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

Determinants of Subjective Mental and Functional Health of Critical Illness Survivors: Comparing Pre-ICU and Post-ICU Status

OBJECTIVES

To compare ICU survivors' subjective mental and functional health before ICU admission and after discharge and to assess determinants of subjective health decline or improvement.

DESIGN

Secondary analysis of the multicenter cluster-randomized Enhanced Recovery after Intensive Care trial ( ClinicalTrials.gov : NCT03671447).

SETTING

Ten ICU clusters in Germany.

PATIENTS

Eight hundred fifty-five patients with 1478 follow-up assessments.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

At two patient follow-ups scheduled 3 and 6 months after ICU discharge, patients rated their subjective mental and functional/physical health on two separate visual analog scales from 0 (worst) to 10 (best) in the previous week and before ICU admission. We compared pre-ICU and post-ICU subjective health and used mixed-effects regression to assess determinants of a health decline or improvement. At the first follow-up, 20% ( n = 165/841) and 30% ( n = 256/849) of patients reported a decline in subjective mental and functional health of at least three points, respectively; 16% ( n = 133/841 and n = 137/849) outlined improvements of mental and functional health. For 65% ( n = 543/841) and 54% ( n = 456/849), mental and functional health did not change three points or more at the first follow-up. Multivariable mixed-effects logistic regressions revealed that the ICU length of stay was a predictor of mental (adjusted odds ratio [OR] per ICU day, 1.04; 95% CI, 1.00-1.09; p = 0.038) and functional health (adjusted OR per ICU day, 1.06; 95% CI, 1.01-1.12; p = 0.026) decline. The odds of a mental health decline decreased with age (adjusted OR per year, 0.98; 95% CI, 0.96-0.99; p = 0.003) and the odds of a functional health decline decreased with time after discharge (adjusted OR per month, 0.86; 95% CI, 0.79-0.94; p = 0.001).

CONCLUSIONS

The majority of ICU survivors did not experience substantial changes in their subjective health status, but patients with long ICU stays were prone to subjective mental and functional health decline. Hence, post-ICU care in post-ICU clinics could focus on these patients.

Health-Related Quality of Life Among Liver Disorder Patients in Northern India

Objective:

The present study aims to determine the health-related quality of life (HRQoL) among liver disorder patients being treated in tertiary care hospital in north India and exploration of factors affecting HRQoL.

Methodology:

The HRQoL was assessed among 230 patients visiting either the outpatient department (OPD) or those admitted in high dependency unit (HDU) or liver intensive care unit (ICU) using direct measuring tools such as Euro QoL five-dimension questionnaire (EQ-5D) and EQ visual analog scale. Multivariate regression was used to explore the factors influencing HRQoL.

Results:

Mean EQ-5D scores among chronic hepatitis and compensated cirrhosis patients were 0.639 ± 0.062 and 0.562 ± 0.048, respectively. Among those who were admitted in the ICU or HDU, mean EQ-5D score was 0.295 ± 0.031. At discharge, this score improved significantly to 0.445 ± 0.055 (P < 0.001). The multivariate results implied that HRQoL was significantly better among patients with lower literacy level (P = 0.018) and those treated in OPD settings (P < 0.001).

Conclusion:

HRQoL is impaired among patients suffering from liver disorders specifically those admitted in ICU. Further, there is a need to generate more evidence to explore the impact of determinants and treatment-associated costs on the HRQoL.

Physical, cognitive, and mental health impacts of COVID-19 after hospitalisation (PHOSP-COVID): a UK multicentre, prospective cohort study

BACKGROUND

The impact of COVID-19 on physical and mental health and employment after hospitalisation with acute disease is not well understood. The aim of this study was to determine the effects of COVID-19-related hospitalisation on health and employment, to identify factors associated with recovery, and to describe recovery phenotypes.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a multicentre, long-term follow-up study of adults (aged ≥18 years) discharged from hospital in the UK with a clinical diagnosis of COVID-19, involving an assessment between 2 and 7 months after discharge, including detailed recording of symptoms, and physiological and biochemical testing. Multivariable logistic regression was done for the primary outcome of patient-perceived recovery, with age, sex, ethnicity, body-mass index, comorbidities, and severity of acute illness as covariates. A post-hoc cluster analysis of outcomes for breathlessness, fatigue, mental health, cognitive impairment, and physical performance was done using the clustering large applications k-medoids approach. The study is registered on the ISRCTN Registry (ISRCTN10980107).

FINDINGS

We report findings for 1077 patients discharged from hospital between March 5 and Nov 30, 2020, who underwent assessment at a median of 5·9 months (IQR 4·9-6·5) after discharge. Participants had a mean age of 58 years (SD 13); 384 (36%) were female, 710 (69%) were of white ethnicity, 288 (27%) had received mechanical ventilation, and 540 (50%) had at least two comorbidities. At follow-up, only 239 (29%) of 830 participants felt fully recovered, 158 (20%) of 806 had a new disability (assessed by the Washington Group Short Set on Functioning), and 124 (19%) of 641 experienced a health-related change in occupation. Factors associated with not recovering were female sex, middle age (40-59 years), two or more comorbidities, and more severe acute illness. The magnitude of the persistent health burden was substantial but only weakly associated with the severity of acute illness. Four clusters were identified with different severities of mental and physical health impairment (n=767): very severe (131 patients, 17%), severe (159, 21%), moderate along with cognitive impairment (127, 17%), and mild (350, 46%). Of the outcomes used in the cluster analysis, all were closely related except for cognitive impairment. Three (3%) of 113 patients in the very severe cluster, nine (7%) of 129 in the severe cluster, 36 (36%) of 99 in the moderate cluster, and 114 (43%) of 267 in the mild cluster reported feeling fully recovered. Persistently elevated serum C-reactive protein was positively associated with cluster severity.

INTERPRETATION

We identified factors related to not recovering after hospital admission with COVID-19 at 6 months after discharge (eg, female sex, middle age, two or more comorbidities, and more acute severe illness), and four different recovery phenotypes. The severity of physical and mental health impairments were closely related, whereas cognitive health impairments were independent. In clinical care, a proactive approach is needed across the acute severity spectrum, with interdisciplinary working, wide access to COVID-19 holistic clinical services, and the potential to stratify care.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Changes in health-related quality of life after discharge from an intensive care unit: a systematic review

Quality of life after critical illness is becoming increasingly important as survival improves. Various measures have been used to study the quality of life of patients discharged from intensive care. We systematically reviewed validated measures of quality of life and their results. We searched PubMed, CENTRAL, CINAHL, Web of Science and Open Grey for studies of quality of life, measured after discharge from intensive care. We categorised studied populations as: general; restricted to level-3 care or critical care beyond 5 days; and septic patients. We included quality of life measured at any time after hospital discharge. We identified 48 studies. Thirty-one studies used the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) and 19 used the EuroQol-5D (EQ-5D); eight used both and nine used alternative validated measures. Follow-up rates ranged from 26-100%. Quality of life after critical care was worse than for age- and sex-matched populations. Quality of life improved for one year after hospital discharge. The aspects of life that improved most were physical function, physical role, vitality and social function. However, these domains were also the least likely to recover to population norms as they were more profoundly affected by critical illness.

Diaries and memories following an ICU stay: a 2-month follow-up study

BACKGROUND

Many patients lack a clear recollection from their stay in the intensive care unit (ICU). Diaries have been introduced as a tool to complete memories and reduce the risk of posttraumatic stress disorder (PTSD).

AIMS

To describe and compare patients' memories and PTSD in relation to having received and read or not received a diary and patients' experiences of having received and read their diary, without having discussed the contents with ICU staff.

DESIGN

Descriptive and comparative.

METHODS

Patients received their diaries at ICU discharge. After 2 months patients answered the ICU Memory Tool, a screening instrument for PTSD (PTSS-14) and a questionnaire including space for own comments about the diaries.

RESULTS

Of 96 patients, 52(54%) received a diary, 44 did not. Patients with diaries had significantly longer stay and more mechanical ventilation. Of these, 40 patients responded to PTSS-14 and had evaluated and read the diary and 34 patients served as controls. No significant differences were found in presence/absence of memories between these groups. In the diary-group patients with emotional memories had lower APACHE. Feelings of being anxious or frightened were more common in the diary-group. At 2 months, 12% scored above cut-off on the PTSS14 with no difference between groups. The diaries were helpful for understanding the ICU-stay.

CONCLUSIONS

Diaries seem valuable in understanding what happened, as an act of caring and as a tool for discussion with relatives and friends. Patients valued reading their diaries. None expressed the wish to have read the diary together with a member of staff. The diary and non-diary groups however reported similar memories.

RELEVANCE TO CLINICAL PRACTICE

Diaries seem to be valuable in understanding what happened, giving a feeling of trust and for talking about their ICU-stay. As many patients described stressful memories, sessions should be offered with ICU staff.

Our paper 20 years later: 1-year survival and 6-month quality of life after intensive care

INTRODUCTION

In the early 1990s, the in-hospital mortality rate of intensive care unit (ICU) patients dropped, and interest in the quality of life (QOL) of ICU survivors increased. In 1996, we published a study to investigate 1-year survival after hospital discharge and 6-month QOL after intensive care. Now, we compare our previous results with those reported in the recent literature to appraise any changes, and new knowledge in the area.

RESULTS

The 1-year survival of ICU patients after hospital discharge is substantial, lower than in the general population, and different among subgroups. Some studies showed a reduction in QOL at 6 months, as in our study, while others showed an improvement. Different results seem to be related mainly to the case mix. Studies on different types of patients found long-term cognitive impairment in ICU survivors, possibly not disease specific. The proportions of patients with neuropsychological morbidities such as posttraumatic stress disorder, anxiety, and depression, described after our study, did not show any change over time.

CONCLUSIONS

Differences between studies on long-term survival and QOL do not allow conclusions to be drawn about change over time. No change was found in neuropsychological morbidities. However, a lack of change may not be viewed negatively, because critically ill patients who survive ICU today may be at higher risk for poor long-term outcome than in the past due to the higher severity of their illness and the more aggressive treatments received. Future studies may provide understanding of the relationships between psychiatric symptoms, cognitive impairment, functional disability, and QOL.

The experience of communication difficulties in critically ill patients in and beyond intensive care: Findings from a larger phenomenological study

Communication difficulties in intensive care units (ICU) with critically ill patients have been well documented for more than three decades. However, there is only a paucity of literature that has explored communication difficulties beyond the ICU environment. This paper discusses the experience of communication difficulties in critically ill patients in ICU and beyond as part of findings from a larger study that explored the lived experiences of critically ill patients in ICU in the context of daily sedation interruption (DSI). The aim of the study was to describe the lived experience of people who experienced critical illness in ICU using a hermeneutic phenomenological approach in the DSI context. Twelve participants aged between 20 and 76 years with an ICU stay ranging from 3 to 36 days were recruited from a 16 bed ICU in a large regional referral hospital in New South Wales (NSW), Australia. Participants were intubated, mechanically ventilated and subjected to (DSI) during their critical illness in ICU. In-depth face to face interviews with participants were conducted at two weeks after discharge from ICU and at six to eleven months later. Interviews were audio taped and transcribed. Thematic analysis using van Manen's (1990) method was completed. The overarching theme; 'Being in limbo' and subthemes 'Being disrupted'; 'Being imprisoned' and 'Being trapped' depict the main elements of the experience. This paper discusses communication difficulties in critically ill patients as one of the main findings relating to the theme 'Being trapped'. Participants' reports of communication difficulties in ICU are similar to those reported by patients in other studies where DSI was not used. However, not many studies have reported ongoing communication difficulties after ICU hospitalisation. Recommendations are made for new models of care and support to mitigate critically ill patients' communication concerns in ICU and for further research into the causes and treatment to benefit this group of patients. Most importantly, extra care is recommended not to damage vocal cords during intubation and cuff inflation in the course of mechanical ventilation.

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.

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.

A cohort study of short-term functional outcomes following injury: the role of pre-injury socio-demographic and health characteristics, injury and injury-related healthcare

Background

Injury outcome studies have tended to collect limited pre-injury characteristics, focus on a narrow range of injury types, predictors and outcomes, and be restricted to high threat to life injuries. We sought to identify the role of pre-injury socio-demographic and health characteristics, injury and injury-related healthcare in determining short-term functional outcomes for a wide range of injuries.

Methods

Study participants (aged 18-64 years inclusive) were those in the Prospective Outcomes of Injury Study, a cohort of 2856 persons who were injured and registered with New Zealand's national no-fault injury insurance agency. All information used in this paper was obtained directly from the participants, primarily by telephone interviews, approximately three months after their injury. The functional outcomes of interest were the five dimensions of the EQ-5D plus a cognitive dimension. We initially examined bivariate relationships between our independent measures and the dependent measures. Our multivariate analyses included adjustment for pre-injury EQ-5D status and time between injury and when information was obtained from participants.

Results

Substantial portions of participants continued to have adverse outcomes approximately three months after their injury. Key pervasive factors predicting adverse outcomes were: being female, prior chronic illness, injuries to multiple body regions, being hospitalized for injury, self-perceived threat to life, and difficulty accessing health services.

Conclusion

Future injury outcome studies should include participants whose injuries are considered 'minor', as judged by acute health service utilization, and also consider a wider range of potential predictors of adverse outcomes.