Changes in quality of life after intensive care: comparison with normal data

Quality of Life at Three Years after Cardiac Surgery: Relationship with Preoperative Status and Quality of Recovery

A reduction in symptoms, increased longevity, and improved quality of life (QoL), are goals of cardiac surgery. We measured QoL in 108 adult cardiac surgical patients at about three years after cardiac surgery, and assessed the predictive ability of a 40-item quality of recovery (QoR-40) score. Our follow-up rate was 86% (n=93). When compared with preoperative status, QoL was improved at three years after surgery (P<0.0005). The dimensions of QoL that were most affected were physical functioning, role limitations due to physical problems, vitality, social functioning, and role limitations due to emotional problems (all P<0.005). There was a mild correlation between the day 3 QoR-40 and the three year SF-36, r=0.23 (P=0.029). There was a strong correlation between the three year QoR-40 and the three year SF-36, r=0.73 (P<0.0005). The QoR-40 and SF-36 done at three years after cardiac surgery demonstrated good internal consistency, QoR-40 α=0.86 (P<0.0005), SF-36 α=0.91 (P<0.0005). A poor quality recovery in the days after surgery can predict a poor QoL at three years after surgery. The QoR-40 is a valid and reliable measure of quality of recovery after surgery and anaesthesia. The QoR-40 is a useful, patient-oriented method of assessing recovery from anaesthesia and surgery.

Physical fitness and physical function in survivors of sepsis after hospital discharge

Abstract Introduction: Severe sepsis may be accompanied by long-term sequelae, and physical aspects related to physical fitness and physical function of sepsis survivors after discharge are still poorly explored. Objective: This is an integrative review aimed at analyzing if sepsis survivors present impairment of the physical fitness components and/or physical conditioning and physical function after hospital discharge. Methods: The search was performed in six electronic databases: LILACS, PubMed, CINAHL, Cochrane Library, Web of Science and Scopus. Controlled descriptors (Sepsis, Septic Shock, Physical Fitness and Activities of Daily Living) and uncontrolled descriptors or keywords (Severe Sepsis, Physical Function, and Physical Status) were used. Results: The search resulted in a total of 434 articles, of which seven were eligible for analysis. Of these, none applied a specific physical test to assess the components of physical fitness. Regarding physical function, it was verified that four studies applied specific tests to evaluate the activities of daily living. However, it was observed in most of the studies that the physical aspects were only subjectively assessed through health-related quality of life questionnaires. Overall, all studies analyzed showed that the health-related quality of life of sepsis survivors may be impaired after long periods of hospital discharge. Conclusion: Most sepsis survivors presented impairments related to physical fitness and physical function after hospital discharge, as they showed impairments in their functional autonomy, resulting in loss of independence and autonomy in performing the activities of daily living.

Long term outcomes in survivors of epidemic Influenza A (H7N9) virus infection

Patients who survive influenza A (H7N9) virus infection are at risk of physical and psychological complications of lung injury and multi-organ dysfunction. However, there were no prospectively individualized assessments of physiological, functional and quality-of-life measures after hospital discharge. The current study aims to assess the main determinants of functional disability of these patients during the follow-up. Fifty-six influenza A (H7N9) survivors were investigated during the 2-year after discharge from the hospital. Results show interstitial change and fibrosis on pulmonary imaging remained 6 months after hospital discharge. Both ventilation and diffusion dysfunction improved, but restrictive and obstructive patterns on ventilation function test persisted throughout the follow-up period. For patients with acute respiratory distress syndrome lung functions improved faster during the first six months. Role-physical and Role-emotional domains in the 36-Item Short-Form Health Survey were worse than those of a sex- and age-matched general population group. The quality of life of survivors with ARDS was lower than those with no ARDS. Our findings suggest that pulmonary function and imaging findings improved during the first 6 months especially for those with ARDS, however long-term lung disability and psychological impairment in H7N9 survivors persisted at 2 years after discharge from the hospital.

[Health-related quality of life after mechanical ventilation in the intensive care unit]

BACKGROUND

It is unknown whether health related quality of life measured in German patients one year after mechanical ventilation in the intensive care unit is impaired or not.

OBJECTIVES

The aim of this study was to assess health related quality of life one year after inclusion into a randomized controlled trial for weaning from mechanical ventilation with the help of a questionnaire that has never been used in critically ill patients and to investigate whether health related quality of life scores differ between the study population and a general German population.

METHODS

We followed up with patients one year after inclusion into a randomized control trial investigating the effect of SmartCare/PS on total ventilation time compared to protocol-driven weaning (ASOPI trial, clinicaltrials.gov ID00445289). Health related quality of life was measured using the quality of life questionnaire C‑30 version 3.0 from the European Organization of Research and Treatment of Cancer (EORTC). Mean differences of at least 10 score points in the quality of life scales were considered clinically significant.

RESULTS

Of the 232 patients who were alive 90 days after study inclusion, 24 patients died one year after study inclusion and 64 patients were lost to follow-up. Of the remaining145 patients who were successfully contacted, 126 patients agreed to fill out the questionnaire. Questionnaires were sent back to the study site by 83 patients and these were analyzed. Health-related quality of life was significantly lower in five of the six functional scales (physical functioning, role functioning, cognitive functioning, social functioning, global health status) and in eight of the nine symptom scales (fatigue, pain, dyspnea, insomnia, appetite loss, constipation, diarrhea, financial difficulties) compared to the reference values of a German normal population.

CONCLUSIONS

The EORTC QLQ-C30 questionnaire is suitable for the acquisition of the health-related quality of life in formerly critically ill patients. Health-related quality of life is severely impaired after mechanical ventilation in the intensive care unit. Future studies should consider health related quality of life as a possible study endpoint.

Interventions to reduce cognitive impairments following critical illness: a topical systematic review

BACKGROUND

Critical illness is associated with cognitive impairments. Effective treatment or prevention has not been established. The aim of this review was to create a systematic summary of the current evidence concerning clinical interventions during intensive care admission to reduce cognitive impairments after discharge.

METHODS

Medline, Embase, Cochrane Central, PsycInfo and Cinahl were searched. Inclusion criteria were studies assessing the effect of interventions during intensive care admission on cognitive function in adult patients. Studies were excluded if they were reviews or reported solely on survivors of cardiac arrest, stroke or traumatic brain injury.

RESULTS

Of 4877 records were identified. Seven studies fulfilled the eligibility criteria. The interventions described covered strategies for enteral nutrition, fluids, sedation, weaning, mobilization, cognitive activities, statins and sleep quality improvement. Data were synthesized to provide an overview of interventions, quality, follow-up assessments and neuropsychological outcomes.

CONCLUSION

None of the interventions had significant positive effects on cognitive impairments following critical illness. Quality was negatively affected by study limitations, imprecision and indirectness in evidence. Clinical research on cognition is feasible, but large, well designed trials with a specific aim at reducing cognitive impairments are needed.

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.

Long-term survival and quality of life after open abdominal aortic aneurysm repair

BACKGROUND

Open repair of abdominal aortic aneurysm (AAA) generally involves postsurgery admission to the intensive care unit (ICU). Few studies have evaluated the impact of surgery for either ruptured or nonruptured AAA (with postoperative ICU treatment) on long-term survival and quality of life. The primary aim of this study was to quantify long-term survival and health-related quality of life (HrQpL) of a cohort of patients undergoing open AAA repair after hospital discharge.

METHODS

Consecutive patients undergoing open elective or acute AAA reconstruction with postoperative admission to the ICU and discharged alive from the hospital during 2009 were identified. Primary outcome measures were 1-year and long-term mortality. The secondary outcome was the HrQoL using the EuroQol-6D (EQ-6D) questionnaire at the end of the follow-up period.

RESULTS

A total of 263 patients were treated and postoperatively discharged alive: 56 had a ruptured AAA (rAAA), 35 a symptomatic AAA, and 172 an asymptomatic AAA. The 1-year mortality after open AAA repair was 8 %. Overall, 39 % of patients died within 10 postoperative years (mean 6.0 ± 2.8 years). Long-term survival of patients with a ruptured or symptomatic aneurysm was similar to that of patients undergoing elective aneurysm repair. Long-term HrQoL of the total study population was worse than that of an age-matched general Dutch population on the EQ-us (range 0-1, difference 0.12). This decrease in HrQoL was mainly seen in mobility, self-care, usual activities, and cognition.

CONCLUSIONS

Ten years after open AAA repair, the overall survival rate was 59 %. Long-term survival and HrQoL were similar for patients with a repaired ruptured or symptomatic aneurysm and those who underwent elective aneurysm repair. There were also no differences in patients with infrarenal versus juxtarenal/suprarenal aneurysms. Surviving patients had a lower HrQoL than the age-matched general Dutch population, especially regarding mobility, self-care, usual activities, and cognition.

ICU survivors show no decline in health-related quality of life after 5 years

PURPOSE

Severe critical illness requiring treatment in the intensive care unit (ICU) may have a serious impact on patients and their families. However, optimal follow-up periods are not defined and data on health-related quality of life (HRQOL) before ICU admission as well as those beyond 2 years follow-up are limited. The aim of our study was to assess the impact of ICU stay up to 5 years after ICU discharge.

METHODS

We performed a long-term prospective cohort study in patients admitted for longer than 48 h in a medical-surgical ICU. The Short-Form 36 was used to evaluate HRQOL before admission (by proxy within 48 h after admission of the patient), at ICU discharge, and at 1, 2, and 5 years following ICU discharge (all by patients). Changes in HRQOL were assessed using linear mixed modeling.

RESULTS

We included a total of 749 patients (from 2000 to 2007). At 5 years after ICU discharge 234 patients could be evaluated. After correction for natural decline in HRQOL, the mean scores of four dimensions-physical functioning (p < 0.001), role-physical (p < 0.001), general health (p < 0.001), and social functioning (p = 0.003)-were still significantly lower 5 years after ICU discharge compared with their pre-admission levels, although effect sizes were small (<0.5).

CONCLUSIONS

After correction for natural decline, the effect sizes of decreases in HRQOL were small, suggesting that patients regain their age-specific HRQOL 5 years after their ICU stay.

Economic evaluation of nurse-led intensive care follow-up programmes compared with standard care: the PRaCTICaL trial

OBJECTIVE

Following intensive care discharge, many patients suffer severe physical and psychological morbidity and a continuing high use of health services. Follow-up programmes have been proposed to improve the outcomes for these patients. We tested the hypothesis that nurse-led intensive care follow-up programmes are cost-effective.

METHODS

A pragmatic, multicentre, randomised controlled trial of nurse-led intensive care unit follow-up programmes versus standard care. A cost-utility analysis was conducted after 12 months' follow-up to compare the two interventions. Costs were assessed from the perspective of the UK NHS and outcomes were measured in quality-adjusted life years (QALYs) based upon responses to the EQ-5D administered at baseline, 6 and 12 months.

RESULTS

A total of 286 patients were recruited to the trial. Total mean cost was £ 5,789 for standard care and £ 7,577 for the discharge clinic. The adjusted difference in means was £ 2,435 [95 % confidence interval (CI) -297 to 5,566]. Mean QALYs were 0.58 for standard care and 0.60 for the discharge clinic. The adjusted mean difference was -0.003 (95 % CI -0.066 to 0.060). If society were willing to pay £ 20,000 per QALY then there would be a 93 % chance that standard care would be considered most efficient.

CONCLUSIONS

A nurse-led intensive care unit (ICU) follow-up programme showed no evidence of being cost-effective at 12 months. Further work should focus on evidence-based development of discharge clinic services and current ICU follow-up programmes should review their practice in light of these results.

Validation of the Turkish version of the Quality of Recovery-40 questionnaire

Background

The Quality of Recovery-40 questionnaire (QoR-40) is a self-rated questionnaire used to assess the postoperative recovery quality and health status of patients in the early stages following surgery; however, there is no Turkish version of the QoR-40. The aim of this study was to assess the reliability, validity, and responsiveness of the Turkish version of the QoR-40 (QoR-40 T).

Methods

After the approval of the ethics committee, a total of 137 patients completed the questionnaire during the preoperative period, on the third day, and one month after surgery. The quality of life was evaluated by using a health-related quality of life questionnaire (Short-Form Health Survey-36; SF-36) on the third day and one month after surgery. Reliability, feasibility, and validity were assessed to validate the QoR-40 T.

Results

The Cronbach’s alpha of the global QoR-40 T on the third day after surgery was 0.936. A positive moderate correlation was obtained between the physical comfort, emotional state, physical independence, and pain dimensions of the QoR-40 T and the physical component summary, mental health, physical functioning, and bodily pain subscales of the SF-36 on the third day after surgery, respectively (physical comfort - physical component summary, ρ = 0.292, p = 0.001; emotional state - mental health, ρ = 0.252, p = 0.003; physical independence - physical functioning, ρ = 0.340, p < 0.01; pain - bodily pain, ρ = 0.381, p < 0.01). The standardized responsive mean of the total QoR-40 T was 0.62.

Conclusions

The QoR-40 T showed satisfactory reliability and validity in evaluating the quality of recovery after surgery in the Turkish population.

Physical and cognitive performance of patients with acute lung injury 1 year after initial trophic versus full enteral feeding. EDEN trial follow-up

RATIONALE

We hypothesized that providing patients with acute lung injury two different protein/calorie nutritional strategies in the intensive care unit may affect longer-term physical and cognitive performance.

OBJECTIVES

To assess physical and cognitive performance 6 and 12 months after acute lung injury, and to evaluate the effect of trophic versus full enteral feeding, provided for the first 6 days of mechanical ventilation, on 6-minute-walk distance, cognitive impairment, and secondary outcomes.

METHODS

A prospective, longitudinal ancillary study of the ARDS Network EDEN trial evaluating 174 consecutive survivors from 5 of 12 centers. Blinded assessments of patients' arm anthropometrics, strength, pulmonary function, 6-minute-walk distance, and cognitive status (executive function, language, memory, verbal reasoning/concept formation, and attention) were performed.

MEASUREMENTS AND MAIN RESULTS

At 6 and 12 months, respectively, the mean (SD) percent predicted for 6-minute-walk distance was 64% (22%) and 66% (25%) (P = 0.011 for difference between assessments), and 36 and 25% of survivors had cognitive impairment (P = 0.001). Patients performed below predicted values for secondary physical tests with small improvement from 6 to 12 months. There was no significant effect of initial trophic versus full feeding for the first 6 days after randomization on survivors' percent predicted for 6-minute-walk distance, cognitive impairment status, and all secondary outcomes.

CONCLUSIONS

EDEN trial survivors performed below predicted values for physical and cognitive performance at 6 and 12 months, with some improvement over time. Initial trophic versus full enteral feeding for the first 6 days after randomization did not affect physical and cognitive performance.

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.

An exploration of social and economic outcome and associated health-related quality of life after critical illness in general intensive care unit survivors: a 12-month follow-up study

INTRODUCTION

The socio-economic impact of critical illnesses on patients and their families in Europe has yet to be determined. The aim of this exploratory study was to estimate changes in family circumstances, social and economic stability, care requirements and access to health services for patients during their first 12 months after ICU discharge.

METHODS

Multi-center questionnaire-based study of survivors of critical illness at 6 and 12 months after ICU discharge.

RESULTS

Data for 293 consenting patients who spent greater than 48 hours in one of 22 UK ICUs were obtained at 6 and 12 months post-ICU discharge. There was little evidence of a change in accommodation or relationship status between pre-admission and 12 months following discharge from an ICU. A negative impact on family income was reported by 33% of all patients at 6 months and 28% at 12 months. There was nearly a 50% reduction in the number of patients who reported employment as their sole source of income at 12 months (19% to 11%) compared with pre-admission. One quarter of patients reported themselves in need of care assistance at 6 months and 22% at 12 months. The majority of care was provided by family members (80% and 78%, respectively), for half of whom there was a negative impact on employment. Amongst all patients receiving care, 26% reported requiring greater than 50 hours a week. Following discharge, 79% of patients reported attending their primary care physician and 44% had seen a community nurse. Mobility problems nearly doubled between pre-admission and 6 months (32% to 64%). Furthermore, 73% reported moderate or severe pain at 12 months and 44% remained significantly anxious or depressed.

CONCLUSIONS

Survivors of critical illness in the UK face a negative impact on employment and commonly have a care requirement after discharge from hospital. This has a corresponding negative impact on family income. The majority of the care required is provided by family members. This effect was apparent by 6 months and had not materially improved by 12 months. This exploratory study has identified the potential for a significant socio-economic burden following critical illness.

Long-term mortality and quality of life after septic shock: a follow-up observational study

PURPOSE

In septic shock, short-term outcomes are frequently reported, while long-term outcomes are not. The aim of this study was to evaluate mortality and health-related quality of life (HRQOL) in survivors 6 months after an episode of septic shock.

METHODS

This single-centre observational study was conducted in an intensive care unit in a university hospital. All patients with septic shock were included. Mortality was assessed 6 months after the onset of septic shock, and a comparison between patients who survived and those who died was performed. HRQOL was assessed using the MOS SF-36 questionnaire prior to hospital admission (baseline) and at 6 months in survivors. HRQOL at baseline and at 6 months were compared to the general French population, and HRQOL at baseline was compared to 6-month HRQOL.

RESULTS

Ninety-six patients were included. Six-month mortality was 45%. Survivors were significantly younger, had significantly lower lactate levels and SAPS II scores, required less renal support, received less frequent administration of corticosteroids, and had a longer length of hospital stay. At baseline (n = 39) and 6 months (n = 46), all of the components of the SF-36 questionnaire were significantly lower than those in the general population. Compared to baseline (n = 23), the Physical Component Score (CS) improved significantly at 6 months, the Mental CS did not differ.

CONCLUSIONS

Mortality 6 months after septic shock was high. HRQOL at baseline was impaired when compared to that of the general population. Although improvements were noted at 6 months, HRQOL remained lower than that in the general population.

Measuring quality of life after intensive care using the Arabic version for Morocco of the EuroQol 5 Dimensions

Background

Health-related quality of life (HRQL) is a relevant outcome measures in intensive care unit (ICU). The aim of this study was to evaluate HRQL of ICU patients 3 months after discharge using the Arabic version for Morocco of the EuroQol-5-Dimension (EQ-5D), and to examine the psychometric properties of the questionnaire.

Results

The Arabic version for Morocco of the EQ-5D was approved by the EuroQol group. A prospective cohort study was conducted after medical ICU discharge. At 3-month follow up, the EQ-5D (self classifier and EQ-VAS) was administered in consultation or by telephone. EQ-VAS varies from 0 (better HRQL) to 100 (worst HRQL). An unweighted scoring for EQ5D-index was calculated. EQ5D-index ranges from -0.59 to 1. Test-retest reliability of the EQ-5D was tested using Kappa coefficient and intraclass correlation coefficient (ICC). Criterion validity was assessed by correlating EQ-VAS and EQ5D-index with the Short Form 36 (SF-36). Construct validity was tested using simple and multiple liner regression to assess factors influencing patients'HRQL. 145 survivors answered the EQ-5D. Median EQ5D-index was 0.52 [0.20-1]. Mean EQ-VAS was 62 ± 20. Test-retest reliability was conducted in 83 patients. ICCs of EQ5D-index and EQ-VAS were 0.95 and 0.92 respectively. For EQ-5D self classifier, agreement by kappa was above 0.40. Significant correlations were noted between EQ5D-index, EQ-VAS and SF-36 (p < 0.001). In multivariate analysis, factors associated with poorer HRQL for EQ5D-index were longer ICU length of stay (β = -0.01; p = 0.017) and higher educational level (β = -0.2; p = 0.001). For EQ-VAS men were associated with better HRQL (β = 6.5; p = 0.048).

Conclusions

The Arabic version for Morocco of the EQ-5D is reliable and valid. Women, high educational level and longer ICU length of stay were associated with poorer HRQL.

A longitudinal qualitative exploration of healthcare and informal support needs among survivors of critical illness: the RELINQUISH protocol

INTRODUCTION AND BACKGROUND

Survival following critical illness is associated with a significant burden of physical, emotional and psychosocial morbidity. Recovery can be protracted and incomplete, with important and sustained effects upon everyday life, including family life, social participation and return to work. In stark contrast with other critically ill patient groups (eg, those following cardiothoracic surgery), there are comparatively few interventional studies of rehabilitation among the general intensive care unit patient population. This paper outlines the protocol for a sub study of the RECOVER study: a randomised controlled trial evaluating a complex intervention of enhanced ward-based rehabilitation for patients following discharge from intensive care.

METHODS AND ANALYSIS

The RELINQUISH study is a nested longitudinal, qualitative study of family support and perceived healthcare needs among RECOVER participants at key stages of the recovery process and at up to 1 year following hospital discharge. Its central premise is that recovery is a dynamic process wherein patients' needs evolve over time. RELINQUISH is novel in that we will incorporate two parallel strategies into our data analysis: (1) a pragmatic health services-oriented approach, using an a priori analytical construct, the 'Timing it Right' framework and (2) a constructivist grounded theory approach which allows the emergence of new themes and theoretical understandings from the data. We will subsequently use Qualitative Health Needs Assessment methodology to inform the development of timely and responsive healthcare interventions throughout the recovery process.

ETHICS AND DISSEMINATION

The protocol has been approved by the Lothian Research Ethics Committee (protocol number HSRU011). The study has been added to the UK Clinical Research Network Database (study ID. 9986). The authors will disseminate the findings in peer reviewed publications and to relevant critical care stakeholder groups.

Lung function and quality of life in survivors of the acute respiratory distress syndrome (ARDS)

Recent studies have begun to describe the long-term outcomes of acute respiratory distress syndrome (ARDS) survivors. These patients experience a number of physical, mental and psychological morbidities that significantly impair their health-related quality of life (HRQL). The trajectory of pulmonary recovery in survivors of ARDS, as it relates to lung function, structure and health-related quality of life (HRQL), is predictable and often persists years after hospital discharge. True pulmonary parenchymal morbidity is uncommon and when present, persistent restrictive disease is likely related to diaphragmatic weakness with a mild reduction in diffusion capacity (DLCO). Future research should focus on identifying patients at risk for long-term functional limitations and the design of rehabilitation interventions tailored to individual patient needs.

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.

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.

Rationale for a long-term evaluation of the consequences of potentially life-threatening maternal conditions and maternal "near-miss" incidents using a multidimensional approach

Recent advances in health care mean that women survive severe conditions and events related to pregnancy that would previously have resulted in death. Therefore, a greater number of women will experience significant maternal morbidity with significant consequences. Little is known, however, about these long-term consequences. Some investigators have evaluated the repercussions of severe biological or traumatic events, and have reported that survivors are at an increased risk of death in the five years after the event. In addition, they continue to experience both organic and emotional problems such as clinical, cardiac, respiratory, and neurological complications, as well as anxiety and depression, following discharge from hospital. Following a maternal "near-miss" incident, various life domains may be affected (organic, mental, cognitive, and social function), and these must be evaluated in addition to the related economic issues and quality of life. However, because of the diversity of methods and instruments used to evaluate possible repercussions, comparisons between the few studies available on the subject are difficult. An in-depth debate should be initiated to discuss the methodological aspects of such investigation. We propose a conceptual and methodological discussion on the long-term repercussions of severe maternal morbidity based on the evaluation of the following variables: reproductive health, quality of life, posttraumatic stress syndrome, sexual function, postpartum depression, daily functioning, and the physical, neurological, and psychomotor development of the children born after a complicated pregnancy.

Quality of life after intensive care: a systematic review of the literature

OBJECTIVES

To evaluate quality of life at least 12 months after discharge from the intensive care unit of adult critically ill patients, to evaluate the methodology used to assess long-term quality of life, and to give an overview of factors influencing quality of life.

DATA SOURCES

EMBASE-PubMed, MEDLINE (OVID), SCI/Web of Science, the Cochrane Library, Google Scholar, and personal files.

DATA EXTRACTION

Data extraction was performed independently and cross-checked by two reviewers using a predefined data extraction form. Eligible studies were published between 1999 and 2009 and assessed quality of life ≥12 months after intensive care unit discharge by means of the Medical Outcomes Study 36-Item Short Form Health Survey, the RAND 36-Item Health Survey, EuroQol-5D, and/or the Nottingham Health Profile in adult intensive care unit patients.

DATA SYNTHESIS

Fifty-three articles (10 multicenters) were included, with the majority of studies performed in Europe (68%). The Medical Outcomes Study 36-Item Short Form Health Survey was used in 55%, and the EuroQol-5D, the Nottingham Health Profile, the RAND 36-Item Health Survey, or a combination was used in 21%, 9%, 8%, or 8%, respectively. A response rate of ≥80% was attained in 26 studies (49%). Critically ill patients had a lower quality of life than an age- and gender-matched population, but quality of life tended to improve over years. The worst reductions in quality of life were seen in cases of severe acute respiratory distress syndrome, prolonged mechanical ventilation, severe trauma, and severe sepsis. Study quality criteria, defined as a baseline quality of life assessment, the absence of major exclusion criteria, a description of nonresponders, and a comparison with a reference population were met in only four studies (8%). Results concerning the influence of severity of illness, comorbidity, preadmission quality of life, age, gender, or acquired complications were conflicting.

CONCLUSIONS

Quality of life differed on diagnostic category but, overall, critically ill patients had a lower quality of life than an age- and gender-matched population. A minority of studies met the predefined methodologic quality criteria. Results concerning the influence of the patients' characteristics and illnesses on long-term quality of life were conflicting.

Health-related quality of life before planned admission to intensive care: memory over three and six months

Background

The validity of Health-Related Quality of Life (HRQOL) recalled by ICU admitted patients have not been published. The aim of this study was to compare the baseline HRQOL measured before surgery and ICU admission with that recalled at 3 and 6 months in a population of patients with planned ICU admission after surgery.

Methods

This prospective study was performed in three Italian centres on patients who had undergone General, Orthopaedic or Urologic surgery. All adult patients with planned ICU admission between October 2007 and July 2008 were considered for enrolment. At hospital admission, the Mini Mental Status Examination and EuroQoL (EQ) questionnaire (referring to the last two weeks) were administered to the patients who consented. Three and six months after ICU admission, the researchers administered by phone the EQ questionnaire and Post-Traumatic Stress Syndrome 14 questions Inventory, asking the patients to rate their HRQOL before surgery and ICU admission. Past medical history demographic and clinical ICU-related variables were collected.

Statistical analysis

Chi-square test and non parametric statistics were used to compare groups of patients. The EQ-5D was transformed in the time trade-off (TTO) to obtain a continuous variable, subsequently analysed using the Intraclass Correlation Coefficient (ICC).

Results

Of the 104 patients assessed at baseline and discharged from the hospital, 93 had the EQ administered at 3 months, and 89 at 6 months. The ICC for TTO recalled at 3 months vs pre-ICU TTO was 0.851, and that for TTO recalled at 6 months vs pre-ICU TTO was 0.833. The ICC for the EQ-VAS recalled at 3 months vs pre-ICU EQ-VAS was 0.648, and that for the EQ-VAS recalled at 6 months vs pre-ICU EQ-VAS was 0.580. Forty-two (45%) patients assessed at 3 months gave the same score in all EQ-5D items as at baseline. They underwent mainly orthopaedic surgery (p 0.011), and perceived the severity of their illness as lower (p 0.009) than patients scoring differently at 3 months in comparison with baseline.

Conclusions

The patients with planned ICU admission have a good memory of their health status as measured by EQ-5D in the period preceding surgery and ICU admission, especially at three months.

Pre-existing disease: the most important factor for health related quality of life long-term after critical illness: a prospective, longitudinal, multicentre trial

INTRODUCTION

The aim of the present multicenter study was to assess long term (36 months) health related quality of life in patients after critical illness, compare ICU survivors health related quality of life to that of the general population and examine the impact of pre-existing disease and factors related to ICU care on health related quality of life.

METHODS

Prospective, longitudinal, multicentre trial in three combined medical and surgical intensive care units of one university and two general hospitals in Sweden. By mailed questionnaires, health related quality of life was assessed at 6, 12, 24 and 36 months after the stay in ICU by EQ-5D and SF-36, and information of pre-existing disease was collected at the 6 months measure. ICU related factors were obtained from the local ICU database. Comorbidity and health related quality of life (EQ-5D; SF-36) was examined in the reference group. Among the 5306 patients admitted, 1663 were considered eligible (>24 hrs in the intensive care unit, and age >or= 18 yrs, and alive 6 months after discharge). At the 6 month measure 980 (59%) patients answered the questionnaire. Of these 739 (75%) also answered at 12 month, 595 (61%) at 24 month, and 478 (47%) answered at the 36 month measure. As reference group, a random sample (n = 6093) of people from the uptake area of the hospitals were used in which concurrent disease was assessed and adjusted for.

RESULTS

Only small improvements were recorded in health related quality of life up to 36 months after ICU admission. The majority of the reduction in health related quality of life after care in the ICU was related to the health related quality of life effects of pre-existing diseases. No significant effect on the long-term health related quality of life by any of the ICU-related factors was discernible.

CONCLUSIONS

A large proportion of the reduction in the health related quality of life after being in the ICU is attributable to pre-existing disease. The importance of the effect of pre-existing disease is further supported by the small, long term increment in the health related quality of life after treatment in the ICU. The reliability of the conclusions is supported by the size of the study populations and the long follow-up period.

One-year mortality, quality of life and predicted life-time cost-utility in critically ill patients with acute respiratory failure

Introduction

High daily intensive care unit (ICU) costs are associated with the use of mechanical ventilation (MV) to treat acute respiratory failure (ARF), and assessment of quality of life (QOL) after critical illness and cost-effectiveness analyses are warranted.

Methods

Nationwide, prospective multicentre observational study in 25 Finnish ICUs. During an eight-week study period 958 consecutive adult ICU patients were treated with ventilatory support over 6 hours. Of those 958, 619 (64.6%) survived one year, of whom 288 (46.5%) answered the quality of life questionnaire (EQ-5D). We calculated EQ-5D index and predicted lifetime quality-adjusted life years (QALYs) gained using the age- and sex-matched life expectancy for survivors after one year. For expired patients the exact lifetime was used. We divided all hospital costs for all ARF patients by the number of hospital survivors, and by all predicted lifetime QALYs. We also adjusted for those who died before one year and for those with missing QOL to be able to estimate the total QALYs.

Results

One-year mortality was 35% (95% CI 32 to 38%). For the 288 respondents median [IQR] EQ-5D index after one year was lower than that of the age- and sex-matched general population 0.70 [0.45 to 0.89] vs. 0.84 [0.81 to 0.88]. For these 288, the mean (SD) predicted lifetime QALYs was 15.4 (13.3). After adjustment for missing QOL the mean predicted lifetime (SD) QALYs was 11.3 (13.0) for all the 958 ARF patients. The mean estimated costs were 20.739 € per hospital survivor, and mean predicted lifetime cost-utility for all ARF patients was 1391 € per QALY.

Conclusions

Despite lower health-related QOL compared to reference values, our result suggests that cost per hospital survivor and lifetime cost-utility remain reasonable regardless of age, disease severity, and type or duration of ventilation support in patients with ARF.

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

OBJECTIVE

To compare acute lung injury patients' self-reported, retrospective baseline quality of life before their intensive care hospitalization with population norms and retrospective proxy estimates.

DESIGN

Prospective cohort study using the Short Form 36 quality-of-life survey.

SETTING

Thirteen intensive care units at four teaching hospitals in Baltimore, Maryland.

PATIENTS

One hundred thirty-six acute lung injury survivors and their designated proxies.

INTERVENTIONS

Both patients and proxies were asked to estimate patient baseline quality of life before hospital admission using the Short Form 36 survey.

MEASUREMENTS AND MAIN RESULTS

Compared with population norms, quality-of-life scores were lower in acute lung injury patients across all eight domains, but the difference was significantly greater than the minimum clinically important difference in only two of eight domains (Physical Role and General Health). The mean paired difference between patient and proxy responses revealed no clinically important difference. However, kappa statistics demonstrated only fair to moderate agreement for all domains. Bland-Altman analysis revealed that, for all domains, proxies tended to overestimate quality of life when patient scores were low and underestimate the quality of life when patient scores were high.

CONCLUSION

Retrospective assessment of quality of life before hospitalization revealed that acute lung injury patients' scores were consistently lower than population norms, but the magnitude of this difference may not be clinically important. Proxy assessments had only fair to moderate agreement with patient assessments. Across all eight Short Form 36 quality-of-life domains, proxy responses represented an attenuation of patient quality-of-life estimates.

Quality of life in the five years after intensive care: a cohort study

INTRODUCTION

Data on quality of life beyond 2 years after intensive care discharge are limited and we aimed to explore this area further. Our objective was to quantify quality of life and health utilities in the 5 years after intensive care discharge.

METHODS

A prospective longitudinal cohort study in a University Hospital in the UK. Quality of life was assessed from the period before ICU admission until 5 years and quality adjusted life years calculated.

RESULTS

300 level 3 intensive care patients of median age 60.5 years and median length of stay 6.7 days, were recruited. Physical quality of life fell to 3 months (P = 0.003), rose back to pre-morbid levels at 12 months then fell again from 2.5 to 5 years after intensive care (P = 0.002). Mean physical scores were below the population norm at all time points but the mean mental scores after 6 months were similar to those population norms. The utility value measured using the EuroQOL-5D quality of life assessment tool (EQ-5D) at 5 years was 0.677. During the five years after intensive care unit, the cumulative quality adjusted life years were significantly lower than that expected for the general population (P < 0.001).

CONCLUSIONS

Intensive care unit admission is associated with a high mortality, a poor physical quality of life and a low quality adjusted life years gained compared to the general population for 5 years after discharge. In this group, critical illness associated with ICU admission should be treated as a life time diagnosis with associated excess mortality, morbidity and the requirement for ongoing health care support.

The PRaCTICaL study of nurse led, intensive care follow-up programmes for improving long term outcomes from critical illness: a pragmatic randomised controlled trial

OBJECTIVES

To test the hypothesis that nurse led follow-up programmes are effective and cost effective in improving quality of life after discharge from intensive care.

DESIGN

A pragmatic, non-blinded, multicentre, randomised controlled trial.

SETTING

Three UK hospitals (two teaching hospitals and one district general hospital).

PARTICIPANTS

286 patients aged >or=18 years were recruited after discharge from intensive care between September 2006 and October 2007.

INTERVENTION

Nurse led intensive care follow-up programmes versus standard care. Main outcome measure(s) Health related quality of life (measured with the SF-36 questionnaire) at 12 months after randomisation. A cost effectiveness analysis was also performed.

RESULTS

286 patients were recruited and 192 completed one year follow-up. At 12 months, there was no evidence of a difference in the SF-36 physical component score (mean 42.0 (SD 10.6) v 40.8 (SD 11.9), effect size 1.1 (95% CI -1.9 to 4.2), P=0.46) or the SF-36 mental component score (effect size 0.4 (-3.0 to 3.7), P=0.83). There were no statistically significant differences in secondary outcomes or subgroup analyses. Follow-up programmes were significantly more costly than standard care and are unlikely to be considered cost effective.

CONCLUSIONS

A nurse led intensive care follow-up programme showed no evidence of being effective or cost effective in improving patients' quality of life in the year after discharge from intensive care. Further work should focus on the roles of early physical rehabilitation, delirium, cognitive dysfunction, and relatives in recovery from critical illness. Intensive care units should review their follow-up programmes in light of these results.

TRIAL REGISTRATION

ISRCTN 24294750.

Quality of life and persisting symptoms in intensive care unit survivors: implications for care after discharge

BACKGROUND

We assessed the quality of life of ICU survivors using SF-36 at 4 months after ICU discharge and investigated any correlation of PCS and MCS with age, illness severity and hospital or ICU length of stay. We examined the relationship between these variables, persisting physical and psychological symptoms and the perceived benefit of individual patients of follow-up.

FINDINGS

For one year, adult patients admitted for multiple organ or advanced respiratory support for greater than 48 hours to a 16-bedded teaching hospital general intensive care unit were identified. Those surviving to discharge were sent a questionnaire at 4 months following ICU discharge assessing quality of life and persisting symptoms. Demographic, length of stay and illness severity data were recorded. Higher or lower scores were divided at the median value. A two-tailed Students t-test assuming equal variances was used for normally-distributed data and Mann-Whitney tests for non-parametric data.87 of 175 questionnaires were returned (50%), but only 65 had sufficient data giving a final response rate of 37%. Elderly patients had increased MCS as compared with younger patients. The PCS was inversely related to hospital LOS. There was a significant correlation between the presence of psychological and physical symptoms and desire for follow-up.

CONCLUSION

Younger age and prolonged hospital stay are associated with lower mental or physical quality of life and may be targets for rehabilitation. Patients with persisting symptoms at 4 months view follow-up as beneficial and a simple screening questionnaire may identify those likely to attend outpatient services.

Functional outcome in patients with critical illness polyneuropathy

PURPOSE

To evaluate the functional outcome of intensive care patients with critical illness polyneuropathy (CIP), 6 and 12 months after the onset.

METHODS

DESIGN

A prospective observational cohort study and a cross-sectional study.

SETTING

University hospital in the Netherlands.

PATIENTS

Eight consecutive intensive care patients with CIP for the prospective study and eight patients diagnosed with CIP in the past 6 months for the cross-sectional study.

MAIN OUTCOME MEASURES

Functional outcome regarding body functions and structure, activities, participation and perceived quality of life.

RESULTS

Nine patients (56%) died within one year. Functional outcome, participation and subjective health status in survivors varied widely at 6 and 12 months. After 12 months, physical functioning was improved in all patients. However activities related to mobility outdoors, autonomy, participation and quality of life were restricted in most patients.

CONCLUSIONS

The majority of survivors have persistent functional disabilities in activities, reduced quality of life and restrictions in autonomy and participation one year after the onset of CIP. Prolonged rehabilitation treatment is necessary for an increasing number of intensive care patients who develop CIP, in order to reduce handicaps and achieve optimal autonomy and social participation.

What patients think about ICU follow-up services: a qualitative study

Introduction

UK policy recommendations advocate the use of intensive care unit (ICU) follow-up services to help detect and treat patients' physical and emotional problems after hospital discharge and as a means of service evaluation. This study explores patients' perceptions and experiences of these services.

Methods

Thirty-four former ICU patients were recruited throughout the UK, using maximum variation sampling to achieve as broad a range of experiences of the ICU as possible. Participants were interviewed at home by a qualitative researcher unconnected to their hospital care. Interviews were recorded and transcribed for analysis. We report a qualitative thematic analysis of patients' experiences of ICU follow up.

Results

Former patients said they valued ICU follow-up services, which had made an important contribution to their physical, emotional and psychological recovery in terms of continuity of care, receiving information, gaining expert reassurance and giving feedback to ICU staff. Continuity of care included having tests and being monitored, referrals to other specialists and ICU follow-up appointments soon after hospital discharge. Information about physical, emotional and psychological recovery was particularly important to patients, as was information that helped them make sense of their ICU experience. Those without access to ICU follow-up care often felt abandoned or disappointed because they had no opportunity to be monitored, referred or get more information.

Conclusions

Former patients value having ICU follow-up services but many found that their healthcare needs were unmet because hospitals were unable to provide the aftercare they required. Most participants were aware of the financial constraints on the health system. Although they valued ICU follow-up care, they did not want it to continue indefinitely, with many of them declining appointment invitations when they themselves felt they no longer needed them.

[Changes in health-related quality of life after ICU according to diagnostic category. Comparison of two measurement instruments]

OBJECTIVE

Assessment of health related quality of life (HRQOL) before and 12 months after discharge from a mixed intensive care unit (ICU) according to diagnostic category and the relationship between both instruments.

DESIGN

Prospective observational study.

SETTING

The combined medical/surgical ICU in a secondary university hospital with 450 beds.

PATIENTS

Patients admitted to the ICU over an 18-month period.

MAIN VARIABLES

Variables on demography, diagnosis on admission, severity of acute illness score (APACHE II), length of stay, procedures, mortality and the HRQOL were collected using the Short Form SF-36 and EQ-5D questionnaires. Health status prior to admission was evaluated retrospectively.

RESULTS

Both questionnaires were answered by 189 patients. A significant deterioration in the quality of life was observed 12 months after ICU discharge. Head injury and neurological patients had worse HRQOL one year after discharge. Multiple trauma patients presented severe physical limitations and pain, but without significant differences on the emotional level. The EQ Visual Analogue Scale and the EQ Index score showed clinically relevant differences in these three groups. Respiratory patients are the only group in whom the HRQOL improved. Comparison between both measurement instruments showed a strong correlation on the physical functioning level, but a weaker correlation on the emotional functioning one.

CONCLUSIONS

HRQOL assessment of ICU patients must be done according to a diagnostic category. Both instruments (the EQ-5D and SF-36) are capable of detecting changes in HRQOL. Despite differences in structure and content, both measure similar aspects of quality of life.

Quality of life after carotid endarterectomy

Background

Most studies documenting beneficial outcomes after carotid endarterectomy (CE) are limited to mortality and morbidity rates, costs, and length of hospital stay (LOS). Few have examined the dependency of patients and how they perceive their own health changes after surgery. The aim of the present study was to evaluate quality of life and independence in activities of daily living (ADL) and to study its determinants.

Methods

Sixty-three patients admitted in the Post Anaesthesia Care Unit (PACU) after CE were eligible for this 14-month follow-up study. Patients were contacted 6 months after discharge to complete a Short Form-36 questionnaire (SF-36) and to have their dependency in ADL evaluated.

Results

Among 59 hospital survivors at 6 months follow-up, 43 completed the questionnaires. Sixty-three percent reported that their general level of health was better on the day they answered the questionnaire than 12 months earlier. Patients had worse SF-36 scores for all domains except bodily pain than a general urban population, and comparison with a group of patients 6 months after surgical ICU discharge showed no differences. Six months after PACU discharge, the Lawton Instrumental Activities of ADL Scale and the Katz Index of ADL demonstrated higher dependency scores (5.9 ± 2.2 versus 4.3 ± 2.4 and 0.3 ± 0.8 versus 0.6 ± 0.9, p < 0.001 and p = 0.047). Sixty-five percent and 33% were dependent in at least one activity in instrumental and personal ADL, respectively. Patients dependent in at least one ADL task had higher Revised Cardiac Risk Index (RCRI) scores (1.0 versus 1.5, p = 0.017). After controlling for multiple comparisons, no significant differences were found.

Conclusion

Patients undergoing CE have improved self-perception of quality of life despite being more dependent. Almost all their scores are worse than those in an urban population. We could identify no predictors of greater dependency in ADL tasks six months after PACU discharge.

[Outcome for adults with acute respiratory distress syndrome]

Acute respiratory distress syndrome in adults (ARDS) is a relatively frequent disease, the mortality of which has diminished considerably in recent years. The long-term outcome of patients who have survived ARDS has been studied extensively and should in the future be taken into account in assessing new treatment modalities. The long-term respiratory sequelae are generally minimal and moderately disabling. Secondary deterioration of respiratory function is not part of the natural history of ARDS and should suggest other diagnoses. The various studies find a clear diminution in quality of life after ARDS (compared with the general population), essentially related to neuromuscular deficiencies associated with the neuromyopathies of resuscitation or to neuropsychological damage combining cognitive disorders and symptoms of posttraumatic stress. These symptoms are not at all specific to ARDS. They are found in varying degrees in patients who have survived intensive care or resuscitation. Appropriate management for these symptoms remains to be determined. Critical care units must now work at preventing the onset of these disorders, by limiting the treatments at risk when possible and by identifying these disorders before discharge to prepare for optimal subsequent management. Patients with ARDS are only a subgroup of more severe illness among all patients in critical care departments.

Study protocol: the Intensive Care Outcome Network ('ICON') study

Background

Extended follow-up of survivors of ICU treatment has shown many patients suffer long-term physical and psychological consequences that affect their health-related quality of life. The current lack of rigorous longitudinal studies means that the true prevalence of these physical and psychological problems remains undetermined.

Methods/Design

The ICON (Intensive Care Outcome Network) study is a multi-centre, longitudinal study of survivors of critical illness. Patients will be recruited prior to hospital discharge from 20–30 ICUs in the UK and will be assessed at 3, 6, and 12 months following ICU discharge for health-related quality of life as measured by the Short Form-36 (SF-36) and the EuroQoL (EQ-5D); anxiety and depression as measured by the Hospital Anxiety and Depression Scale (HADS); and post traumatic stress disorder (PTSD) symptoms as measured by the PTSD Civilian Checklist (PCL-C). Postal questionnaires will be used.

Discussion

The ICON study will create a valuable UK database detailing the prevalence of physical and psychological morbidity experienced by patients as they recover from critical illness. Knowledge of the prevalence of physical and psychological morbidity in ICU survivors is important because research to generate models of causality, prognosis and treatment effects is dependent on accurate determination of prevalence. The results will also inform economic modelling of the long-term burden of critical illness.

Trial Registration

ISRCTN69112866

Quality of life before surgical ICU admission

BACKGROUND

Examining the quality of life (QOL) of patients before ICU admission will allow outcome variables to be compared and analyzed in relation to it. The objective of this study was to analyze QOL of patients before admission to a surgical ICU and to study its relationship to outcome and to the baseline characteristics of the patients.

METHODS

All adult patients consecutively admitted to the surgical ICU between November 2004 and April 2005, who underwent non-cardiac surgery, were enrolled in this observational and prospective study. The following patient characteristics were recorded: age, gender, body mass index, ASA physical status, type and magnitude of surgical procedure, length of stay (LOS), in ICU and in hospital, mortality, Simplified Acute Physiology Score II (SAPS), history of co-morbidities and quality of life survey score (QOLSS). The relationships between QOLSS and ICU variables and outcome were evaluated. The relationship between the total QOLSS and each variable or outcome was assessed by multiple linear regression.

RESULTS

One hundred eighty seven patients completed the study. The preadmission QOLSS of the patients studied was 4.43 +/- 4.90; 28% of patients had a normal quality of life (0 points), 38% had between 1 and 5 points (considered mild deterioration), 21% had between 6 and 10 points (moderate deterioration), 10% had between 11 and 15 points (considered major deterioration) and 3% had more than 15 points (severe limitation of quality of life). A worse preadmission QOLSS was associated with higher SAPS II scores, with older patients (age> 65 years) and with ASA physical status (ASA III/IV). Total QOLSS was significantly worse in elderly patients and in patients with co-morbidities and in patients more severely ill at ICU admission. Patients who died in the ICU and in hospital had worse QOLSS scores compared to those who survived. However, no statistical differences in QOLSS were found in relation to longer ICU stays (ICU LOS).

CONCLUSION

Preadmission QOL correlates with age and severity of illness. Patients with co-morbidities and those who died during ICU or hospital stay had worse QOLSS scores.

The impact of critical illness on perceived health-related quality of life during ICU treatment, hospital stay, and after hospital discharge: a long-term follow-up study

BACKGROUND

The time course of changes in health-related quality of life (HRQOL) following discharge from the ICU and during a general ward stay has not been studied. We therefore studied the immediate impact of critical illness on HRQOL and its recovery over time.

METHODS

In a prospective study, all patients admitted to the ICU for > 48 h who ultimately survived to follow-up at 6 months were included. The Medical Outcomes Study 36-item short form was used to measure HRQOL before ICU admission, at discharge from the ICU and hospital, and at 3 and 6 months following discharge from the ICU and hospital. An age-matched healthy Dutch population was used as a reference.

RESULTS

Of the 451 included patients, 252 could be evaluated at 6 months (40 were lost to follow-up, and 159 died). Pre-ICU admission HRQOL in survivors was significantly worse compared to the healthy population. Patients who died between ICU admission and long-term follow-up had significantly worse HRQOL in all dimensions already at ICU admission when compared to the long-term survivors. HRQOL decreased in all dimensions (p < 0.001) during ICU stay followed by a rapid improvement during hospital stay, gradually improving to near pre-ICU admission HRQOL at 6 months following ICU discharge. Physical functioning (PF), general health (GH), and social functioning (SF) remained significantly lower than pre-ICU admission values. Compared to the healthy Dutch population, ICU survivors had significantly lower HRQOL 6 months following ICU discharge (except for the bodily pain score).

CONCLUSIONS

A sharp multidimensional decline in HRQOL occurs during ICU admission where recovery already starts following ICU discharge to the general ward. Recovery is incomplete for PF, GH, and SF when compared to baseline values and the healthy population.

Quality of life after stay in surgical intensive care unit

BACKGROUND

In addition to mortality, Health Related Quality of Life (HRQOL) has increasingly been claimed as an important outcome variable. The aim of this study was to assess HRQOL and independence in activities of daily living (ADL) six months after discharge from an Intensive Care Unit (ICU), and to study its determinants.

METHODS

All post-operative adult patients admitted to a surgical ICU between October 2004 and July 2005, were eligible for the study. The following variables were recorded on admission: age, gender, American Society of Anesthesiologists physical status (ASA-PS), type and magnitude of surgical procedure, ICU and hospital length of stay (LOS), mortality and Simplified Acute Physiology Score II (SAPS II). Six months after discharge, a Short Form-36 questionnaire (SF-36) and a questionnaire to assess dependency in ADL were sent to all survivors. Descriptive statistics was used to summarize data. Patient groups were compared using non-parametric tests. A logistic regression analysis was performed to identify covariate effects of each variable on dependency in personal and instrumental ADL, and for the change-in-health question of SF-36.

RESULTS

Out of 333 hospital survivors, 226 completed the questionnaires. Fifty-nine percent reported that their general level of health was better on the day they answered the questionnaire than 12 months earlier. Patients with greater co-morbidities (ASA-PS III/IV), had lower SF-36 scores in all domains and were more frequently dependent in instrumental and personal ADL. Logistic regression showed that SAPS II was associated with changes in general level of health (OR 1.06, 95%CI, 1.01-1.11, p = 0,016). Six months after ICU discharge, 60% and 34% of patients, respectively, were dependent in at least one activity in instrumental ADL (ADLI) and personal ADL (ADLP). ASA-PS (OR 3.00, 95%CI 1.31-6.87, p = 0.009) and age (OR 2.36, 95%CI, 1.04-5.34, p = 0.04) were associated with dependency in ADLI. For ADLP, only ASA-PS (OR 4.58, 95%CI, 1.68-12.46, p = 0.003) was associated with higher dependency.

CONCLUSION

ASA-PS, age, type of surgery, ICU LOS and SAPS II could be seen as determinants of HRQOL.

A pragmatic randomised, controlled trial of intensive care follow up programmes in improving longer-term outcomes from critical illness. The PRACTICAL study

Background

A number of intensive care (ICU) patients experience significant problems with physical, psychological, and social functioning for some time after discharge from ICU. These problems have implications not just for patients, but impose a continuing financial burden for the National Health Service. To support recovery, a number of hospitals across the UK have developed Intensive Care follow-up clinics. However, there is a lack of evidence base to support these, and this study aims to test the hypothesis that intensive care follow up programmes are effective and cost-effective at improving physical and psychological quality of life in the year after intensive care discharge.

Methods/Design

This is a multi-centre, pragmatic, randomised controlled trial. Patients (n = 270) will be recruited prior to hospital discharge from three intensive care units in the UK, and randomised to one of two groups. The control group will receive standard in-hospital follow-up and the intervention group will participate in an ICU follow-up programme with clinic appointments 2–3 and 9 months after ICU discharge.

The primary outcome measure is Health-related Quality of Life (HRQoL) 12 months after ICU discharge as measured by the Short Form-36. Secondary measures include: HRQoL at six months; Quality-adjusted life years using EQ-5D; posttraumatic psychopathology as measured by Davidson Trauma Scale; and anxiety and depression using the Hospital Anxiety and Depression Scale at both six and twelve months after ICU discharge. Contacts with health services in the twelve months after ICU discharge will be measured as part of the economic analysis.

Discussion

The provision of intensive care follow-up clinics within the UK has developed in an ad hoc manner, is inconsistent in both the number of hospitals offering such a service or in the type of service offered. This study provides the opportunity to evaluate such services both in terms of patient benefit and cost-effectiveness. The results of this study therefore will inform clinical practice and policy with regard to the appropriate development of such services aimed at improving outcomes after intensive care.

Trial Registration

ISRCTN24294750.

Cost effectiveness of adult intensive care in the UK

We wished to investigate whether intensive care represents good value for money to the National Health Service in the UK using cost-effectiveness analysis. We developed a cost-effectiveness model using secondary data sources to estimate the incremental cost per quality adjusted life year gained of treatment in intensive care vs non-intensive care treatment in adults. Estimates of hospital mortality with and without intensive care were obtained from seven published studies and from data published by the Intensive Care National Audit and Research Centre. Quality of life estimates were obtained from a literature review and NHS reference costs were used. Relative to non-intensive care treatment, the incremental cost per quality adjusted life year gained of treatment in intensive care is 7010 pounds. This figure is sensitive to the mortality risk reduction associated with intensive care. Despite the high daily cost of intensive care, its cost-effectiveness is excellent and compares favourably with other commonly used health interventions. Our findings suggest that adult intensive care represents good value for money.

Measurement properties of the short form 36 and health-related quality of life after intensive care in Morocco

BACKGROUND

Intensive care patients have a health-related quality of life (HRQL) that differs from the normal population. The aim of this study was to evaluate the measurement properties of the Arabic version of the short form (SF)-36 and study the HRQL determinants in adult patients 3 months after discharge from an intensive care unit (ICU).

METHODS

A prospective cohort study after ICU discharge. At 3-month follow up, the SF-36 was administered in consultation or by telephone. Multitrait scaling analysis was used to confirm the hypothesized scale structure of the SF-36. Reliability was tested using (i) measuring internal consistency; and (ii) the test-retest reliability assessed using an intraclass correlation coefficient. Construct validity was tested by known-groups comparison using one-way analysis of variance (ANOVA) and analysis of covariance (ANCOVA).

RESULTS

A total of 145 survivors answered the SF-36. Item internal convergency was higher than 0.40 (0.77-0.99; 100% scaling success) and item discriminant validity was perfect (100% scaling success) except for physical functioning (81% scaling success). Cronbach's alpha exceeded 0.70 in all eight scales (0.84-0.99). Test-retest reliability conducted in 73 patients was above 0.80. Acceptability to patients appeared reasonable although considerable interview time was required to administer the SF-36. Construct validity was confirmed by lower scores being reported by women, older age and a high level of comorbidities groups. When adjusted for background data, ICU variables were not associated with the SF-36 scores.

CONCLUSIONS

The Arabic version of the SF-36 appears to be a robust tool in ICU. Background variables are the only significant determinants of HRQL 3 months after medical ICU discharge.

A national survey of intensive care follow-up clinics

Intensive care follow-up clinics allow extended review of survivors of critical illness. However, the current provision of intensive care follow-up clinics in the UK is unknown. We performed a survey of intensive care follow-up clinic practice in the UK. A questionnaire was sent to 298 intensive care units in the UK to determine the number of follow-up clinics and details of current follow-up practice. Responses were received from 266 intensive care units, an 89% response rate. Eighty units (30%) ran a follow-up clinic. Only 47 (59%) of these clinics were funded. Of those intensive care units without a follow-up clinic, 158 (88%) cited 'financial constraints' as the reason. Over half of the follow-up clinics (44 clinics, 55%) were nurse-led, and the majority (56 clinics, 77%) only routinely review patients treated on the intensive care unit for 3 or 4 days or longer. Nearly half of the follow-up clinics (39 clinics, 49%) have pre-negotiated access to at least one other out-patient service.

Predictors of early recovery of health status after intensive care

OBJECTIVE

To identify factors predictive of good or poor recovery of health status and health-related quality of life (HRQOL) 90 days after admission to an intensive care unit (ICU).

DESIGN AND SETTING

Prospective international multicentre study in 19 ICUs participating in the HRQOL substudy of the SAPS 3 project.

INTERVENTION

The EuroQol questionnaire (EQ) was administered to discharged ICU patients 90 days after admission. A question to compare present health status with that 3 months before ICU admission (same/better/worse) was added.

PATIENTS

Six hundred and eighteen patients who spent >24h in an ICU and survived for 90 days. EQ data and health comparison were available in 559 (90.5%) of them.

MEASUREMENTS AND RESULTS

Patients reported their general level of health to be better (33.8%), the same (31.1%), or worse (35.1%) in comparison with baseline. Recovery was considered to be good for answers "better" or "the same". Regression analysis showed that transplantation surgery [odds ratio (OR) 0.07, 95% confidence interval (CI) 0.01-0.63], coronary artery bypass surgery without valvular repair (OR 0.39, 95% CI 0.17-0.92) and being admitted to the ICU from a ward or other location (OR 0.55, 95% CI 0.31-0.95) predicted good recovery of health. Predictors of poor recovery (all present at the time of ICU admission) were unplanned ICU admission, hypothermia, serum creatinine level >or=2mg/dl, pH<or=7.25 and metastatic cancer.

CONCLUSIONS

More than 60% of ICU patients report good recovery of their health 90 days after ICU admission, depending on their illness and circumstances of ICU admission.

Quality of life after acute respiratory distress syndrome: a meta-analysis

OBJECTIVE

To summarize long-term quality of life (QOL) and the degree of variation in QOL estimates across studies of acute respiratory distress (ARDS) survivors.

DESIGN

A systematic review of studies evaluating QOL in ARDS survivors was conducted. Medline, EMBASE, CINAHL, pre-CINAHL, and the Cochrane Library were searched, and reference lists from relevant articles were evaluated. Two authors independently selected studies reporting QOL in adult survivors of ARDS or acute lung injury at least 30 days after intensive care unit discharge and extracted data on study design, patient characteristics, methods, and results.

MEASUREMENTS AND RESULTS

Thirteen independent observational studies (557 patients) met inclusion criteria. Eight of these studies used eight different QOL instruments, allowing only qualitative synthesis of results. The five remaining studies (330 patients) measured QOL using the Medical Outcomes Study 36-Item Short Form survey (SF-36). Mean QOL scores were similar across these studies, falling within a range of 20 points for all domains. Pooled domain-specific QOL scores in ARDS survivors 6 months or later after discharge ranged from 45 (role physical) to 66 (social functioning), or 15-26 points lower than population norms, in all domains except mental health (11 points) and role physical (39 points). Corresponding confidence intervals were no wider than +/-9 points. Six studies all found stable or improved QOL over time, but only one found significant improvement beyond 6 months after discharge.

CONCLUSIONS

ARDS survivors in different clinical settings experience similar decrements in QOL. The precise magnitude of these decrements helps clarify the long-term prognosis for ARDS survivors.