Baseline quality of life before intensive care: a comparison of patient versus proxy responses

Changes in quality of life 1 year after intensive care: a multicenter prospective cohort of ICU survivors

BACKGROUND

With survival rates of critical illness increasing, quality of life measures are becoming an important outcome of ICU treatment. Therefore, to study the impact of critical illness on quality of life, we explored quality of life before and 1 year after ICU admission in different subgroups of ICU survivors.

METHODS

Data from an ongoing prospective multicenter cohort study, the MONITOR-IC, were used. Patients admitted to the ICU in one of eleven participating hospitals between July 2016 and June 2021 were included. Outcome was defined as change in quality of life, measured using the EuroQol five-dimensional (EQ-5D-5L) questionnaire, and calculated by subtracting the EQ-5D-5L score 1 day before hospital admission from the EQ-5D-5L score 1 year post-ICU. Based on the minimal clinically important difference, a change in quality of life was defined as a change in EQ-5D-5L score of ≥ 0.08. Subgroups of patients were based on admission diagnosis.

RESULTS

A total of 3913 (50.6%) included patients completed both baseline and follow-up questionnaires. 1 year post-ICU, patients admitted after a cerebrovascular accident, intracerebral hemorrhage, or (neuro)trauma, on average experienced a significant decrease in quality of life. Conversely, 11 other subgroups of ICU survivors reported improvements in quality of life. The largest average increase in quality of life was seen in patients admitted due to respiratory disease (mean 0.17, SD 0.38), whereas the largest average decrease was observed in trauma patients (mean -0.13, SD 0.28). However, in each of the studied 22 subgroups there were survivors who reported a significant increase in QoL and survivors who reported a significant decrease in QoL.

CONCLUSIONS

 This large prospective multicenter cohort study demonstrated the diversity in long-term quality of life between, and even within, subgroups of ICU survivors. These findings emphasize the need for personalized information and post-ICU care.

TRIAL REGISTRATION

The MONITOR-IC study was registered at ClinicalTrials.gov: NCT03246334 on August 2nd 2017.

Physical, Mental, and Cognitive Health Status of ICU Survivors Before ICU Admission: A Cohort Study

OBJECTIVES

Although patient's health status before ICU admission is the most important predictor for long-term outcomes, it is often not taken into account, potentially overestimating the attributable effects of critical illness. Studies that did assess the pre-ICU health status often included specific patient groups or assessed one specific health domain. Our aim was to explore patient's physical, mental, and cognitive functioning, as well as their quality of life before ICU admission.

DESIGN

Baseline data were used from the longitudinal prospective MONITOR-IC cohort study.

SETTING

ICUs of four Dutch hospitals.

PATIENTS

Adult ICU survivors (n = 2,467) admitted between July 2016 and December 2018.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patients, or their proxy, rated their level of frailty (Clinical Frailty Scale), fatigue (Checklist Individual Strength-8), anxiety and depression (Hospital Anxiety and Depression Scale), cognitive functioning (Cognitive Failure Questionnaire-14), and quality of life (Short Form-36) before ICU admission. Unplanned patients rated their pre-ICU health status retrospectively after ICU admission. Before ICU admission, 13% of all patients was frail, 65% suffered from fatigue, 28% and 26% from symptoms of anxiety and depression, respectively, and 6% from cognitive problems. Unplanned patients were significantly more frail and depressed. Patients with a poor pre-ICU health status were more often likely to be female, older, lower educated, divorced or widowed, living in a healthcare facility, and suffering from a chronic condition.

CONCLUSIONS

In an era with increasing attention for health problems after ICU admission, the results of this study indicate that a part of the ICU survivors already experience serious impairments in their physical, mental, and cognitive functioning before ICU admission. Substantial differences were seen between patient subgroups. These findings underline the importance of accounting for pre-ICU health status when studying long-term outcomes.

Long-Term Outcome after Prolonged Mechanical Ventilation. A Long-Term Acute-Care Hospital Study

Rationale: Patients managed at a long-term acute-care hospital (LTACH) for weaning from prolonged mechanical ventilation are at risk for profound muscle weakness and disability. Objectives: To investigate effects of prolonged ventilation on survival, muscle function, and its impact on quality of life at 6 and 12 months after LTACH discharge. Methods: This was a prospective, longitudinal study conducted in 315 patients being weaned from prolonged ventilation at an LTACH. Measurements and Main Results: At discharge, 53.7% of patients were detached from the ventilator and 1-year survival was 66.9%. On enrollment, maximum inspiratory pressure (Pi_max) was 41.3 (95% confidence interval, 39.4-43.2) cm H₂O (53.1% predicted), whereas handgrip strength was 16.4 (95% confidence interval, 14.4-18.7) kPa (21.5% predicted). At discharge, Pi_max did not change, whereas handgrip strength increased by 34.8% (P < 0.001). Between discharge and 6 months, handgrip strength increased 6.2 times more than did Pi_max. Between discharge and 6 months, Katz activities-of-daily-living summary score improved by 64.4%; improvement in Katz summary score was related to improvement in handgrip strength (r = -0.51; P < 0.001). By 12 months, physical summary score and mental summary score of 36-item Short-Form Survey returned to preillness values. When asked, 84.7% of survivors indicated willingness to undergo mechanical ventilation again. Conclusions: Among patients receiving prolonged mechanical ventilation at an LTACH, 53.7% were detached from the ventilator at discharge and 1-year survival was 66.9%. Respiratory strength was well maintained, whereas peripheral strength was severely impaired throughout hospitalization. Six months after discharge, improvement in muscle function enabled patients to perform daily activities, and 84.7% indicated willingness to undergo mechanical ventilation again.

Can Patient Reported Outcomes (PROs) from Population Surveys Provide Accurate Estimates of Pre-Admission Health Status of Emergency Hospital Admissions?

INTRODUCTION

The use of PROs for assessing the outcomes of emergency hospital admissions requires a means of estimating patients' pre-admission health status. A possible alternative to asking patients to recall how their health was before the incident causing admission is to use estimates derived from matched samples from population surveys. Our aims were to explore the impact of different methods of matching and to compare the results with estimates based on retrospective reporting.

METHODS

First, elective hip arthroplasty patients were matched to respondents to the General Practice Patient Survey using age, sex, socio-economic status and number of comorbidities. The impact of restricting matching for locality and specific co-morbidities was explored. Second, the best matching method was applied to emergency admissions for laparotomy and for percutaneous coronary intervention (PCI) after acute myocardial infarction. Data were stratified by patient characteristics. Differences in mean EQ-5D scores between the patients and matched population respondents were tested using t tests.

RESULTS

Modifying the most basic form of matching by also taking locality and the specific comorbid conditions into account made no significant difference to the mean EQ-5D score for hip arthroplasty patients. Even using the most detailed matching possible, patients' mean EQ-5D score was significantly different to that of the general population for all three cohorts. The difference was greatest for elective hip arthroplasty (0.22 v 0.64), less so for emergency laparotomy (0.56 v 0.72) and least for PCI (0.79 v 0.71). This reflects hip arthroplasty patients having a long-standing condition characterised by pain and limited mobility, whereas the other two cohorts may have enjoyed reasonable health until an unexpected acute episode led to their emergency admission.

CONCLUSION

Routine PRO data acquired from population surveys cannot be used as an accurate alternative to retrospectively reported PROMs by patients during their emergency admission episode.

The needs of patients with post-intensive care syndrome: A prospective, observational study

BACKGROUND

The needs of critical illness survivors and how best to address these are unclear.

OBJECTIVES

The objective of this study was to identify critical illness survivors who had developed post-intensive care syndrome and to explore their use of community healthcare resources, the socioeconomic impact of their illness, and their self-reported unmet healthcare needs.

METHODS

Patients from two intensive care units (ICUs) in Western Australia who were mechanically ventilated for 5 days or more and/or had a prolonged ICU admission were included in this prospective, observational study. Questionnaires were used to assess participants' baseline health and function before admission, which were then repeated at 1 and 3 months after ICU discharge.

RESULTS

Fifty participants were enrolled. Mean Functional Activities Questionnaire scores increased from 1.8 out of 30 at baseline (95% confidence interval [CI]: 0-3.5) to 8.9 at 1 month after ICU discharge (95% CI: 6.5-11.4; P = <0.001) and 7.0 at 3 months after ICU discharge (95% CI: 4.9-9.1; P = < 0.001). Scores indicating functional dependence increased from 8% at baseline to 54% and 33% at 1 and 3 months after ICU discharge, respectively. Statistically significant declines in health-related quality of life were identified in the domains of Mobility, Personal Care, Usual Activities, and Pain/Discomfort at 1 month after ICU discharge and in Mobility, Personal Care, Usual Activities, and Anxiety/Depression at 3 months after ICU discharge. An increase in healthcare service use was identified after ICU discharge. Participants primarily identified mental health services as the service that they felt they would benefit from but were not accessing. Very low rates of return to work were observed, with 35% of respondents at 3 months, indicating they were experiencing financial difficulty as a result of their critical illness.

CONCLUSIONS

Study participants developed impairments consistent with post-intensive care syndrome, with associated negative socioeconomic ramifications, and identified mental health as an area they need more support in.

Chronic pain in critical care survivors: a narrative review

Chronic pain is an important problem after critical care admission. Estimates of the prevalence of chronic pain in the year after discharge range from 14% to 77% depending on the type of cohort, the tool used to measure pain, and the time point when pain was assessed. The majority of data available come from studies using health-related quality of life tools, although some have included pain-specific tools. Nociceptive, neuropathic, and nociplastic pain can occur in critical care survivors, but limited information about the aetiology, body site, and temporal trajectory of pain is currently available. Older age, pre-existing pain, and medical co-morbidity have been associated with pain after critical care admission. No trials were identified of interventions to target chronic pain in survivors specifically. Larger studies, using pain-specific tools, over an extended follow-up period are required to confirm the prevalence, identify risk factors, explore any association between acute and chronic pain in this setting, determine the underlying pathological mechanisms, and inform the development of future analgesic interventions.

Long-term health-related quality of life of critically ill patients with haematological malignancies: a prospective observational multicenter study

Background

Although outcomes of critically ill patients with haematological malignancies (HMs) have been fully investigated in terms of organ failure and mortality, data are scarce on health-related quality of life (HRQOL) in this population. We aim to assess post-intensive care unit (ICU) burden and HRQOL of critically ill patients with HMs and to identify risk factors for quality-of-life (QOL) impairment.

Results

In total, 1011 patients with HMs who required ICU admission in 17 ICUs in France and Belgium were included in the study; 278 and 117 patients were evaluated for QOL at 3 months and 1 year, respectively, after ICU discharge. HRQOL was determined by applying the interview form of the Short Form 36 (SF-36) questionnaire. Psychological distress symptoms were evaluated using the Hospital Anxiety Depression Score (HADS) and the Impact of Event Scale (IES). In-hospital mortality rates at 3 months and 1 year were, respectively, 39.1, 50.7 and 57.2%, respectively. At 3 months, median [IQR] physical and mental component summary scores (PCS and MCS) (SF-36) were 37 [28–46] and 51 [45–58], respectively. PCS was lower in ICU patients with HMs when compared to general ICU septic patients (52 [5–13], p = 0.00001). The median combined HAD score was 8 [5–13], and the median IES score was 8 [3–16]. However, recovery during the first year after ICU discharge was not consistent in all dimensions of HRQOL. Three months after ICU discharge, the maximum daily Sequential Organ Failure Assessment score and status of the underlying malignancy at ICU admission were significantly associated with MCS impairment (− 0.54 points [95% CI − 0.99; − 0.1], p = 0.018 and − 4.83 points [95% CI − 8.44; − 1.22], p = 0.009, respectively).

Conclusion

HRQOL is strongly impaired in critically ill patients with HMs at 3 months and 1 year after ICU discharge. Organ failure and disease status are strongly associated with QOL. The kinetic evaluation of QOL at 3 months and 1 year offers the opportunity to focus on QOL aspects that may be improved by therapeutic interventions during the first year after ICU discharge.

Electronic supplementary material

The online version of this article (10.1186/s13613-018-0478-3) contains supplementary material, which is available to authorized users.

Feasibility of collecting retrospective patient reported outcome measures (PROMs) in emergency hospital admissions

INTRODUCTION

Outcome of emergency admissions is usually limited to mortality with little attempt to capture the views of health status of survivors. This is because of the challenge of determining patient reported outcome measures (PROMs) for the period before their emergency admission. The aim was to assess the feasibility of collecting retrospective PROMs to capture the pre-admission health status of patients admitted as emergencies.

METHODS

Prospective study of two cohorts: patients undergoing primary coronary angioplasty for acute ST elevation myocardial infarction (STEMI) in five hospitals and emergency laparotomy (EL) for gastro-intestinal conditions in 11 hospitals. Three rates were calculated: proportion of patients eligible for inclusion; proportion of eligible patients invited to participate; proportion of invitees who participated. Staff views were thematically analysed to understand factors that affected recruitment.

RESULTS

About 85% of patients were eligible of whom most were invited to participate (84% EL; 79% STEMI). The proportions of invitees agreeing to participate differed between STEMI (92%) and EL (72%), probably reflecting greater post-intervention morbidity in the latter. Variation between hospitals was observed in the proportion deemed eligible (EL 72-97%; STEMI 63-100%), proportion invited (EL 60-93%; STEMI 71-96%) and the proportion of invitees agreeing to participate (EL 55-92%; STEMI 67-100%). While this might reflect case-mix differences between hospitals, it suggests there is scope for less well performing hospitals to improve their recruitment processes. The extent to which this initial feasibility study was able to assess selection bias was limited to the age and sex of patients. There was no bias evident for EL patients but for STEMI, younger men were more likely to participate.

CONCLUSION

It appears to be feasible to collect retrospective PROMs from patients admitted unexpectedly as emergencies for the two conditions studied. The relevance of these findings to other causes of emergency admissions needs to be established. In addition, these findings justify the case for a large, multi-site study that could explore unresolved concerns about selection bias, particularly those arising from the clinical characteristics of patients. It would also enable estimates of the extent of variation in PROMs between hospitals to determine the usefulness of using PROMs in emergency admissions.

Factors associated with missed assessments in a 2-year longitudinal study of acute respiratory distress syndrome survivors

Background

To evaluate participant-related variables associated with missing assessment(s) at follow-up visits during a longitudinal research study.

Methods

This is a prospective, longitudinal, multi-site study of 196 acute respiratory distress syndrome (ARDS) survivors. More than 30 relevant sociodemographic, physical status, and mental health variables (representing participant characteristics prior to ARDS, at hospital discharge, and at the immediately preceding follow-up visit) were evaluated for association with missed assessments at 3, 6, 12, and 24-month follow-up visits (89–95% retention rates), using binomial logistic regression.

Results

Most participants were male (56%), white (58%), and ≤ high school education (64%). Sociodemographic characteristics were not associated with missed assessments at the initial 3-month visit or subsequent visits. The number of dependencies in Activities of Daily Living (ADLs) at hospital discharge was associated with higher odds of missed assessments at the initial visit (OR: 1.26, 95% CI: 1.12, 1.43). At subsequent 6-, 12-, and 24 months visits, post-hospital discharge physical and psychological status were not associated with subsequent missed assessments. Instead, the following were associated with lower odds of missed assessments: indicators of poorer health prior to hospital admission (inability to walk 5 min (OR: 0.46; 0.23, 0.91), unemployment due to health (OR: 0.47; 0.23, 0.96), and alcohol abuse (OR: 0.53; 0.28, 0.97)) and having the preceding visit at the research clinic rather than at home/facility, or by phone/mail (OR: 0.54; 0.31, 0.96). Inversely, variables associated with higher odds of missed assessments at subsequent visits include: functional dependency prior to hospital admission (i.e. dependency with > = 2 Instrumental Activities of Daily Living (IADLs) (OR: 1.96; 1.08, 3.52), and missing assessments at preceding visit (OR: 2.26; 1.35, 3.79).

Conclusions

During the recovery process after hospital discharge, dependencies in physical functioning (e.g. ADLs, IADLs) prior to hospitalization and at hospital discharge were associated with higher odds of missed assessments. Conversely, other indicators of poorer health at baseline were associated with lower odds of missed assessments after the initial post-discharge visit. To reduce missing assessments, longitudinal clinical research studies may benefit from focusing additional resources on participants with dependencies in physical functioning prior to hospitalization and at hospital discharge.

Electronic supplementary material

The online version of this article (10.1186/s12874-018-0508-8) contains supplementary material, which is available to authorized users.

Perspectives of survivors, families and researchers on key outcomes for research in acute respiratory failure

BACKGROUND

There is heterogeneity among the outcomes evaluated in studies of survivors of acute respiratory failure (ARF).

AIM

To evaluate the importance of specific outcome domains to acute respiratory distress syndrome (ARDS) survivors, their family members and clinical researchers.

METHODS

Nineteen outcome domains were identified from the National Institutes of Health's Patient Reported Outcomes Measurement Information System; WHO's International Classification of Functioning, Disability, and Health; Society of Critical Care Medicine's Post-Intensive Care Syndrome (PICS); as well as patient, clinician and researcher input. We surveyed ARDS survivors, family members and critical care researchers, 279 respondents in total, using a 5-point scale (strongly disagree, disagree, neutral, agree and strongly agree) to rate the importance of measuring each domain in studies of ARF survivors' postdischarge outcomes.

MEASUREMENTS AND MAIN RESULTS

At least 80% of patients and family members supported (ie, rated 'agree' or 'strongly agree') that 15 of the 19 domains should be measured in all future studies. Among researchers, 6 of 19 domains were supported, with researchers less supportive for all domains, except survival (95% vs 72% support). Overall, four domains were supported by all groups: physical function, cognitive function, return to work or prior activities and mental health.

CONCLUSION

Patient, family and researcher groups supported inclusion of outcome domains that fit within the PICS framework. Patients and family members also supported many additional domains, emphasising the importance of including patients/family, along with researchers, in consensus processes to select core outcome domains for future research studies.

Wide Disagreement Between Alternative Assessments of Premorbid Physical Activity: Subjective Patient and Surrogate Reports and Objective Smartphone Data

OBJECTIVES

Surrogate-decision maker and patient self-reported estimates of the distances walked prior to acute illness are subjective and may be imprecise. It may be possible to extract objective data from a patient's smartphone, specifically, step and global position system data, to quantify physical activity. The objectives were to 1) assess the agreement between surrogate-decision maker and patient self-reported estimates of distance and time walked prior to resting and daily step-count and 2) determine the feasibility of extracting premorbid physical activity (step and global position system) data from critically ill patients.

DESIGN

Prospective cohort study.

SETTING

Quaternary ICU.

PATIENTS

Fifty consecutively admitted adult patients who owned a smartphone, who were ambulatory at baseline, and who remained in ICU for more than 48 hours participated.

MEASURMENTS AND MAIN RESULTS

There was no agreement between patients and surrogates for all premorbid walking metrics (mean bias 108% [99% lower to 8,700% higher], 83% [97% to 2,100%], and 71% [96% to 1,080%], for distance, time, and steps, respectively). Step and/or global position system data were successfully extracted from 24 of 50 phones (48%; 95% CI, 35-62%). Surrogate-decision makers, but not patient self-reported, estimates of steps taken per day correlated with smartphone data (surrogates: n = 13, ρ = 0.56, p < 0.05; patients: n = 13, ρ = 0.30, p = 0.317).

CONCLUSION

There was a lack of agreement between surrogate-decision maker and patient self-reported subjective estimates of distance walked. Obtaining premorbid physical activity data from the current-generation smartphones was feasible in approximately 50% of patients.

The rapid and accurate categorisation of critically ill patients (RACE) to identify outcomes of interest for longitudinal studies: a feasibility study

The capacity to measure the impact of an intervention on long-term functional outcomes might be improved if research methodology reflected our clinical approach, which is to individualise goals of care to what is achievable for each patient. The objective of this multicentre inception cohort study was to evaluate the feasibility of rapidly and accurately categorising patients, who were eligible for simulated enrolment into a clinical trial, into unique categories based on premorbid function. Once a patient met eligibility criteria a rapid 'baseline assessment' was conducted to categorise patients into one of eight specified groups. A subsequent 'gold standard' assessment was made by an independent blinded assessor once patients had recovered sufficiently to allow such an assessment to occur. Accuracy was predefined as agreement in >80% of assessments. One hundred and twenty-two patients received a baseline assessment and 104 (85%) were categorised to a unique category. One hundred and six patients survived to have a gold standard assessment performed, with 100 (94%) assigned to a unique category. Ninety-two patients had both a baseline and gold standard assessment, and these agreed in 65 (71%) patients. It was not feasible to rapidly and accurately categorise patients according to premorbid function.

Surrogate inaccuracy in predicting older adults' desire for life-sustaining interventions in the event of decisional incapacity: is it due in part to erroneous quality-of-life assessments?

BACKGROUND

Family members are often called upon to make decisions for an incapacitated relative. Yet they have difficulty predicting a loved one's desire to receive treatments in hypothetical situations. We tested the hypothesis that this difficulty could in part be explained by discrepant quality-of-life assessments.

METHODS

The data come from 235 community-dwelling adults aged 70 years and over who rated their quality of life and desire for specified interventions in four health states (current state, mild to moderate stroke, incurable brain cancer, and severe dementia). All ratings were made on Likert-type scales. Using identical rating scales, a surrogate chosen by the older adult was asked to predict the latter's responses. Linear mixed models were fitted to determine whether differences in quality-of-life ratings between the older adult and surrogate were associated with surrogates' inaccuracy in predicting desire for treatment.

RESULTS

The difference in quality-of-life ratings was a significant predictor of prediction inaccuracy for the three hypothetical health states (p < 0.01) and nearly significant for the current health state (p = 0.077). All regression coefficients were negative, implying that the more the surrogate overestimated quality of life compared to the older adult, the more he or she overestimated the older adult's desire to be treated.

CONCLUSION

Discrepant quality-of-life ratings are associated with surrogates' difficulty in predicting desire for life-sustaining interventions in hypothetical situations. This finding underscores the importance of discussing anticipated quality of life in states of cognitive decline, to better prepare family members for making difficult decisions for their loved ones.

TRIAL REGISTRATION NUMBER

ISRCTN89993391.

Reliability of health-related quality-of-life assessments made by older adults and significant others for health states of increasing cognitive impairment

Background

Older adults are encouraged by many organizations to engage in advance care planning in the event of decisional incapacity. Planning for future health care often involves anticipating health-related quality of life (HRQoL) in states of reduced cognitive functioning. No study has yet examined whether anticipated HRQoL is stable over time. The accuracy with which significant others can predict how an older adult envisions HRQoL in a future state of cognitive impairment is also unknown. We investigated the extent to which health-related quality-of-life ratings made by older adults and designated proxies for health states of increasing cognitive impairment are consistent over time and agree with each other.

Methods

Results are based on HRQoL ratings made on a 5-point Likert scale by 235 community-based elder-proxy dyads on three occasions. Ratings were obtained for the older adult’s current health state as well as under the assumption that he/she had a mild to moderate stroke, incurable brain cancer or severe dementia. Data were analyzed using both traditional approaches (e.g., intraclass correlation coefficients, Bland-Altman plots) and the theory of generalizability.

Results

We found ratings to be reasonably consistent over time and in good agreement within dyads, even more so as implied cognitive functioning worsened. Across health states, ratings over time or within elder-proxy dyads were no more than one category apart in over 87% of cases. Using the theory of generalizability, we further found that, of the two facets investigated, rater had a greater influence on score variability than occasion.

Conclusions

These findings underscore the importance of discussing health-related quality-of-life issues during advance care planning and involving designated proxies in the discussion to enhance their understanding of the role that HRQoL should play in actual decision-making situations. Medical decision-making may be influenced by healthcare providers’ and family members’ assessments of an incapacitated patient’s health-related quality of life, in addition to that of the designated proxy. Future studies should investigate whether these two groups of individuals share the views of the patient and the designated proxy on anticipated HRQoL.

Electronic supplementary material

The online version of this article (doi:10.1186/s12955-016-0579-3) contains supplementary material, which is available to authorized users.

Retrospectively patient-reported pre-event health status showed strong association and agreement with contemporaneous reports

OBJECTIVE

The unpredictability of the occurrence of illnesses and injuries leading to most emergency admissions to hospital makes it impossible prospectively to collect preadmission patient-reported outcome measures (PROMs). Our aims were to review the evidence for using retrospective PROMs to determine pre-event health status and the validity of using general population norms instead of retrospective PROMs.

STUDY DESIGN AND SETTING

Searches of Medline, PsycINFO, Embase, Global Health, and Health Management information. Six studies met the inclusion criteria for the first aim, and 11 studies addressed the second aim. Narrative syntheses were conducted.

RESULTS

Strong associations were found between retrospective and contemporary PROMs in 21 of 30 comparisons (correlation coefficients over 0.68) and 20 of 24 showed strong agreement for continuous measures (intraclass correlations over 0.75). Categorical measures revealed only fair to moderate levels of agreement (kappa 0.3-0.6). Associations were stronger for indices than for individual items and for shorter time intervals. The direction of differences was inconsistent. Retrospective PROMs reported by elderly patients were similar to the general population but younger adults had been healthier.

CONCLUSION

Retrospective collection offers a means of assessing PROMs in unexpected emergency admissions. However, further research is needed to establish the best policy for their use.

The conceptualisation of health-related quality of life in decision-making by intensive care physicians: A qualitative inquiry

OBJECTIVES

To explore how intensive care physicians conceptualise and prioritise patient health-related quality of life in their decision-making.

RESEARCH METHODOLOGY/DESIGN

General qualitative inquiry using elements of Grounded Theory. Six ICU physicians participated.

SETTING

A large, closed, mixed ICU at a university-affiliated hospital, Australia.

RESULTS

Three themes emerged: (1) Multi-dimensionality of HRQoL-HRQoL was described as difficult to understand; the patient was viewed as the best informant. Proxy information on HRQoL and health preferences was used to direct clinical care, despite not always being trusted. (2) Prioritisation of HRQoL within decision-making-this varied across the patient's health care trajectory. Premorbid HRQoL was prioritised when making admission decisions and used to predict future HRQoL. (3) Role of physician in decision-making-the physicians described their role as representing society with peers influencing their decision-making. All participants considered their practice to be similar to their peers, referring to their practice as the "middle of the road". This is a novel finding, emphasising other important influences in high-stakes decision-making.

CONCLUSION

Critical care physicians conceptualised HRQoL as a multi-dimensional subjective construct. Patient (or proxy) voice was integral in establishing patient HRQoL and future health preferences. HRQoL was important in high stakes decision-making including initiating invasive and burdensome therapies or in redirecting therapeutic goals.

The effect of augmenting early nutritional energy delivery on quality of life and employment status one year after ICU admission

Augmenting energy delivery during the acute phase of critical illness may reduce mortality and improve functional outcomes. The objective of this sub-study was to evaluate the effect of early augmented enteral nutrition (EN) during critical illness, on outcomes one year later. We performed prospective longitudinal evaluation of study participants, initially enrolled in The Augmented versus Routine approach to Giving Energy Trial (TARGET), a feasibility study that randomised critically ill patients to 1.5 kcal/ml (augmented) or 1.0 kcal/ml (routine) EN administered at the same rate for up to ten days, who were alive at one year. One year after randomisation Short Form-36 version 2 (SF-36v2) and EuroQol-5D-5L quality of life surveys, and employment status were assessed via telephone survey. At one year there were 71 survivors (1.5 kcal/ml 38 versus 1.0 kcal/ml 33; P=0.55). Thirty-nine (55%) patients consented to this follow-up study and completed the surveys (n = 23 and 16, respectively). The SF-36v2 physical and mental component summary scores were below normal population means but were similar in 1.5 kcal/ml and 1.0 kcal/ml groups (P=0.90 and P=0.71). EuroQol-5D-5L data were also comparable between groups (P=0.70). However, at one-year follow-up, more patients who received 1.5 kcal/ml were employed (7 versus 2; P=0.022). The delivery of 1.5 kcal/ml for a maximum of ten days did not affect self-rated quality of life one year later.

Winning the war against ICU-acquired weakness: new innovations in nutrition and exercise physiology

Over the last 10 years we have significantly reduced hospital mortality from sepsis and critical illness. However, the evidence reveals that over the same period we have tripled the number of patients being sent to rehabilitation settings. Further, given that as many as half of the deaths in the first year following ICU admission occur post ICU discharge, it is unclear how many of these patients ever returned home. For those who do survive, the latest data indicate that 50-70% of ICU "survivors" will suffer cognitive impairment and 60-80% of "survivors" will suffer functional impairment or ICU-acquired weakness (ICU-AW). These observations demand that we as intensive care providers ask the following questions: "Are we creating survivors ... or are we creating victims?" and "Do we accomplish 'Pyrrhic Victories' in the ICU?" Interventions to address ICU-AW must have a renewed focus on optimal nutrition, anabolic/anticatabolic strategies, and in the future employ the personalized muscle and exercise evaluation techniques utilized by elite athletes to optimize performance. Specifically, strategies must include optimal protein delivery (1.2-2.0 g/kg/day), as an athlete would routinely employ. However, as is clear in elite sports performance, optimal nutrition is fundamental but alone is often not enough. We know burn patients can remain catabolic for 2 years post burn; thus, anticatabolic agents (i.e., beta-blockers) and anabolic agents (i.e., oxandrolone) will probably also be essential. In the near future, evaluation techniques such as assessing lean body mass at the bedside using ultrasound to determine nutritional status and ultrasound-measured muscle glycogen as a marker of muscle injury and recovery could be utilized to help find the transition from the acute phase of critical illness to the recovery phase. Finally, exercise physiology testing that evaluates muscle substrate utilization during exercise can be used to diagnose muscle mitochondrial dysfunction and to guide a personalized ideal heart rate, assisting in recovery of muscle mitochondrial function and functional endurance post ICU. In the end, future ICU-AW research must focus on using a combination of modern performance-enhancing nutrition, anticatabolic/anabolic interventions, and muscle/exercise testing so we can begin to create more "survivors" and fewer victims post ICU care.

Long-term treated intensive care patients outcomes: the one-year mortality rate, quality of life, health care use and long-term complications as reported by general practitioners

BACKGROUND

The purpose of this study was to determine the one-year mortality rate and its predictors regarding long-term intensive care-treated patients together with their health-related quality of life (HRQL), place of living, healthcare use and long-term complication characteristics after intensive care unit (ICU) discharge.

METHODS

A retrospective cohort study was performed in a 20-bed mixed ICU. The patients that were treated for more than 72 h between 2007 and 2012 were included in this study. The one-year mortality rate was calculated, and the characteristics of the ICU survivors that died within one year after ICU discharge were further analysed. For all patients, the Dutch version of the SF-36 questionnaire was used to assess their current HRQL. The results were compared with a normal population. Additionally, patients were questioned about their place of living, and their general practitioners (GPs) were questioned about the patients' possible long-term complications.

RESULTS

Seven hundred and forty patients were included in this study, and their one-year mortality rate was 28 %, of which half died within the first week after ICU discharge. The one-year mortality rate predictors included age at the time of ICU admission, APACHE IV-predicted mortality score, number of comorbidities and ICU re-admissions. The ICU survivor HRQL was significantly lower compared with the normal population. Half of the patients did not return to their pre-hospital place of living, and numerous possible long-term complications were reported, particularly decreased tolerance, chronic fatigue and processing problems of relatives.

CONCLUSIONS

One-year mortality rate of long-term ICU-treated patient was 28 %, and this was predicted by age, disease severity, comorbidities and ICU re-admissions. The ICU survivors reported a lower HRQL, and a minority of these patients returned home directly after hospital discharge; however, GPs reported numerous possible long-term complications.

Six-month quality-of-life and functional status of acute respiratory distress syndrome survivors compared to patients at risk: a population-based study

Introduction

The long-term attributable burden related to acute respiratory distress syndrome (ARDS) is not fully investigated. The aim of this study is to evaluate the quality of life (QOL) and functional status at 6 months after hospitalization in patients at risk for ARDS who did and did not develop the syndrome.

Method

This is a population-based prospective cohort study of adult patients from Olmsted County, Minnesota, with or at risk for ARDS hospitalized from October 2008 to July 2011. The primary outcomes were changes in QOL and functional status, measured through 12-Item Short Form Survey (SF-12) and Barthel Index (BI) respectively, from baseline to 6 months, compared between survivors who did and did not develop ARDS.

Results

Of 410 patients with or at risk for ARDS, 98 had baseline surveys collected and 67 responded to a 6-month survey (26 ARDS, 41 non-ARDS). Both ARDS and non-ARDS groups had lower physical component of SF-12 at baseline compared to general population (P < 0.001 for both). ARDS patients had poorer baseline functional status compared to non-ARDS (mean BI 80 ± 25 vs. 88 ± 22, P = 0.03). No significant differences were observed for the change between 6 months and baseline BI (delta 2.3 for ARDS vs. 2.0 for non-ARDS, P = 0.5), or mental (delta 2.7 vs. 2.4, P = 0.9) or physical (delta –3 vs. –3.3, P = 0.9) component of SF-12 between survivors with and without ARDS.

Conclusion

In this population-based study, decreased QOL and functional status 6 months after hospitalization were largely explained by baseline condition, with similar recovery in survivors who did and did not develop ARDS.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-1062-y) contains supplementary material, which is available to authorized users.

The Association Between Nutritional Adequacy and Long-Term Outcomes in Critically Ill Patients Requiring Prolonged Mechanical Ventilation: A Multicenter Cohort Study

OBJECTIVE

To examine the association between short-term nutritional adequacy received while in the ICU and long-term outcomes including 6-month survival and health-related quality of life in critically ill patients requiring prolonged mechanical ventilation.

DESIGN

Retrospective analysis of data prospectively collected in the context of a multicenter randomized controlled trial.

SETTING

An international sample of ICUs.

PATIENTS

Adult patients who were mechanically ventilated for more than 8 days in the ICU.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Nutritional adequacy was obtained from the average proportion of prescribed calories received over the amount prescribed during the first 8 days. Survival status and health-related quality of life as assessed using the Short-Form 36 v2 were obtained at 3- and 6 months post ICU admission. Of the 1,223 patients enrolled in the randomized controlled trial, 475 met the inclusion criteria for this study. At 6-month follow-up, 302 of the 475 patients (64%) were alive. Survival time in those who received low nutritional adequacy was significantly shorter than those who received high nutritional adequacy while adjusting for important covariates (adjusted hazard ratio, 1.7; 95% CI, 1.1-2.6). At 3-month follow-up, a 25% increase in nutritional adequacy was associated with improvements in Physical Functioning and Role Physical of 7.3 (p = 0.02) and 8.3 (p = 0.004) points, respectively. At 6-month follow-up, adjusted increases in Physical Functioning and Role Physical scores for every 25% increase in nutrition adequacy became smaller and were no longer statistically significant (adjusted estimate for Physical Functioning = 4.2, p = 0.14; for Role Physical = 3.2, p = 0.25).

CONCLUSIONS

Greater amounts of nutritional intake received during the first week in the ICU were associated with longer survival time and faster physical recovery to 3 months but not 6 months post ICU discharge in critically ill patients requiring prolonged mechanical ventilation. Current recommendations to underfeed critically ill patients may cause harm in some long-stay patients.

Combining nutrition and exercise to optimize survival and recovery from critical illness: Conceptual and methodological issues

Survivors of critical illness commonly experience neuromuscular abnormalities, including muscle weakness known as ICU-acquired weakness (ICU-AW). ICU-AW is associated with delayed weaning from mechanical ventilation, extended ICU and hospital stays, more healthcare-related hospital costs, a higher risk of death, and impaired physical functioning and quality of life in the months after ICU admission. These observations speak to the importance of developing new strategies to aid in the physical recovery of acute respiratory failure patients. We posit that to maintain optimal muscle mass, strength and physical function, the combination of nutrition and exercise may have the greatest impact on physical recovery of survivors of critical illness. Randomized trials testing this and related hypotheses are needed. We discussed key methodological issues and proposed a common evaluation framework to stimulate work in this area and standardize our approach to outcome assessments across future studies.

Should additional domains be added to the EQ-5D health-related quality of life instrument for community-based studies? An analytical descriptive study

Background

There is increasing interest in monitoring the health-related quality of life (HRQoL) of populations as opposed to clinical populations. The EQ-5D identifies five domains as being most able to capture the HRQoL construct. The question arises as to whether these domains are adequate within a community-based population or whether additional domains would add to the explanatory power of the instrument.

Methods

As part of a community-based survey, the responses of 310 informants who reported at least one problem in one domain filled in the EQ-5D three-level version and the WHOQOL-BREF (World Health Organization Quality of Life Scale – Abbreviated version). Using the EQ-5D visual analogue scale (VAS) of rating of health as a dependent variable, the five EQ-5D and four selected WHOQOL-BREF items were entered as dummy variables in multiple regression analysis.

Results

The additional domains increased the explanatory power of the model from 52 % (EQ-5D only) to 57 % (all domains). The coefficients of Self-Care and Usual Activities were not significant in any model. The most parsimonious model included the EQ-5D domains of Mobility, Pain/Discomfort, Anxiety/Depression, Concentration, and Sleep (adjusted r² = .57).

Conclusions

The EQ-5D-3L performed well, but the addition of domains such as Concentration and Sleep increased the explanatory power. The user needs to weigh the advantage of using the EQ-5D, which allows for the calculation of a single summary index, against the use of a set of domains that are likely to be more responsive to differences in HRQoL within community living respondents. The poor predictive power of the Self-Care and Usual Activities domains within this context needs to be further examined.

Validation of the Intermountain patient perception of quality (PPQ) survey among survivors of an intensive care unit admission: a retrospective validation study

Background

Patients’ perceptions of the quality of their hospitalization have become important to the American healthcare system. Standard surveys of perceived quality of healthcare do not focus on the Intensive Care Unit (ICU) portion of the stay. Our objective was to evaluate the construct validity and internal consistency of the Intermountain Patient Perception of Quality (PPQ) survey among patients discharged from the ICU.

Methods

We analyzed prospectively collected results from the ICU PPQ survey of all inpatients at Intermountain Medical Center whose hospitalization included an ICU stay. We employed principal components analysis to determine the constructs present in the PPQ survey, and Cronbach’s alpha to evaluate the internal consistency (reliability) of the items representing each construct.

Results

We identified 5,680 patients who had completed the PPQ survey. There were three basic domains measured: nursing care, physician care, and overall perception of quality. Most of the variability was explained with the first two principal components. Constructs did not vary by type of respondent.

Conclusions

The Intermountain ICU PPQ survey demonstrated excellent construct validity across three distinct constructs. This, in addition to its previously established content validity, suggests the utility of the PPQ survey as an assay of the perceived quality of the ICU experience.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-0828-x) contains supplementary material, which is available to authorized users.

Single-center large-cohort study into quality of life in Dutch intensive care unit subgroups, 1 year after admission, using EuroQoL EQ-6D-3L

PURPOSE

The goal of this study was to describe long-term survival and health-related quality of life (HRQoL), measured by EQ-6D, in a general intensive care unit (ICU) population.

MATERIALS AND METHODS

We included 5934 consecutive adult patients admitted to a mixed-population ICU. There were no exclusion criteria. One-year survival status was determined using the Dutch municipal population register. Subsequently, all survivors received the EuroQoL EQ-6D-3L questionnaire. The primary outcome was overall HRQoL and survival of the ICU survivors, compared to overall QoL of an age- and sex-matched reference population.

RESULTS

A total of 5138 patients (86.6%) survived until hospital discharge, with 4647 (78.3%) patients surviving the 1-year of follow-up. The EuroQoL questionnaire was sent to 4465 survivors and returned by 3034 (68.0%) of 4465. The median HRQoL in surviving patients was 0.83 (interquartile range [IQR], 0.64-1.00) vs 0.86 (IQR, 0.85-0.86) in the reference population (P < .001). There was marked variation across admission diagnosis groups: cardiac surgery patients had an HRQoL of 0.94 (IQR, 0.74-1.00), whereas patients admitted with chronic renal failure had an HRQoL of 0.65 (IQR, 0.47-0.83).

CONCLUSIONS

One year after ICU admission, HRQoL was significantly lower than in the reference population. Notably, marked variations were found across subgroups.

Quality of life before admission to the intensive care unit

Objective

To examine the reliability of the SF-36 general health questionnaire when used to evaluate the health status of critically ill patients before admission to intensive care and to measure their health-related quality of life prior to admission and its relation to severity of illness and length of stay in the intensive care unit.

Methods

Prospective cohort study conducted in the intensive care unit of a public teaching hospital. Over three months, communicative and oriented patients were interviewed within the first 72 hours of intensive care unit admission; 91 individuals participated. The APACHE II score was used to assess severity of illness, and the SF-36 questionnaire was used to measure health-related quality of life.

Results

The reliability of SF-36 was verified in all dimensions using Cronbach's alpha coefficient. In six dimensions of eight domains the value exceeded 0.70. The average SF-36 scores of the health-related quality of life dimensions for the patients before admission to intensive care unit were 57.8 for physical functioning, 32.4 for role-physical, 53.0 for bodily pain, 63.2 for general health, 50.6 for vitality, 56.2 for social functioning, 54.6 for role-emotional and 60.3 for mental health. The correlations between severity of illness and length of stay and the health-related quality of life scores were very low, ranging from -0.152 to 0.175 and -0.158 to 0.152, respectively, which were not statistically significant.

Conclusion

In the sample studied, the SF-36 demonstrated good reliability when used to measure health-related quality of life in critically ill patients before admission to the intensive care unit. The worst score was role-physical and the best was general health. Health-related quality of life of patients before admission was not correlated with severity of illness or length of stay in the intensive care unit.

Health-related quality of life scores after intensive care are almost equal to those of the normal population: a multicenter observational study

INTRODUCTION

Health-related quality of life (HRQoL) in patients treated in intensive care has been reported to be lower compared with age- and sex-adjusted control groups. Our aim was to test whether stratifying for coexisting conditions would reduce observed differences in HRQoL between patients treated in the ICU and a control group from the normal population. We also wanted to characterize the ICU patients with the lowest HRQoL within these strata.

METHODS

We did a cross-sectional comparison of scores of the short-form health survey (SF-36) questionnaire in a multicenter study of patients treated in the ICU (n = 780) and those from a local public health survey (n = 6,093). Analyses were in both groups adjusted for age and sex, and data stratified for coexisting conditions. Within each stratum, patients with low scores (below -2 SD of the control group) were identified and characterized.

RESULTS

After adjustment, there were minor and insignificant differences in mean SF-36 scores between patients and controls. Eight (n = 18) and 22% (n = 51) of the patients had low scores (-2 SD of the control group) in the physical and mental dimensions of SF-36, respectively. Patients with low scores were usually male, single, on sick leave before admission to critical care, and survived a shorter time after being in ICU.

CONCLUSIONS

After adjusting for age, sex, and coexisting conditions, mean HRQoL scores were almost equal in patients and controls. Up to 22% (n = 51) of the patients had, however, a poor quality of life as compared with the controls (-2 SD). This group, which more often consisted of single men, individuals who were on sick leave before admission to the ICU, had an increased mortality after ICU. This group should be a target for future support.

Conflicts and communication gaps in the intensive care unit

PURPOSE OF REVIEW

Conflicts occur frequently in the ICU. Research on ICU conflicts is an emerging field, with only few recent studies being available on intrateam and team-family conflicts. Research on communication in the ICU is developing at a faster pace.

RECENT FINDINGS

Recent findings come from one multinational epidemiological survey on intrateam conflicts and one qualitative study on the causes and consequences of conflicts. Advances in research on communication with families in the ICU have improved our understanding of team-family and intrateam conflicts, thus suggesting targets for improvement.

SUMMARY

Data about ICU conflicts depend on conflict definition, study designs (qualitative versus quantitative), patient case-mix, and detection bias. Conflicts perceived by caregivers are frequent and consist mainly in intrateam conflicts. The two main sources of conflicts in the ICU are end-of-life decisions and communication issues. Conflicts negatively impact patient safety, patient/family-centered care, and team welfare and cohesion. They generate staff burnout and increase healthcare costs. Further qualitative studies rooted in social-science theories about workplace conflicts are needed to better understand the typology of ICU conflicts (sources and consequences) and to address complex ICU conflicts that involve systems as opposed to people. Conflict prevention and resolution are complex issues requiring multimodal interventions. Clinical research in this field is insufficiently developed, and no guidelines are available so far. Prevention strategies need to be developed along two axes: improved understanding of family experience, preferences, and values, as well as evidence-based communication may reduce team-family conflicts and organizational measures including restoring leadership, multidisciplinary teamwork, and improved communication within the team may prevent intrateam conflicts in the ICU.

Symptoms of depression in survivors of severe sepsis: a prospective cohort study of older Americans

OBJECTIVES

To examine if incident severe sepsis is associated with increased risk of subsequent depressive symptoms and to assess which patient characteristics are associated with increased risk of depressive symptoms.

DESIGN

Prospective longitudinal cohort study.

SETTING

Population-based cohort of older U.S. adults interviewed as part of the Health and Retirement Study (1998-2006).

PARTICIPANTS

A total of 439 patients who survived 471 hospitalizations for severe sepsis and completed at least one follow-up interview.

MEASUREMENTS

Depressive symptoms were assessed with a modified version of the Center for Epidemiologic Studies Depression Scale. Severe sepsis was identified using a validated algorithm in Medicare claims.

RESULTS

The point prevalence of substantial depressive symptoms was 28% at a median of 1.2 years before sepsis, and remained 28% at a median of 0.9 years after sepsis. Neither incident severe sepsis (relative risk [RR]: 1.00; 95% confidence interval [CI]: 0.73, 1.34) nor severe sepsis-related clinical characteristics were significantly associated with subsequent depressive symptoms. These results were robust to potential threats from missing data or alternative outcome definitions. After adjustment, presepsis substantial depressive symptoms (RR: 2.20; 95% CI: 1.66, 2.90) and worse postsepsis functional impairment (RR: 1.08 per new limitation; 95% CI: 1.03, 1.13) were independently associated with substantial depressive symptoms after sepsis.

CONCLUSIONS

The prevalence of substantial depressive symptoms in severe sepsis survivors is high but is not increased relative to their presepsis levels. Identifying this large subset of severe sepsis survivors at increased risk for major depression, and beginning interventions before hospital discharge, may improve outcomes.

A framework for understanding quality of life in individuals without capacity

PURPOSE

The wide range of tools and methods developed for measuring and valuing health-related quality of life for use in economic evaluations are appropriate for use in most populations. However, for certain populations, specific tools may need to be developed to reflect the particular needs of that population. Patients without capacity--particularly patients with severe dementia--are such a population. At present, the tools available to economists for measuring and valuing quality of life in these patients lack validity. Here, we seek to understand the framework within which common instruments have been developed, critique these instruments with respect to patients with severely restricted capacity and to develop a new way of thinking about how to value health-related quality of life in such patients.

METHOD

In this essay, we describe and critique the conceptual framework by which common instruments used for measuring and valuing quality of life have been developed.

RESULTS

We show that current common instruments used for measuring and valuing quality of life in general populations are not appropriate for populations with severely restricted capacity.

CONCLUSIONS

We propose a new framework for thinking about quality of life in this population, based on notions of observable person-centred outcomes and utility derived from processes of care.

One year outcomes in patients with acute lung injury randomised to initial trophic or full enteral feeding: prospective follow-up of EDEN randomised trial

OBJECTIVE

To evaluate the effect of initial low energy permissive underfeeding ("trophic feeding") versus full energy enteral feeding ("full feeding") on physical function and secondary outcomes in patients with acute lung injury.

DESIGN

Prospective longitudinal follow-up evaluation of the NHLBI ARDS Clinical Trials Network's EDEN trial

SETTING

41hospitals in the United States.

PARTICIPANTS

525 patients with acute lung injury.

INTERVENTIONS

Randomised assignment to trophic or full feeding for up to six days; thereafter, all patients still receiving mechanical ventilation received full feeding.

MEASUREMENTS

Blinded assessment of the age and sex adjusted physical function domain of the SF-36 instrument at 12 months after acute lung injury. Secondary outcome measures included survival; physical, psychological, and cognitive functioning; quality of life; and employment status at six and 12 months.

RESULTS

After acute lung injury, patients had substantial physical, psychological, and cognitive impairments, reduced quality of life, and impaired return to work. Initial trophic versus full feeding did not affect mean SF-36 physical function at 12 months (55 (SD 33) v 55 (31), P=0.54), survival to 12 months (65% v 63%, P=0.63), or nearly all of the secondary outcomes.

CONCLUSION

In survivors of acute lung injury, there was no difference in physical function, survival, or multiple secondary outcomes at 6 and 12 month follow-up after initial trophic or full enteral feeding.

TRIAL REGISTRATION

NCT No 00719446.

Quality of life before intensive care using EQ-5D: patient versus proxy responses

OBJECTIVE

To compare patients' retrospectively reported baseline quality of life before intensive care hospitalization with population norms and proxy reports.

DESIGN

Prospective cohort study.

SETTING

Thirteen ICUs at four teaching hospitals in Baltimore, MD.

PATIENTS

One hundred forty acute lung injury survivors and their designated proxies.

INTERVENTIONS

Around the time of hospital discharge, both patients and proxies were asked to retrospectively estimate patients' baseline quality of life before hospital admission using the EQ-5D quality-of-life instrument.

MEASUREMENTS AND MAIN RESULTS

Mean patient-rated EQ-5D visual analog scale scores and utility scores were significantly lower than population norms but were significantly higher than proxy ratings. However, the magnitude of difference in average utility scores between patients and either population norms or proxies was not clinically important. For the five individual EQ-5D domains, κ statistics revealed slight to fair agreement between patients and proxies. Bland-Altman plots demonstrated that for both the visual analog scale and utility scores, proxies underestimated scores when patients reported high ratings and overestimated scores for low patient ratings.

CONCLUSIONS

Patients retrospectively reported worse baseline health status before acute lung injury than population norms and better status than proxy reports; however, the magnitude of these differences in health status may not be clinically important. Proxies had only slight to fair agreement with patients in all five EQ-5D domains, attenuating patients' more extreme ratings toward moderate scores. Caution is required when interpreting proxy retrospective reports of baseline health status for survivors of acute lung injury.

Depressive symptoms in spouses of older patients with severe sepsis

OBJECTIVE

To examine whether spouses of patients with severe sepsis are at increased risk for depression independent of the spouse's presepsis history, whether this risk differs by sex, and is associated with a sepsis patient's disability after hospitalization.

DESIGN

Prospective longitudinal cohort study.

SETTING

Population-based cohort of U.S. adults over 50 yrs old interviewed as part of the Health and Retirement Study (1993-2008).

PATIENTS

Nine hundred twenty-nine patient-spouse dyads comprising 1,212 hospitalizations for severe sepsis.

MEASUREMENTS AND MAIN RESULTS

Severe sepsis was identified using a validated algorithm in Medicare claims. Depression was assessed with a modified version of the Center for Epidemiologic Studies Depression Scale. All analyses were stratified by gender. The prevalence of substantial depressive symptoms in wives of patients with severe sepsis increased by 14 percentage points at the time of severe sepsis (from 20% at a median of 1.1 yrs presepsis to 34% at a median of 1 yr postsepsis) with an odds ratio of 3.74 (95% confidence interval: 2.20, 6.37), in multivariable regression. Husbands had an 8 percentage point increase in the prevalence of substantial depressive symptoms, which was not significant in multivariable regression (odds ratio 1.90, 95% confidence interval 0.75, 4.71). The increase in depression was not explained by bereavement; women had greater odds of substantial depressive symptoms even when their spouse survived a severe sepsis hospitalization (odds ratio 2.86, 95% confidence interval 1.06, 7.73). Wives of sepsis survivors who were disabled were more likely to be depressed (odds ratio 1.35 per activities of daily living limitation of sepsis survivor, 95% confidence interval 1.12, 1.64); however, controlling for patient disability only slightly attenuated the association between sepsis and wives' depression (odds ratio 2.61, 95% confidence interval 0.93, 7.38).

CONCLUSIONS

Older women may be at greater risk for depression if their spouse is hospitalized for severe sepsis. Spouses of patients with severe sepsis may benefit from greater support and depression screening, both when their loved one dies and when their loved one survives.

Level of agreement between patient and proxy responses to the EQ-5D health questionnaire 12 months after injury

BACKGROUND

Health-related quality of life represents a patient's experiences and expectations and should be collected from the patient. In trauma, collection of information from the patient can be challenging, particularly for subgroups where cognitive impairment is prevalent, increasing reliance on proxy reporting. This study assessed the agreement between patient and proxy reporting of health-related quality of life 12 months after injury.

METHODS

The Victorian State Trauma Registry and Victorian Orthopaedic Trauma Outcomes Registry collect EQ-5D data at 12 months after injury. Cases where data were collected from the patient and proxy were extracted. Agreement between patient and proxy responses was compared using kappa (K) coefficients for the individual EQ-5D items, and Bland-Altman plots and Wilcoxon signed-rank tests for the EQ-5D summary score and visual analog scale (VAS).

RESULTS

Agreement between patient and proxy respondents was substantial for the mobility (K = 0.61) and personal care items (K = 0.67) and moderate for the usual activities (K = 0.50), pain/discomfort (K = 0.42), and anxiety/depression items (K = 0.47). The mean difference between proxy and patient-reported scores for the VAS (0.74, 95% confidence interval: -2.73, 4.21) and the EQ-5D summary score (-0.02, 95% confidence interval: -0.07, 0.03) was small, but the limits of agreement were wide (-34.22 to 35.71 for VAS and -0.55 to 0.51 for summary score), suggesting no systematic bias.

CONCLUSIONS

Although proxy and patient responses for the EQ-5D VAS may differ, the differences show random variability rather than systematic bias. Group comparisons using proxy responses are unlikely to be biased, but proxy responses should be used with caution when assessing individual patient recovery.

Spurious inferences about long-term outcomes: the case of severe sepsis and geriatric conditions

RATIONALE

Survivors of critical illness suffer significant limitations and disabilities.

OBJECTIVES

Ascertain whether severe sepsis is associated with increased risk of so-called geriatric conditions (injurious falls, low body mass index [BMI], incontinence, vision loss, hearing loss, and chronic pain) and whether this association is measured consistently across three different study designs.

METHODS

Patients with severe sepsis were identified in the Health and Retirement Study, a nationally representative cohort interviewed every 2 years, 1998 to 2006, and in linked Medicare claims. Three comparators were used to assess an association of severe sepsis with geriatric conditions in survivors: the prevalence in the United States population aged 65 years and older, survivors' own pre-sepsis levels assessed before hospitalization, or survivors' own pre-sepsis trajectory.

MEASUREMENTS AND MAIN RESULTS

Six hundred twenty-three severe sepsis hospitalizations were followed a median of 0.92 years. When compared with the 65 years and older population, surviving severe sepsis was associated with increased rates of low BMI, injurious falls, incontinence, and vision loss. Results were similar when comparing survivors to their own pre-sepsis levels. The association of low BMI and severe sepsis persisted when controlling for patients' pre-sepsis trajectories, but there was no association of severe sepsis with injurious falls, incontinence, vision loss, hearing loss, and chronic pain after such controls.

CONCLUSIONS

Geriatric conditions are common after severe sepsis. However, severe sepsis is associated with increased rates of only a subset of geriatric conditions, not all. In studying outcomes after acute illness, failing to measure and control for both preillness levels and trajectories may result in erroneous conclusions.

Health-related quality of life in Australian survivors of critical illness

OBJECTIVE

To document health-related quality of life of an Australian sample of intensive care unit survivors 6 months after intensive care unit discharge and compare this with preadmission health-related quality of life, health-related quality of life of national population norms, and international samples of intensive care unit survivors.

DESIGN

Prospective observational single-center study.

SETTING

Eighteen-bed medical-surgical tertiary intensive care unit of an Australian metropolitan hospital.

PATIENTS

Of the 122 eligible patients, 100 were recruited (intensive care unit length of stay >48 hrs, age >18 yrs, not imminently at risk of death) and the final sample comprised 67 patients, age (median [interquartile range], 61 yrs [49-73 yrs]), 60% male admitted to the intensive care unit for a median [interquartile range] 101 hrs (68-149 hrs). Normative age- and sex-matched Australian Short-Form 36 data from the Australian Bureau of Statistics, selected international cohorts of intensive care unit survivors, and their respective national age-matched normative data were included for comparison.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Sixty-seven participants provided responses to questions rating health-related quality of life (Australian Short-Form 36) at preadmission (on admission to the intensive care unit or through retrospective recall as soon as able) and 6 months after intensive care unit discharge. Ten additional participants were unable to provide study data without proxy input and were excluded from analysis. Participants reported clinically meaningful improvements in bodily pain (p = .001), social functioning (p = .03), role-emotional domains of the Short-Form 36 (p = .04), and mental component summary score (p = .01) at 6 months after intensive care unit discharge, mostly attributable to the patients undergoing cardiac surgery, whereas remaining Short-Form 36 domains showed no difference between preadmission and 6 months (p > .05). Participants reported clinically meaningful decrements in preadmission Short-Form 36 data compared with the Australian normative population with role-physical (p < .001) and physical functioning (p < .001) most affected at follow-up. Health-related quality of life in this sample was comparable with international samples of intensive care unit survivors.

CONCLUSIONS

Although the majority of health-related quality of life domains did not differ between preadmission and 6-month follow-up, participants reported significant and clinically meaningful improvements in pain and mental health at follow-up. Critical illness survivors' health-related quality of life remained within 1 sd of Australian norms at follow-up and physical function health-related quality of life was most affected. Health-related quality of life in these Australian survivors of the intensive care unit was comparable with international survivors 6 months after intensive care unit admission.

The Academic Medical Center Linear Disability Score for evaluation of physical reserve on admission to the ICU: can we query the relatives?

Introduction

Evaluating the pre-morbid functional status in critically ill patients is important and frequently done using the physical component score (PCS) of the Short Form 36, although this approach has its limitations. The Academic Medical Center Linear Disability Score (ALDS) is a recently developed generic item bank used to measure the disability status of patients with a broad range of diseases. We aimed to study whether proxy scoring with the ALDS could be used to assess the patients' functional status on admission for cardiac care unit (CCU) or ICU patients and how the ALDS relates to the PCS using the Short Form 12 (SF-12).

Methods

Patients and proxies completed the ALDS and SF-12 score in the first 72 hours following ICU scheduled surgery (n = 14), ICU emergency admission (n = 56) and CCU emergency admission (n = 70).

Results

In all patients (n = 140) a significant intra-class correlation was found for the ALDS (0.857), the PCS (0.798) and the mental component score (0.679) between patients and their proxy. In both scheduled and emergency admissions, a significant correlation was found between patients and their proxy for the ALDS, although the lowest correlation was found for the ICU scheduled admissions (0.755) compared with the ICU emergency admissions (0.889). In CCU patients, the highest significant correlation between patients and proxies was found for the ALDS (0.855), for the PCS (0.807) and for the mental component score (0.740).

Conclusions

Relatives in close contact with critically ill patients can adequately reflect the patient's level of disability on ICU and CCU admission when using the ALDS item bank, which performed at least as well as the PCS. The ALDS could therefore be a useful alternative for the PCS of the SF-12.

Does intensive care unit severity of illness influence recall of baseline physical function?

PURPOSE

The aim of this study is to evaluate if severity of illness in the intensive care unit influences patients' retrospective recall of their baseline physical function from before hospital admission.

MATERIALS AND METHODS

This is a prospective cohort study of 193 acute lung injury survivors who, before hospital discharge, retrospectively reported their prehospitalization physical function using the Short Form 36 quality of life survey.

RESULTS

Four measures were used to evaluate intensive care unit (ICU) severity of illness: (1) Acute Physiology and Chronic Health Evaluation II Acute Physiologic Score at ICU admission, (2) Lung Injury Score at acute lung injury diagnosis, (3) Sequential Organ Failure Assessment score at study enrollment, and (4) maximum daily Sequential Organ Failure Assessment score during the entire ICU stay. In multivariable linear regression analysis, no measure of severity of illness was associated with prehospitalization physical function. Education level significantly modified the relationship between ICU severity of illness and baseline physical function with lower educational attainment having a stronger association with baseline physical function.

CONCLUSION

Intensive care unit severity of illness was not associated with patients' retrospectively recalled baseline physical function. Patients with a lower level of education may be more influenced by ICU severity of illness, but the magnitude of this effect may not be clinically meaningful.