical data of patients from diverse backgrounds. Future studies should evaluate processes of care for respiratory failure that may mechanistically contribute to disparities in order to develop interventions that improve outcomes.
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Affiliation(s)
| | - Mari Armstrong-Hough
- New York University School of Global Public Health, Department of Social & Behavioral Sciences, Department of Epidemiology
| | - Thomas S. Valley
- University of Michigan, Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine
- VA Center for Clinical Management Research, Ann Arbor, Michigan
- Institute for Healthcare Policy and Innovation, University of Michigan
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11
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Harrod M, Hauschildt K, Kamphuis LA, Korpela PR, Rouse M, Nallamothu BK, Iwashyna TJ. Disrupted Lives: Caregivers' Experiences of In-Hospital Cardiac Arrest Survivors' Recovery 5 Years Later. J Am Heart Assoc 2023; 12:e028746. [PMID: 37671627 PMCID: PMC10547269 DOI: 10.1161/jaha.122.028746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 04/25/2023] [Indexed: 09/06/2023]
Abstract
Background Survivors of in-hospital cardiac arrest (IHCA) experience ongoing physical and cognitive impairments, often requiring support from a caregiver at home afterwards. Caregivers are important in the survivor's recovery, yet there is little research specifically focused on their experiences once the survivor is discharged home. In this study, we highlight how caregivers for veteran IHCA survivors described and experienced their caregiver role, the strategies they used to fulfill their role, and the additional needs they still have years after the IHCA event. Methods and Results Between March and July 2019, semistructured telephone interviews were conducted with 12 caregivers for veteran IHCA survivors. Interviews were transcribed, and content analysis was performed. Patterns within the data were further analyzed and grouped into themes. A predominant theme of "disruption" was identified across 3 different domains including the following: (1) disruption in caregiver's life, (2) disruption in caregiver-patient relationship, and (3) disruption in caregiver's well-being. Disruption was associated with both positive and negative caregiver experiences. Strategies caregivers used and resources they felt would have helped them adjust to their caregiver role were also identified. Conclusions Caregivers for veteran IHCA survivors experienced a disruption in many facets of their lives. Caregivers felt the veterans' IHCA impacted various aspects of their lives, and they continued to need additional support in order to care for the IHCA survivor and themselves. Although some were able to procure coping strategies, such as counseling and engaging in stress-relieving activities, most indicated additional help and resources were still needed.
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Affiliation(s)
- Molly Harrod
- Lieutenant Colonel Charles S. Kettles VA Medical CenterCenter for Clinical Management ResearchAnn ArborMIUSA
| | - Katrina Hauschildt
- Lieutenant Colonel Charles S. Kettles VA Medical CenterCenter for Clinical Management ResearchAnn ArborMIUSA
- Department of SociologyPopulation Studies CenterUniversity of MichiganAnn ArborMIUSA
- Division of Pulmonary and Critical Care MedicineDepartment of Internal MedicineUniversity of MichiganAnn ArborMIUSA
- Division of Pulmonary and Critical Care MedicineThe Johns Hopkins University School of MedicineBaltimoreMDUSA
| | - Lee A. Kamphuis
- Lieutenant Colonel Charles S. Kettles VA Medical CenterCenter for Clinical Management ResearchAnn ArborMIUSA
| | - Peggy R. Korpela
- Lieutenant Colonel Charles S. Kettles VA Medical CenterCenter for Clinical Management ResearchAnn ArborMIUSA
| | - Marylena Rouse
- Lieutenant Colonel Charles S. Kettles VA Medical CenterCenter for Clinical Management ResearchAnn ArborMIUSA
| | - Brahmajee K. Nallamothu
- Lieutenant Colonel Charles S. Kettles VA Medical CenterCenter for Clinical Management ResearchAnn ArborMIUSA
- Center for Healthcare Outcomes and PolicyUniversity of MichiganAnn ArborMIUSA
- Department of Internal MedicineUniversity of MichiganAnn ArborMIUSA
| | - Theodore J. Iwashyna
- Lieutenant Colonel Charles S. Kettles VA Medical CenterCenter for Clinical Management ResearchAnn ArborMIUSA
- Division of Pulmonary and Critical Care MedicineDepartment of Internal MedicineUniversity of MichiganAnn ArborMIUSA
- Division of Pulmonary and Critical Care MedicineThe Johns Hopkins University School of MedicineBaltimoreMDUSA
- Department of Internal MedicineUniversity of MichiganAnn ArborMIUSA
- Health Policy and Management, School of Public HealthThe Johns Hopkins UniversityBaltimoreMDUSA
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12
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Kumar AJ, Parthasarathy C, Prescott HC, Denstaedt SJ, Newstead MW, Bridges D, Bustamante A, Singer K, Singer BH. Pneumosepsis survival in the setting of obesity leads to persistent steatohepatitis and metabolic dysfunction. Hepatol Commun 2023; 7:e0210. [PMID: 37556193 PMCID: PMC10412436 DOI: 10.1097/hc9.0000000000000210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 05/19/2023] [Indexed: 08/10/2023] Open
Abstract
BACKGROUND As critical care practice evolves, the sepsis survivor population continues to expand, often with lingering inflammation in many organs, including the liver. Given the concurrently increasing population of patients with NAFLD, in this study, we aimed to understand the long-term effect of sepsis on pre-existing NAFLD and hyperglycemia. METHODS Male mice were randomized to a high-fat diet or a control diet (CD). After 24 weeks on diet, mice were inoculated with Klebsiella pneumoniae (Kpa). Serial glucose tolerance tests, and insulin and pyruvate challenge tests were performed 1 week before infection and at 2 and 6 weeks after infection. Whole tissue RNA sequencing and histological evaluation of the liver were performed. To test whether persistent inflammation could be reproduced in other abnormal liver environments, mice were also challenged with Kpa after exposure to a methionine-choline-deficient high-fat diet. Finally, a retrospective cohort of 65,139 patients was analyzed to evaluate whether obesity was associated with liver injury after sepsis. RESULTS After Kpa inoculation, high-fat diet mice had normalized fasting blood glucose without a change in insulin sensitivity but with a notable decrease in pyruvate utilization. Liver examination revealed focal macrophage collections and a unique inflammatory gene signature on RNA analysis. In the clinical cohort, preobesity, and class 1 and class 2 obesity were associated with increased odds of elevated aminotransferase levels 1-2 years after sepsis. CONCLUSIONS The combination of diet-induced obesity and pneumosepsis survival in a murine model resulted in unique changes in gluconeogenesis and liver inflammation, consistent with the progression of benign steatosis to steatohepatitis. In a cohort study, obese patients had an increased risk of elevated aminotransferase levels 1-2 years following sepsis.
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Affiliation(s)
- Avnee J. Kumar
- Department of Internal Medicine, Division of Pulmonary and Critical Care, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Chitra Parthasarathy
- Department of Internal Medicine, Division of Pulmonary and Critical Care, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Hallie C. Prescott
- Department of Internal Medicine, Division of Pulmonary and Critical Care, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
- VA Center for Clinical Management Research, Ann Arbor, Michigan, USA
| | - Scott J. Denstaedt
- Department of Internal Medicine, Division of Pulmonary and Critical Care, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Michael W. Newstead
- Department of Internal Medicine, Division of Pulmonary and Critical Care, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Dave Bridges
- Department of Nutritional Sciences, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Angela Bustamante
- Department of Internal Medicine, Division of Pulmonary and Critical Care, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Kanakadurga Singer
- Department of Pediatrics, Division of Endocrinology, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Benjamin H. Singer
- Department of Internal Medicine, Division of Pulmonary and Critical Care, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
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13
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Short A, McPeake J, Andonovic M, McFee S, Quasim T, Leyland A, Shaw M, Iwashyna T, MacTavish P. Medication-related problems in critical care survivors: a systematic review. Eur J Hosp Pharm 2023; 30:250-256. [PMID: 37142386 PMCID: PMC10447966 DOI: 10.1136/ejhpharm-2023-003715] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 04/11/2023] [Indexed: 05/06/2023] Open
Abstract
OBJECTIVES There are numerous, often single centre discussions of assorted medication-related problems after hospital discharge in patients who survive critical illness. However, there has been little synthesis of the incidence of medication-related problems, the classes of medications most often studied, the factors that are associated with greater patient risk of such problems or interventions that can prevent them. METHODS We undertook a systematic review to understand medication management and medication problems in critical care survivors in the hospital discharge period. We searched OVID Medline, Embase, PsychINFO, CINAHL and the Cochrane database (2001-2022). Two reviewers independently screened publications to identify studies that examined medication management at hospital discharge or thereafter in critical care survivors. We included randomised and non-randomised studies. We extracted data independently and in duplicate. Data extracted included medication type, medication-related problems and frequency of medication issues, alongside demographics such as study setting. Cohort study quality was assessed using the Newcastle Ottowa Score checklist. Data were analysed across medication categories. RESULTS The database search initially retrieved 1180 studies; following the removal of duplicates and studies which did not fit the inclusion criteria, 47 papers were included. The quality of studies included varied. The outcomes measured and the timepoints at which data were captured also varied, which impacted the quality of data synthesis. Across the studies included, we found that as many as 80% of critically ill patients experienced medication-related problems in the posthospital discharge period. These issues included inappropriate continuation of newly prescribed drugs such as antipsychotics, gastrointestinal prophylaxis and analgesic medications, as well as inappropriate discontinuation of chronic disease medications, such as secondary prevention cardiac drugs. CONCLUSIONS Following critical illness, a high proportion of patients experience problems with their medications. These changes were present across multiple health systems. Further research is required to understand optimal medicine management across the full recovery trajectory of critical illness. PROSPERO REGISTRATION NUMBER CRD42021255975.
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Affiliation(s)
| | - Joanne McPeake
- The Healthcare Improvement Studies Institute, University of Cambridge, Cambridge, UK
| | - Mark Andonovic
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | | | - Tara Quasim
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Alastair Leyland
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
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14
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Chow CP, Chesley CF, Ward M, Neergaard R, Prasad TV, Dress EM, Reagan S, Kalyani P, Smyk N, Turner AP, Agyekum RS, Ittner CAG, Sandsmark DK, Meyer NJ, Harhay MO, Kohn R, Auriemma CL. Patients' Perspectives on Life and Recovery 1 Year After COVID-19 Hospitalization. J Gen Intern Med 2023; 38:2374-2382. [PMID: 37268779 PMCID: PMC10237521 DOI: 10.1007/s11606-023-08246-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 05/15/2023] [Indexed: 06/04/2023]
Abstract
BACKGROUND Many patients hospitalized for COVID-19 experience prolonged symptoms months after discharge. Little is known abou t patients' personal experiences recovering from COVID-19 in the United States (US), where medically underserved populations are at particular risk of adverse outcomes. OBJECTIVE To explore patients' perspectives on the impact of COVID-19 hospitalization and barriers to and facilitators of recovery 1 year after hospital discharge in a predominantly Black American study population with high neighborhood-level socioeconomic disadvantage. DESIGN Qualitative study utilizing individual, semi-structured interviews. PARTICIPANTS Adult patients hospitalized for COVID-19 approximately 1 year after discharge home who were engaged in a COVID-19 longitudinal cohort study. APPROACH The interview guide was developed and piloted by a multidisciplinary team. Interviews were audio-recorded and transcribed. Data were coded and organized into discrete themes using qualitative content analysis with constant comparison techniques. KEY RESULTS Of 24 participants, 17 (71%) self-identified as Black, and 13 (54%) resided in neighborhoods with the most severe neighborhood-level socioeconomic disadvantage. One year after discharge, participants described persistent deficits in physical, cognitive, or psychological health that impacted their current lives. Repercussions included financial suffering and a loss of identity. Participants reported that clinicians often focused on physical health over cognitive and psychological health, an emphasis that posed a barrier to recovering holistically. Facilitators of recovery included robust financial or social support systems and personal agency in health maintenance. Spirituality and gratitude were common coping mechanisms. CONCLUSIONS Persistent health deficits after COVID-19 resulted in downstream consequences in participants' lives. Though participants received adequate care to address physical needs, many described persistent unmet cognitive and psychological needs. A more comprehensive understanding of barriers and facilitators for COVID-19 recovery, contextualized by specific healthcare and socioeconomic needs related to socioeconomic disadvantage, is needed to better inform intervention delivery to patients that experience long-term sequelae of COVID-19 hospitalization.
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Affiliation(s)
- Carolyn P Chow
- Perelman School of Medicine, the University of Pennsylvania, Philadelphia, PA, USA
| | - Christopher F Chesley
- Palliative and Advanced Illness Research (PAIR) Center, the University of Pennsylvania, Philadelphia, PA, USA
- Division of Pulmonary, Allergy and Critical Care, the University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, the University of Pennsylvania, Philadelphia, PA, USA
| | - Michaela Ward
- Mixed Methods Research Laboratory, the University of Pennsylvania, Philadelphia, PA, USA
| | - Rebecca Neergaard
- Mixed Methods Research Laboratory, the University of Pennsylvania, Philadelphia, PA, USA
| | - Taara V Prasad
- Palliative and Advanced Illness Research (PAIR) Center, the University of Pennsylvania, Philadelphia, PA, USA
| | - Erich M Dress
- Palliative and Advanced Illness Research (PAIR) Center, the University of Pennsylvania, Philadelphia, PA, USA
| | - Sara Reagan
- Department of Neurology, the University of Pennsylvania, Philadelphia, PA, USA
| | - Priyanka Kalyani
- Department of Neurology, the University of Pennsylvania, Philadelphia, PA, USA
| | - Nathan Smyk
- Department of Neurology, the University of Pennsylvania, Philadelphia, PA, USA
| | - Alexandra P Turner
- Division of Pulmonary, Allergy and Critical Care, the University of Pennsylvania, Philadelphia, PA, USA
| | - Roseline S Agyekum
- Division of Pulmonary, Allergy and Critical Care, the University of Pennsylvania, Philadelphia, PA, USA
| | - Caroline A G Ittner
- Division of Pulmonary, Allergy and Critical Care, the University of Pennsylvania, Philadelphia, PA, USA
| | | | - Nuala J Meyer
- Division of Pulmonary, Allergy and Critical Care, the University of Pennsylvania, Philadelphia, PA, USA
| | - Michael O Harhay
- Perelman School of Medicine, the University of Pennsylvania, Philadelphia, PA, USA
- Palliative and Advanced Illness Research (PAIR) Center, the University of Pennsylvania, Philadelphia, PA, USA
- Division of Pulmonary, Allergy and Critical Care, the University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, the University of Pennsylvania, Philadelphia, PA, USA
| | - Rachel Kohn
- Perelman School of Medicine, the University of Pennsylvania, Philadelphia, PA, USA
- Palliative and Advanced Illness Research (PAIR) Center, the University of Pennsylvania, Philadelphia, PA, USA
- Division of Pulmonary, Allergy and Critical Care, the University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, the University of Pennsylvania, Philadelphia, PA, USA
| | - Catherine L Auriemma
- Palliative and Advanced Illness Research (PAIR) Center, the University of Pennsylvania, Philadelphia, PA, USA.
- Division of Pulmonary, Allergy and Critical Care, the University of Pennsylvania, Philadelphia, PA, USA.
- Leonard Davis Institute of Health Economics, the University of Pennsylvania, Philadelphia, PA, USA.
- Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
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15
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Eaton TL, Lewis A, Donovan HS, Davis BC, Butcher BW, Alexander SA, Iwashyna TJ, Scheunemann LP, Seaman J. Examining the needs of survivors of critical illness through the lens of palliative care: A qualitative study of survivor experiences. Intensive Crit Care Nurs 2023; 75:103362. [PMID: 36528461 DOI: 10.1016/j.iccn.2022.103362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 11/21/2022] [Accepted: 11/22/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To examine the needs of adult survivors of critical illness through a lens of palliative care. RESEARCH METHODOLOGY A qualitative study of adult survivors of critical illness using semi-structured interviews and framework analysis. SETTING Participants were recruited from the post-intensive care unit clinic of a mid-Atlantic academic medical center in the United States. FINDINGS Seventeen survivors of critical illness aged 34-80 (median, 66) participated in the study. The majority of patients were female (64.7 %, n = 11) with a median length of index ICU stay of 12 days (interquartile range [IQR] 8-19). Interviews were conducted February to March 2021 and occurred a median of 20 months following the index intensive care stay (range, 13-33 months). We identified six key themes which align with palliative care principles: 1) persistent symptom burden; 2) critical illness as a life-altering experience; 3) spiritual changes and significance; 4) interpreting/managing the survivor experience; 5) feelings of loss and burden; and 6) social support needs. CONCLUSION Our findings suggest that palliative care components such as symptom management, goals of care discussions, care coordination, and spiritual and social support may assist in the assessment and treatment of survivors of critical illness.
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Affiliation(s)
- Tammy L Eaton
- Department of Systems, Populations and Leadership, University of Michigan School of Nursing, Ann Arbor, MI, USA; National Clinician Scholars Program (NCSP), Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.
| | - Anna Lewis
- School of Public Health, Department of Health Policy and Management, University of Pittsburgh, PA, USA; Care Management Department, University of Pittsburgh Medical Center Mercy Hospital, Pittsburgh, PA, USA
| | - Heidi S Donovan
- Department of Health & Community Systems, School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA; Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of Pittsburgh, PA, USA
| | - Brian C Davis
- School of Law, Duquesne University, Pittsburgh, PA, USA
| | - Brad W Butcher
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Sheila A Alexander
- Department of Acute and Tertiary Care, School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA; Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Theodore J Iwashyna
- Department of Medicine, Division of Pulmonary & Critical Care, University of Michigan, Ann Arbor, MI, USA; Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Leslie P Scheunemann
- Division of Geriatric Medicine and Gerontology, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jennifer Seaman
- Department of Acute and Tertiary Care, School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
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Abstract
OBJECTIVES To engage critical care end-users (survivors and caregivers) to describe their emotions and experiences across their recovery trajectory, and elicit their ideas and solutions for health service improvements to improve the ICU recovery experience. DESIGN End-user engagement as part of a qualitative design using the Framework Analysis method. SETTING The Society of Critical Care Medicine's THRIVE international collaborative sites (follow-up clinics and peer support groups). SUBJECTS Patients and caregivers following critical illness and identified through the collaboratives. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Eighty-six interviews were conducted. The following themes were identified: 1) Emotions and experiences of patients-"Loss of former self; Experiences of disability and adaptation"; 2) Emotions and experiences of caregivers-"Emotional impacts, adopting new roles, and caregiver burden; Influence of gender roles; Adaptation, adjustment, recalibration"; and 3) Patient and caregiver-generated solutions to improve recovery across the arc of care-"Family-targeted education; Expectation management; Rehabilitation for patients and caregivers; Peer support groups; Reconnecting with ICU post-discharge; Access to community-based supports post-discharge; Psychological support; Education of issues of ICU survivorship for health professionals; Support across recovery trajectory." Themes were mapped to a previously published recovery framework (Timing It Right) that captures patient and caregiver experiences and their support needs across the phases of care from the event/diagnosis to adaptation post-discharge home. CONCLUSIONS Patients and caregivers reported a range of emotions and experiences across the recovery trajectory from ICU to home. Through end-user engagement strategies many potential solutions were identified that could be implemented by health services and tested to support the delivery of higher-quality care for ICU survivors and their caregivers that extend from tertiary to primary care settings.
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Jain S, Hauschildt K, Scheunemann LP. Social determinants of recovery. Curr Opin Crit Care 2022; 28:557-565. [PMID: 35993295 DOI: 10.1097/mcc.0000000000000982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to examine evidence describing the influence of social determinants on recovery following hospitalization with critical illness. In addition, it is meant to provide insight into the several mechanisms through which social factors influence recovery as well as illuminate approaches to addressing these factors at various levels in research, clinical care, and policy. RECENT FINDINGS Social determinants of health, ranging from individual factors like social support and socioeconomic status to contextual ones like neighborhood deprivation, are associated with disability, cognitive impairment, and mental health after critical illness. Furthermore, many social factors are reciprocally related to recovery wherein the consequences of critical illness such as financial toxicity and caregiver burden can put essential social needs under strain turning them into barriers to recovery. SUMMARY Recovery after hospitalization for critical illness may be influenced by many social factors. These factors warrant attention by clinicians, health systems, and policymakers to enhance long-term outcomes of critical illness survivors.
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McPeake J, Boehm L, Hibbert E, Hauschildt K, Bakhru R, Bastin A, Butcher B, Eaton T, Harris W, Hope A, Jackson J, Johnson A, Kloos J, Korzick K, McCartney J, Meyer J, Montgomery-Yates A, Quasim T, Slack A, Wade D, Still M, Netzer G, Hopkins RO, Mikkelsen ME, Iwashyna T, Haines K, Sevin C. Modification of social determinants of health by critical illness and consequences of that modification for recovery: an international qualitative study. BMJ Open 2022; 12:e060454. [PMID: 36167379 PMCID: PMC9516069 DOI: 10.1136/bmjopen-2021-060454] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 08/11/2022] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES Social determinants of health (SDoH) contribute to health outcomes. We identified SDoH that were modified by critical illness, and the effect of such modifications on recovery from critical illness. DESIGN In-depth semistructured interviews following hospital discharge. Interview transcripts were mapped against a pre-existing social policy framework: money and work; skills and education; housing, transport and neighbourhoods; and family, friends and social connections. SETTING 14 hospital sites in the USA, UK and Australia. PARTICIPANTS Patients and caregivers, who had been admitted to critical care from three continents. RESULTS 86 interviews were analysed (66 patients and 20 caregivers). SDoH, both financial and non-financial in nature, could be negatively influenced by exposure to critical illness, with a direct impact on health-related outcomes at an individual level. Financial modifications included changes to employment status due to critical illness-related disability, alongside changes to income and insurance status. Negative health impacts included the inability to access essential healthcare and an increase in mental health problems. CONCLUSIONS Critical illness appears to modify SDoH for survivors and their family members, potentially impacting recovery and health. Our findings suggest that increased attention to issues such as one's social network, economic security and access to healthcare is required following discharge from critical care.
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Affiliation(s)
- Joanne McPeake
- Critical Care, The Healthcare Improvement Studies Institute, University of Cambridge, Cambridge, UK
- Critical Care, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Leanne Boehm
- School of Nursing, Vanderbilt University, Nashville, Tennessee, USA
| | - Elizabeth Hibbert
- Department of Physiotherapy, Western Health Foundation, Sunshine, Victoria, Australia
| | - Katrina Hauschildt
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Rita Bakhru
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Anthony Bastin
- Department of Peri-operative Medicine, Barts Health NHS Trust, London, UK
| | - Brad Butcher
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Tammy Eaton
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation, & Policy, University of Michigan, Ann Arbor, Michigan, US
- Department of Systems, Populations and Leadership, University of Michigan School of Nursing, Ann Arbor, Michigan, US
| | - Wendy Harris
- Intensive Care Unit, University College London, London, UK
| | - Aluko Hope
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Oregon Health & Science University (OHSU), Portland, Oregon, USA
| | - James Jackson
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University, Nashville, Tennessee, USA
| | - Annie Johnson
- Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Janet Kloos
- Department of Acute and Critical Care Nursing, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Karen Korzick
- Department of Pulmonary and Critical Care Medicine, Geisinger Medical Center, Danville, Pennsylvania, USA
| | | | - Joel Meyer
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Tara Quasim
- Critical Care, NHS Greater Glasgow and Clyde, Glasgow, UK
- School of Medicine, Dentistry and Nursing, University of Glasgow College of Medical Veterinary and Life Sciences, Glasgow, UK
| | - Andrew Slack
- Department of Critical Care, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Dorothy Wade
- Critical Care, University College London Hospitals NHS Foundation Trust, London, UK
| | - Mary Still
- Critical Care, Emory University Hospital, Atlanta, Georgia, USA
| | - Giora Netzer
- Division of Pulmonary and Critical Care, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Ramona O Hopkins
- Center for Humanizing Critical Care and Pulmonary/Critical Care Medicine, Intermountain Medical Center, Murray, Utah, USA
- Psychology and Neuroscience, Brigham Young University, Provo, Utah, USA
| | - Mark E Mikkelsen
- Division of Pulmonary, Allergy, and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Theodore Iwashyna
- Department of Internal Medicine, Division of Pulmonary & Critical Care, University of Michigan, Ann Arbor, Michigan, USA
| | - Kimberley Haines
- Department of Physiotherapy, Sunshine Hospital, Melbourne, Victoria, Australia
| | - Carla Sevin
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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19
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Survivorship After Critical Illness and Post-Intensive Care Syndrome. Clin Chest Med 2022; 43:551-561. [PMID: 36116822 DOI: 10.1016/j.ccm.2022.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Improvements in critical care medicine have led to a marked increase in survivors of the intensive care unit (ICU). These survivors encounter many difficulties following ICU discharge. The term post -intensive care syndrome (PICS) provides a framework for identifying the most common symptoms which fall into three domains: cognitive, physical, and mental health. There are numerous risk factors for the development of PICS including premorbid conditions and specific elements of ICU hospitalizations. Management is complex and should take an individualized approach with interdisciplinary care. Future research should focus on prevention, identification, and treatment of this unique population.
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20
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Hauschildt KE, Hechtman RK, Prescott HC, Cagino LM, Iwashyna TJ. Interviews with primary care physicians identify unmet transition needs after ICU. Crit Care 2022; 26:248. [PMID: 35971153 PMCID: PMC9376575 DOI: 10.1186/s13054-022-04125-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 08/08/2022] [Indexed: 11/10/2022] Open
Abstract
AIM We sought to explore unmet needs in transitions of care for critical illness survivors that concern primary care physicians. FINDINGS Semi-structured interviews with primary care physicians identified three categories of concerns about unmet transition needs after patients' ICU stays: patients' understanding of their ICU stay and potential complications, treatments or support needs not covered by insurance, and starting and maintaining needed rehabilitation and assistance across transitions of care. CONCLUSION Given current constraints of access to coordinated post-ICU care, efforts to identify and address the post-hospitalization needs of critical illness survivors may be improved through coordinated work across the health system.
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Affiliation(s)
- Katrina E Hauschildt
- Veterans Affairs Center for Clinical Management Research, HSR&D Center of Innovation, Ann Arbor, MI, USA.
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Rachel K Hechtman
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Hallie C Prescott
- Veterans Affairs Center for Clinical Management Research, HSR&D Center of Innovation, Ann Arbor, MI, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Leigh M Cagino
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Theodore J Iwashyna
- Veterans Affairs Center for Clinical Management Research, HSR&D Center of Innovation, Ann Arbor, MI, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
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21
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McPeake J, Bateson M, Christie F, Robinson C, Cannon P, Mikkelsen M, Iwashyna TJ, Leyland AH, Shaw M, Quasim T. Hospital re-admission after critical care survival: a systematic review and meta-analysis. Anaesthesia 2022; 77:475-485. [PMID: 34967011 DOI: 10.1111/anae.15644] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2021] [Indexed: 12/22/2022]
Abstract
Survivors of critical illness frequently require increased healthcare resources after hospital discharge. We undertook a systematic review and meta-analysis to assess hospital re-admission rates following critical care admission and to explore potential re-admission risk factors. We searched the MEDLINE, Embase and CINAHL databases on 05 March 2020. Our search strategy incorporated controlled vocabulary and text words for hospital re-admission and critical illness, limited to the English language. Two reviewers independently applied eligibility criteria and assessed quality using the Newcastle Ottawa Score checklist and extracted data. The primary outcome was acute hospital re-admission in the year after critical care discharge. Of the 8851 studies screened, 87 met inclusion criteria and 41 were used within the meta-analysis. The analysis incorporated data from 3,897,597 patients and 741,664 re-admission episodes. Pooled estimates for hospital re-admission after critical illness were 16.9% (95%CI: 13.3-21.2%) at 30 days; 31.0% (95%CI: 24.3-38.6%) at 90 days; 29.6% (95%CI: 24.5-35.2%) at six months; and 53.3% (95%CI: 44.4-62.0%) at 12 months. Significant heterogeneity was observed across included studies. Three risk factors were associated with excess acute care rehospitalisation one year after discharge: the presence of comorbidities; events during initial hospitalisation (e.g. the presence of delirium and duration of mechanical ventilation); and subsequent infection after hospital discharge. Hospital re-admission is common in survivors of critical illness. Careful attention to the management of pre-existing comorbidities during transitions of care may help reduce healthcare utilisation after critical care discharge. Future research should determine if targeted interventions for at-risk critical care survivors can reduce the risk of subsequent rehospitalisation.
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Affiliation(s)
- J McPeake
- Intensive Care Unit, Glasgow Royal Infirmary and School of Medicine, Dentistry and Nursing, University of Glasgow, UK
| | - M Bateson
- University of the West of Scotland, Glasgow, UK
| | - F Christie
- NHS Greater Glasgow and Clyde, Glasgow, UK
| | - C Robinson
- Belfast Health and Social Care Trust, Belfast, UK
| | - P Cannon
- University of Glasgow Library, Glasgow, UK
| | - M Mikkelsen
- Center for Clinical Epidemiology and Biostatistics, Division of Pulmonary, Allergy, and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - T J Iwashyna
- Centre for Clinical Management Research, VA Ann Arbor Health System, Ann Arbor, MI, USA.,Department of Internal Medicine, Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, MI, USA
| | - A H Leyland
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
| | - M Shaw
- Clinical Physics, NHS Greater Glasgow and Clyde, Glasgow, UK.,School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - T Quasim
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK.,Intensive Care Unit, Glasgow Royal Infirmary, Glasgow, UK
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22
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Abstract
The multifaceted long-term impairments resulting from critical illness and COVID-19 require interdisciplinary management approaches in the recovery phase of illness. Operational insights into the structure and process of recovery clinics (RCs) from heterogeneous health systems are needed. This study describes the structure and process characteristics of existing and newly implemented ICU-RCs and COVID-RCs in a subset of large health systems in the United States.
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23
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Siuba MT, Sadana D, Gadre S, Bruckman D, Duggal A. Acute respiratory distress syndrome readmissions: A nationwide cross-sectional analysis of epidemiology and costs of care. PLoS One 2022; 17:e0263000. [PMID: 35077505 PMCID: PMC8789165 DOI: 10.1371/journal.pone.0263000] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 01/10/2022] [Indexed: 12/12/2022] Open
Abstract
Background Acute Respiratory Distress Syndrome affects approximately 10% of patients admitted to intensive care units internationally, with as many as 40%-52% of patients reporting re-hospitalization within one year. Research question/aim To describe the epidemiology of patients with acute respiratory distress syndrome who require 30-day readmission, and to describe associated costs. Study design and methods A cross-sectional analysis of the 2016 Healthcare Cost and Utilization Project’s Nationwide Readmission Database, which is a population-based administrative database which includes discharge data from U.S. hospitals. Inclusion criteria: hospital discharge records for adults age > 17 years old, with a diagnosis of ARDS on index admission, with associated procedure codes for endotracheal intubation and/or invasive mechanical ventilation, who were discharged alive. Primary exposure is adult hospitalization for meeting criteria as described. The primary outcome measure is 30-day readmission rate, as well as patient characteristics and time distribution of readmissions. Results Nationally, 25,170 admissions meeting criteria were identified. Index admission mortality rate was 37.5% (95% confidence interval [CI], 36.2–38.8). 15,730 records of those surviving hospitalization had complete discharge information. 30-day readmission rate was 18.4%, with 14% of total readmissions occurring within 2 calendar days of discharge; these early readmissions had higher mortality risk (odds ratio 1.82, 95% CI 1.05–6.56) compared with readmission in subsequent days. For the closest all-cause readmission within 30 days, the mean cost was $26,971, with a total national cost of over $75.6 million. Interpretation Thirty-day readmission occurred in 18.4% of patients with acute respiratory distress syndrome in this sample, and early readmission is strongly associated with increased mortality compared to late readmission. Further research is needed to clarify whether the rehospitalizations or associated mortalities are preventable.
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Affiliation(s)
- Matthew T. Siuba
- Department of Critical Care Medicine, Cleveland Clinic, Respiratory Institute, Cleveland, Ohio, United States of America
- * E-mail:
| | - Divyajot Sadana
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Shruti Gadre
- Department of Critical Care Medicine, Cleveland Clinic, Respiratory Institute, Cleveland, Ohio, United States of America
| | - David Bruckman
- Department of Quantitative Health Sciences, Cleveland Clinic, Center for Populations Health Research, Lerner Research Institute, Cleveland, Ohio, United States of America
| | - Abhijit Duggal
- Department of Critical Care Medicine, Cleveland Clinic, Respiratory Institute, Cleveland, Ohio, United States of America
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24
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Su H, Hopkins RO, Kamdar BB, May S, Dinglas VD, Johnson KL, Hosey M, Hough CL, Needham DM, Thompson HJ. Association of imbalance between job workload and functional ability with return to work in ARDS survivors. Thorax 2022; 77:123-128. [PMID: 33927021 DOI: 10.1136/thoraxjnl-2020-216586] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 03/01/2021] [Accepted: 04/11/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Inability to return to work (RTW) is common after acute respiratory distress syndrome (ARDS). Mismatch in an individual's job workload and his or her functional ability, termed work ability imbalance, is negatively associated with RTW, but has not been evaluated in ARDS survivors. OBJECT We examine associations between work ability imbalance at 6 months and RTW at 6 months and 12 months, as well as the ability to sustain employment in ARDS survivors. METHODS Previously employed participants from the ARDS Network Long-Term Outcomes Study (N=341) were evaluated. Pre-ARDS workload was determined based on the US Occupational Information Network classification. Post-ARDS functional ability was assessed using self-reported 36-Item Short Form Health Survey (SF-36) physical functioning, social functioning and mental health subscales, and Mini-Mental State Examination. ARDS survivors were categorised into four work ability imbalance categories: none, psychosocial, physical, and both psychosocial and physical. RESULTS Almost 90% of ARDS survivors had a physical and/or psychosocial work ability imbalance at both 6-month and 12-month follow-up. Compared with survivors with no imbalance at 6 months, those with both physical and psychosocial imbalance had lower odds of RTW (6 months: OR=0.33, 95% CI=0.13 to 0.82; 12 months: OR=0.22, 95% CI=0.07 to 0.65). Thirty-eight (19%) of those who ever RTW were subsequently jobless at 12 months. CONCLUSION Interventions aimed at rebalancing ARDS survivors' work ability by addressing physical and psychosocial aspects of their functional ability and workload should be explored as part of efforts to improve RTW, maintain employment and reduce the financial impact of joblessness.
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Affiliation(s)
- Han Su
- School of Nursing, University of Washington Seattle Campus, Seattle, Washington, USA
| | - Ramona O Hopkins
- Psychology Department, Brigham Young University, Provo, Utah, USA
- Neuroscience Center, Brigham Young University, Provo, Utah, USA
- Pulmonary and Critical Care, Intermountain Medical Center, Murray, Utah, USA
- Center for Humanizing Critical Care, Intermountain Medical Center, Murray, Utah, USA
| | - Biren B Kamdar
- Division of Pulmonary, Critical Care, Sleep Medicine and Physiology, University of California, San Diego, California, USA
| | - Susanne May
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Victor D Dinglas
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, Maryland, USA
| | - Kurt L Johnson
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Megan Hosey
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Catherine L Hough
- Division of Pulmonary and Critical Care Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Dale M Needham
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Hilaire J Thompson
- School of Nursing, University of Washington Seattle Campus, Seattle, Washington, USA
- Harborview Injury Prevention and Research Center, Seattle, Washington, USA
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25
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Brown SM, Dinglas VD, Akhlaghi N, Bose S, Banner-Goodspeed V, Beesley S, Groat D, Greene T, Hopkins RO, Mir-Kasimov M, Sevin CM, Turnbull AE, Jackson JC, Needham DM. Association between unmet medication needs after hospital discharge and readmission or death among acute respiratory failure survivors: the addressing post-intensive care syndrome (APICS-01) multicenter prospective cohort study. Crit Care 2022; 26:6. [PMID: 34991660 PMCID: PMC8738999 DOI: 10.1186/s13054-021-03848-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 11/29/2021] [Indexed: 11/21/2022] Open
Abstract
Introduction Survivors of acute respiratory failure (ARF) commonly experience long-lasting physical, cognitive, and/or mental health impairments. Unmet medication needs occurring immediately after hospital discharge may have an important effect on subsequent recovery. Methods and analysis In this multicenter prospective cohort study, we enrolled ARF survivors who were discharged directly home from their acute care hospitalization. The primary exposure was unmet medication needs. The primary outcome was hospital readmission or death within 3 months after discharge. We performed a propensity score analysis, using inverse probability weighting for the primary exposure, to evaluate the exposure–outcome association, with an a priori sample size of 200 ARF survivors. Results We enrolled 200 ARF survivors, of whom 107 (53%) were female and 77 (39%) were people of color. Median (IQR) age was 55 (43–66) years, APACHE II score 20 (15–26) points, and hospital length of stay 14 (9–21) days. Of the 200 participants, 195 (98%) were in the analytic cohort. One hundred fourteen (57%) patients had at least one unmet medication need; the proportion of medication needs that were unmet was 6% (0–15%). Fifty-six (29%) patients were readmitted or died by 3 months; 10 (5%) died within 3 months. Unmet needs were not associated (risk ratio 1.25; 95% CI 0.75–2.1) with hospital readmission or death, although a higher proportion of unmet needs may have been associated with increased hospital readmission (risk ratio 1.7; 95% CI 0.96–3.1) and decreased mortality (risk ratio 0.13; 95% CI 0.02–0.99). Discussion Unmet medication needs are common among survivors of acute respiratory failure shortly after discharge home. The association of unmet medication needs with 3-month readmission and mortality is complex and requires additional investigation to inform clinical trials of interventions to reduce unmet medication needs. Study registration number: NCT03738774. The study was prospectively registered before enrollment of the first patient. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03848-3.
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Affiliation(s)
- Samuel M Brown
- Pulmonary and Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, USA. .,Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT, USA. .,Center for Humanizing Critical Care, Intermountain Medical Center, Salt Lake City, UT, USA. .,Shock Trauma ICU, Intermountain Medical Center, 5121 S. Cottonwood Street, Murray, UT, 84107, USA.
| | - Victor D Dinglas
- Outcomes After Critical Illness and Surgery (OACIS) Group and Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Narjes Akhlaghi
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Somnath Bose
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Sarah Beesley
- Pulmonary and Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, USA.,Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT, USA.,Center for Humanizing Critical Care, Intermountain Medical Center, Salt Lake City, UT, USA
| | - Danielle Groat
- Pulmonary and Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, USA.,Center for Humanizing Critical Care, Intermountain Medical Center, Salt Lake City, UT, USA
| | - Tom Greene
- Biostatistics and Epidemiology, University of Utah, Salt Lake City, UT, USA
| | - Ramona O Hopkins
- Center for Humanizing Critical Care, Intermountain Medical Center, Salt Lake City, UT, USA.,Psychology Department and Neuroscience Center, Brigham Young University, Provo, UT, USA
| | - Mustafa Mir-Kasimov
- Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT, USA.,Salt Lake City Veterans Administration, Salt Lake City, UT, USA
| | - Carla M Sevin
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alison E Turnbull
- Outcomes After Critical Illness and Surgery (OACIS) Group and Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | | | - Dale M Needham
- Outcomes After Critical Illness and Surgery (OACIS) Group and Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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26
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27
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Understanding the Impact of Critical Illness on Families: A Call for Standardization of Outcomes and Longitudinal Research. Ann Am Thorac Soc 2021; 18:1783-1785. [PMID: 34723764 PMCID: PMC8641840 DOI: 10.1513/annalsats.202106-757ed] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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28
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Garg A, Soto AL, Knies AK, Kolenikov S, Schalk M, Hammer H, White DB, Holloway RG, Sheth KN, Fraenkel L, Hwang DY. Predictors of Surrogate Decision Makers Selecting Life-Sustaining Therapy for Severe Acute Brain Injury Patients: An Analysis of US Population Survey Data. Neurocrit Care 2021; 35:468-479. [PMID: 33619667 PMCID: PMC8380750 DOI: 10.1007/s12028-021-01200-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 01/29/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Patients with a severe acute brain injury admitted to the intensive care unit often have a poor neurological prognosis. In these situations, a clinician is responsible for conducting a goals-of-care conversation with the patient's surrogate decision makers. The diversity in thought and background of surrogate decision makers can present challenges during these conversations. For this reason, our study aimed to identify predictive characteristics of US surrogate decision makers' favoring life-sustaining treatment (LST) over comfort measures only for patients with severe acute brain injury. METHODS We analyzed data from a cross-sectional survey study that had recruited 1588 subjects from an online probability-based US population sample. Seven hundred and ninety-two subjects had randomly received a hypothetical scenario regarding a relative intubated with severe acute brain injury with a prognosis of severe disability but with the potential to regain some consciousness. Seven hundred and ninety-six subjects had been randomized to a similar scenario in which the relative was projected to remain vegetative. For each scenario, we conducted univariate analyses and binary logistic regressions to determine predictors of LST selection among available respondent characteristics. RESULTS 15.0% of subjects selected LST for the severe disability scenario compared to 11.4% for the vegetative state scenario (p = 0.07), with those selecting LST in both groups expressing less decisional certainty. For the severe disability scenario, independent predictors of LST included having less than a high school education (adjusted OR = 2.87, 95% CI = 1.23-6.76), concern regarding prognostic accuracy (7.64, 3.61-16.15), and concern regarding the cost of care (4.07, 1.80-9.18). For the vegetative scenario, predictors included the youngest age group (30-44 years, 3.33, 1.02-10.86), male gender (3.26, 1.75-6.06), English as a second language (2.94, 1.09-7.89), Evangelical Protestant (3.72, 1.28-10.84) and Catholic (4.01, 1.72-9.36) affiliations, and low income (< $25 K). CONCLUSION Several demographic and decisional characteristics of US surrogate decision makers predict LST selection for patients with severe brain injury with varying degrees of poor prognosis. Surrogates concerned about the cost of medical care may nevertheless be inclined to select LST, albeit with high levels of decisional uncertainty, for patients projected to have severe disabilities.
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Affiliation(s)
- Anisha Garg
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Alexandria L Soto
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, PO Box 208018, New Haven, CT, 06520, USA
| | - Andrea K Knies
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | | | | | | | - Douglas B White
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Robert G Holloway
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
| | - Kevin N Sheth
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, PO Box 208018, New Haven, CT, 06520, USA
- Center for Neuroepidemiology and Clinical Neurological Research, Yale School of Medicine, New Haven, CT, USA
| | - Liana Fraenkel
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Section of Rheumatology, Yale School of Medicine, New Haven, CT, USA
| | - David Y Hwang
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, PO Box 208018, New Haven, CT, 06520, USA.
- Center for Neuroepidemiology and Clinical Neurological Research, Yale School of Medicine, New Haven, CT, USA.
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29
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McPeake J, Sevin CM, Mikkelsen ME. Functional outcomes following critical illness: epidemiology, current management strategies and the future priorities. Curr Opin Crit Care 2021; 27:506-512. [PMID: 34267076 DOI: 10.1097/mcc.0000000000000856] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Intensive care unit (ICU) survivorship has gained significant attention over the course of the COVID-19 pandemic. In this review, we summarize the contemporary literature in relation to the epidemiology and management of post-ICU problems. RECENT FINDINGS Survivors of critical illness can have complex physical, social, emotional and cognitive needs in the months following hospital discharge. Emerging evidence has shown that pre-ICU characteristics such as educational attainment, alongside in-ICU factors such as delirium, may contribute to worsening outcomes. Evidence regarding the impact of post-ICU recovery services is evolving, but models such as post-ICU clinics and peer support programs are gaining rapid momentum. SUMMARY Future research should focus on modifiable risk factors and how identification and treatment of these can improve outcomes. Furthermore, rigorous evaluation of postacute critical care recovery services is necessary.
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Affiliation(s)
- Joanne McPeake
- NHS Greater Glasgow and Clyde, University of Glasgow, School of Medicine, Dentistry and Nursing, THIS Institute (University of Cambridge), Cambridge, UK
| | - Carla M Sevin
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mark E Mikkelsen
- Division of Pulmonary, Allergy, and Critical Care Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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30
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Iwashyna TJ, Kamphuis LA, Gundel SJ, Hope AA, Jolley S, Admon AJ, Caldwell E, Monahan ML, Hauschildt K, Thompson BT, Hough CL. Continuing Cardiopulmonary Symptoms, Disability, and Financial Toxicity 1 Month After Hospitalization for Third-Wave COVID-19: Early Results From a US Nationwide Cohort. J Hosp Med 2021; 16:jhm.3660. [PMID: 34424190 DOI: 10.12788/jhm.3660] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 05/25/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Patients discharged after COVID-19 report ongoing needs. OBJECTIVES To measure incident symptoms after COVID-19 hospitalization. DESIGN, SETTING, AND PARTICIPANTS Preplanned early look at 1-month follow-up surveys from patients hospitalized August 2020 to January 2021 in NHLBI PETAL Network's Biology and Longitudinal Epidemiology: COVID-19 Observational (BLUE CORAL) study. English- or Spanish-speaking hospitalized adults without substantial pre-COVID-19 disability with a positive molecular test for SARS-CoV-2. RESULTS Overall, 253 patients were hospitalized for a median of 5 days (interquartile range [IQR], 3-8), and had a median age of 60 years (IQR, 45-68). By race/ethnicity, 136 (53.8%) were non-Hispanic White, 23 (9.1%) were non-Hispanic Black, and 83 (32.8%) were Hispanic. Most (139 [54.9%]) reported a new or worsened cardiopulmonary symptom, and 16% (n = 39) reported new or increased oxygen use; 213 (84.2%) patients reported not feeling fully back to their pre-COVID-19 level of functioning. New limitations in activities of daily living were present in 130 (52.8%) patients. Financial toxicities, including job loss or change (49 [19.8%]), having a loved one take time off (93 [37.8%]), and using up one's savings (58 [23.2%]), were common. Longer lengths of hospital stay were associated with greater odds of 1-month cardiopulmonary symptoms (adjusted odds ratio [aOR], 1.82 per additional week in the hospital; 95% CI, 1.11-2.98) and new disability (aOR, 2.06; 95% CI, 1.21-3.53). There were not uniform demographic patterns of association. LIMITATIONS We prioritized patients' reports of their own incident problems over objective testing. CONCLUSION Patients who survived COVID-19 in the United States during late 2020/early 2021 still faced new burdens 1 month after hospital discharge.
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Affiliation(s)
- Theodore J Iwashyna
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Lee A Kamphuis
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Stephanie J Gundel
- Department of Emergency Medicine, Harborview Medical Center, Seattle, Washington
| | - Aluko A Hope
- Division of Critical Care Medicine, Albert Einstein College of Medicine of Yeshiva University, New York, New York
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health and Science University School of Medicine, Portland, Oregon
| | - Sarah Jolley
- Division of Pulmonary and Critical Care, University of Colorado, Denver, Colorado
| | - Andrew J Admon
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Ellen Caldwell
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Washington, Seattle, Washington
| | - Max L Monahan
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Katherine Hauschildt
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | | | - Catherine L Hough
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health and Science University School of Medicine, Portland, Oregon
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McPeake J, Iwashyna TJ, Henderson P, Leyland AH, Mackay D, Quasim T, Walters M, Harhay M, Shaw M. Long term outcomes following critical care hospital admission: A prospective cohort study of UK biobank participants ✰,★. THE LANCET REGIONAL HEALTH. EUROPE 2021; 6:100121. [PMID: 34291229 PMCID: PMC8278491 DOI: 10.1016/j.lanepe.2021.100121] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND : This study aimed to understand the impact of a critical care admission on long-term outcomes, compared to other hospitalised patients without a critical care encounter. A secondary aim was to examine the interrelationship between emotional, physical, and social problems during recovery. METHODS : We utilised data from the UK Biobank, an on-going, prospective population-based cohort study. We employed propensity score matching to assess differences in outcomes between patients with a critical care encounter and patients admitted to the hospital (first admission to hospital available) without critical care. Structural equation modelling was used to analyse emotional, physical and social outcomes following critical illness and the relationships between these health domains. FINDINGS : Data from 1,618 patients were analysed. The median time to follow-up in the critical care cohort was 4427 days (IQR:788-6146) vs 4516 days (IQR: 811-6369) in the non-critical care, hospitalised cohort. Across the two time periods assessed (pre and post 2000), patients exposed to critical care were more likely to experience mental health issues such as depression (p < 0.01) and social isolation (p = 0.01) following discharge from hospital. The critical care cohort were also more likely to have social problems such as the requirement for government funded welfare support (p = 0.02). In the critical care cohort, social and emotional health were closely correlated (p < 0.001, 95% CI:0.33-0.54). The nature of physical problems changed over time; pre-2000 there was a significant difference between the critical and non-critical care in physical outcomes following discharge from hospital, however, there was no difference detected between the two cohorts post-2000. INTERPRETATION This cohort study has demonstrated that survivors of critical illness have different psycho-social outcomes to matched patients, hospitalised without a critical care encounter. FUNDING JM is funded by a THIS.Institute (University of Cambridge) Research Fellowship (PD-2019-02-16). AHL is part of the Social and Public Health Sciences Unit, funded by the Medical Research Council (MC_UU_12017/13) and the Scottish Government Chief Scientist Office (SPHSU13).
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Affiliation(s)
- Joanne McPeake
- Intensive Care Unit, Glasgow Royal Infirmary, Glasgow, United Kingdom
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, United Kingdom
| | - Theodore J Iwashyna
- Centre for Clinical Management Research, VA Ann Arbor Health System, Ann Arbor, MI, United States of America
- Department of Internal Medicine, Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Philip Henderson
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, United Kingdom
| | - Alastair H Leyland
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, United Kingdom
| | - Daniel Mackay
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Tara Quasim
- Intensive Care Unit, Glasgow Royal Infirmary, Glasgow, United Kingdom
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, United Kingdom
| | - Matthew Walters
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, United Kingdom
| | - Michael Harhay
- Department of Biostatistics, Epidemiology, and Informatics; and Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Pennsylvania, United States
| | - Martin Shaw
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, United Kingdom
- Clinical Physics, NHS Greater Glasgow and Clyde, Glasgow, United Kingdom
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McPeake J, Quasim T, Henderson P, Leyland AH, Lone NI, Walters M, Iwashyna TJ, Shaw M. Multimorbidity and its relationship with long-term outcomes following critical care discharge: a prospective cohort study. Chest 2021; 160:1681-1692. [PMID: 34153342 PMCID: PMC9199363 DOI: 10.1016/j.chest.2021.05.069] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 05/13/2021] [Accepted: 05/13/2021] [Indexed: 12/02/2022] Open
Abstract
Background Survivors of critical illness have poor long-term outcomes with subsequent increases in health care utilization. Less is known about the interplay between multimorbidity and long-term outcomes. Research Question How do baseline patient demographics impact mortality and health care utilization in the year after discharge from critical care? Study Design and Methods Using data from a prospectively collected cohort, we used propensity score matching to assess differences in outcomes between patients with a critical care encounter and patients admitted to the hospital without critical care. Long-term mortality was examined via nationally linked data as was hospital resource use in the year after hospital discharge. The cause of death was also examined. Results This analysis included 3,112 participants. There was no difference in long-term mortality between the critical care and hospital cohorts (adjusted hazard ratio, 1.09; 95% CI, 0.90-1.32; P = .39). Prehospitalization emotional health issues (eg, clinical diagnosis of depression) were associated with increased long-term mortality (hazard ratio, 1.49; 95% CI, 1.14-1.96; P < .004). Health care utilization was different between the two cohorts in the year after discharge with the critical care cohort experiencing a 29% increased risk of hospital readmission (OR, 1.29; 95% CI, 1.11-1.50; P = .001). Interpretation This national cohort study has demonstrated increased resource use for critical care survivors in the year after discharge but fails to replicate past findings of increased longer-term mortality. Multimorbidity, lifestyle factors, and socioeconomic status appear to influence long-term outcomes and should be the focus of future research.
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Affiliation(s)
- Joanne McPeake
- Intensive Care Unit, Glasgow Royal Infirmary, Glasgow, UK, MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK.
| | - Tara Quasim
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK, Intensive Care Unit, Glasgow Royal Infirmary, Glasgow, UK.
| | - Philip Henderson
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK.
| | - Alastair H Leyland
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK.
| | - Nazir I Lone
- Usher Institute, University of Edinburgh, UK, NHS Lothian, UK.
| | - Matthew Walters
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK.
| | - Theodore J Iwashyna
- Centre for Clinical Management Research, VA Ann Arbor Health System, Ann Arbor, Michigan, United States of America, Department of Internal Medicine, Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, Michigan, United States of America.
| | - Martin Shaw
- Clinical Physics, NHS Greater Glasgow and Clyde, Glasgow, UK, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK.
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Kline JA, Hernandez-Nino J. Quality of Life 3 and 12 Months After Acute Pulmonary Embolism: Analysis From a Prospective Multicenter Cohort Study (New Hope for Outcomes Envy). Chest 2021; 159:2153-2155. [PMID: 34099127 DOI: 10.1016/j.chest.2021.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 02/03/2021] [Indexed: 11/27/2022] Open
Affiliation(s)
- Jeffrey A Kline
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN.
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Anderson S, Stevenson MA, Boller M. Pet health insurance reduces the likelihood of pre-surgical euthanasia of dogs with gastric dilatation-volvulus in the emergency room of an Australian referral hospital. N Z Vet J 2021; 69:267-273. [PMID: 33896404 DOI: 10.1080/00480169.2021.1920512] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
AIMS To determine the association between the presence of pet health insurance and the risk of euthanasia at the time of diagnosis for dogs with gastric dilatation-volvulus (GDV). METHODS Insurance status at the time of GDV diagnosis was sought for a cohort of 147 non-referred, confirmed cases of GDV that presented to the emergency department of a university-based veterinary hospital in Australia between 2008 and 2017. Insurance status was obtained from the medical record (n=18) or after contacting the owners by phone using a standardised questionnaire (n=129). Animal, clinical and outcome data was retrospectively compiled in a research database. The primary outcome measure was whether or not the dog was euthanised before surgery. The Mantel-Haenszel procedure was used to quantify the association between the presence of pet health insurance and the risk of euthanasia at the time of diagnosis for dogs with GDV, adjusting for the confounding effect of age at the time of presentation using Bayesian methods. RESULTS Of the 69 dogs for which insurance information could be obtained, 10 (14%) cases were insured at the time of the GDV event and 59 (86%) cases were not. The majority of non-insured dogs (37/59; 63 (95% CI=50-74)%) were euthanised before surgery, while none (0 (95% CI=0-28)%) of the insured dogs were euthanised at that time (p<0.001). Of the 32 insured and non-insured dogs that underwent surgery, four dogs (13 (95% CI=5-28)%) did not survive to hospital discharge. Three dogs (9%) were euthanised during or after surgery and one dog (3%) experienced cardiopulmonary arrest during treatment. The majority of dogs for which insurance status was known did not survive to hospital discharge (41/69; 59%), and 90 (95% CI=7-96)% of deaths were caused by euthanasia prior to surgery. Uninsured dogs were 5.0 (95% credible interval=1.8-26) times more likely to undergo presurgical euthanasia compared with insured dogs. CONCLUSIONS Euthanasia prior to treatment was most common cause of death in non-referred dogs with GDV; such euthanasia was entirely absent in the cohort of dogs that were insured. CLINICAL RELEVANCE Financial considerations significantly contribute to mortality of dogs with GDV presented to an emergency room. Financial instruments to reduce the out-of-pocket expense for pet owners confronted with unexpected veterinary expenses have potential to reduce pet mortality.
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Affiliation(s)
- S Anderson
- Department of Veterinary Clinical Sciences, Melbourne Veterinary School, University of Melbourne, Werribee, Australia
| | - M A Stevenson
- Department of Veterinary Biosciences, Melbourne Veterinary School, University of Melbourne, Werribee, Australia
| | - M Boller
- Department of Veterinary Clinical Sciences, Melbourne Veterinary School, University of Melbourne, Werribee, Australia
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Hosey MM, Needham DM, Kudchadkar SR. Fatigue in critical care survivors: multidisciplinary and self-management strategies. Anaesthesia 2021; 76:1163-1166. [PMID: 33878209 DOI: 10.1111/anae.15474] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2021] [Indexed: 12/14/2022]
Affiliation(s)
- M M Hosey
- Department of Physical Medicine and Rehabilitation, Outcomes After Critical Illness and Surgery Research Group Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - D M Needham
- Division of Pulmonary and Critical Care Medicine, Outcomes After Critical Illness and Surgery Research Group Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - S R Kudchadkar
- Department of Anesthesiology and Critical Care Medicine, Department of Pediatrics, Department of Physical Medicine and Rehabilitation, Outcomes After Critical Illness and Surgery Research Group Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Hope AA, Johnson AA, McPeake J, Felt H, Sevin CM, Mikkelsen ME, Iwashyna TJ, Lassen-Greene C, Haines KJ, Agarwal S, Bakhru RN, Boehm LM, Butcher BW, Drumright K, Eaton TL, Hibbert E, Hoehn KS, Hornstein D, Imperato-Shedden H, Jackson JC, Kloos JA, Lewis A, Meyer J, Montgomery-Yates A, Rojas V, Schorr C, Wade D, Williams C. Establishing a Peer Support Program for Survivors of COVID-19: A Report From the Critical and Acute Illness Recovery Organization. Am J Crit Care 2021; 30:e1-e5. [PMID: 33566061 PMCID: PMC8364567 DOI: 10.4037/ajcc2021675] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Aluko A Hope
- Aluko A. Hope is an associate professor, Division of Critical Care Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - Andrea Annie Johnson
- Andrea (Annie) Johnson is a nurse practitioner, Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
| | - Joanne McPeake
- Joanne McPeake is a nurse consultant, Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Scotland, United Kingdom and a research fellow, THIS Institute, University of Cambridge, United Kingdom
| | - Hali Felt
- Hali Felt is an author and critical care survivor who is working on her second book, titled Extracorporeal: A Memory of Science and Recovery. She lives in Sacramento, California
| | - Carla M Sevin
- Carla M. Sevin is an associate professor, Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mark E Mikkelsen
- Mark E. Mikkelsen is an associate professor, Division of Pulmonary, Allergy, and Critical Care Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia
| | - Theodore J Iwashyna
- Theodore J. Iwashyna is a professor of internal medicine, Department of Medicine, Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, and a research scientist, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Michigan
| | - Caroline Lassen-Greene
- Caroline Lassen-Greene is an assistant professor, Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center
| | - Kimberley J Haines
- Kimberley J. Haines is the physiotherapy lead and senior ICU physiotherapist, Department of Physiotherapy, Western Health, Sunshine Hospital, St Albans, Australia and an associate professor, Centre for Integrated Critical Care, School of Medicine, The University of Melbourne, Australia
| | - Sachin Agarwal
- Sachin Agarwal is an assistant professor, Department of Neurology (Neurocritical Care), Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, New York
| | - Rita N Bakhru
- Rita N. Bakhru is an assistant professor, Section of Pulmonary, Critical Care, Allergy and Immunology, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Leanne M Boehm
- Leanne M. Boehm is an assistant professor, School of Nursing, Vanderbilt University, Nashville, Tennessee
| | - Brad W Butcher
- Brad W. Butcher is an assistant professor, Department of Critical Care Medicine, University of Pittsburgh Medical Center (UPMC), Pennsylvania
| | - Kelly Drumright
- Kelly Drumright is a clinical nurse leader for the medical intensive care unit, Tennessee Valley Healthcare System VA Medical Center, Nashville, Tennessee
| | - Tammy L Eaton
- Tammy L. Eaton is a PhD candidate at the University of Pittsburgh, School of Nursing, and a founder of the Critical Illness Recovery Center (CIRC) at UPMC Mercy in Pittsburgh, Pennsyvania
| | - Elizabeth Hibbert
- Elizabeth Hibbert is a physiotherapist, Department of Physiotherapy, Western Health, Melbourne, Australia
| | - Karen Sara Hoehn
- Karen Sara Hoehn is director of the Pediatric Palliative Care Team, University of Chicago, Illinois
| | - David Hornstein
- David Hornstein is an assistant professor, McGill University Health Centre, Program of Critical Care and Internal Medicine, Montreal, Québec, Canada
| | - Heather Imperato-Shedden
- Heather Imperato-Shedden is a social worker and family and patient support specialist, Morristown Medical Center, Morristown, New Jersey
| | - James C Jackson
- James C. Jackson is a research professor, Vanderbilt University Medical Center
| | - Janet A Kloos
- Janet A. Kloos is a clinical nurse specialist, Department of Acute and Critical Care Nursing, University Hospitals Cleveland Medical Center, Ohio
| | - Anna Lewis
- Anna Lewis is a senior social worker, CIRC, UPMC Mercy Hospital, Pittsburgh, Pennsylvania
| | - Joel Meyer
- Joel Meyer is a critical care consultant, Guy's and St Thomas' Hospitals, London, United Kingdom
| | - Ashley Montgomery-Yates
- Ashley Montgomery-Yates is an associate professor, Department of Medicine, University of Kentucky
| | - Veronica Rojas
- Veronica Rojas is a critical care nurse leader, Department of Internal Medicine, Hospital Clínico Universidad de Chile, Santiago
| | - Christa Schorr
- Christa Schorr is a clinical nurse scientist and associate professor, Department of Medicine, Division of Critical Care, Cooper Medical School of Rowan University Health Care in New Jersey
| | - Dorothy Wade
- Dorothy Wade is principal health psychologist, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Cydni Williams
- Cydni Williams is an associate professor, Department of Pediatrics, Division of Pediatric Critical Care, Oregon Health & Science University, Portland
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Abstract
PURPOSE OF REVIEW Critical illness survivorship is associated with new and worsening physical, cognitive, and emotional status. Survivors are vulnerable to further health set-backs, most commonly because of infection and exacerbation of chronic medical conditions. Awareness of survivors' challenges are important given the anticipated rise in critical illness survivors because of SARS-CoV-2 viral sepsis. RECENT FINDINGS Studies continue to document challenges of critical illness survivorship. Beyond the cognitive, physical, and mental health sequelae encompassed by postintensive case syndrome, patients commonly experience persistent immunosuppression, re-hospitalization, inability to resume prior employment, and reduced quality of life. Although recommended practices for enhancing recovery from sepsis are associated with better outcomes, only a minority of patients receive all recommended practices. ICU follow-up programs or peer support groups remain important interventions to learn about and address the multifaceted challenges of critical illness survivorship, but there is little evidence of benefit to date. SUMMARY Survivors of sepsis and critical illness commonly experience impaired health status, reduced quality of life, and inability to return to prior employment. Although the challenges of critical illness survivorship are increasingly well documented, there are relatively few studies on enhancing recovery. Future studies must focus on identifying best practices for optimizing recovery and strategies to promote their implementation.
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Affiliation(s)
- Hallie C Prescott
- Department of Internal Medicine, University of Michigan.,VA Center for Clinical Management Research, Ann Arbor, Michigan, USA
| | - Jeremy B Sussman
- Department of Internal Medicine, University of Michigan.,VA Center for Clinical Management Research, Ann Arbor, Michigan, USA
| | - W Joost Wiersinga
- Department of Medicine, Division of Infectious Diseases.,Center for Experimental and Molecular Medicine (CEMM), Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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Financial Toxicity After Hospitalization; Considerations in Coronavirus Disease 2019 Recovery. Crit Care Med 2020; 48:1233-1234. [PMID: 32697496 PMCID: PMC7365585 DOI: 10.1097/ccm.0000000000004436] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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