Association between unmet medication needs after hospital discharge and readmission or death among acute respiratory failure survivors: the addressing post-intensive care syndrome (APICS-01) multicenter prospective cohort study

Effect of the COVID-19 pandemic on unmet healthcare needs after hospital discharge in acute respiratory failure survivors: A multicenter prospective cohort study

Survivors of acute respiratory failure (ARF) have complex healthcare needs postdischarge, frequently resulting in unmet needs. This prospective multicenter study explores the association between COVID-19 status and unmet healthcare needs in survivors of ARF following hospital discharge. We analyzed patient characteristics and unmet healthcare needs by COVID-19 status using a multivariable regression model with propensity weights. Among 195 patients in the final analysis, 54% were COVID-19+, 53% were female, 42% were non-White, and the median (interquartile range [IQR]) age was 54 (42-63). The median (IQR) percentage of unmet healthcare needs was 26% (17%-36%), with follow-up appointments accounting for most unmet needs. Unmet medication needs were found to be very low at 6%. Despite the challenges in healthcare delivery during the COVID-19 pandemic, our data suggest COVID status had no observable effect on unmet healthcare needs for ARF survivors, after controlling for patient baseline and clinical status.

Updates on Post-Intensive Care Syndrome After Acute Respiratory Distress Syndrome: Epidemiology, Core Outcomes, Interventions, and Long-Term Follow-Up

Acute respiratory distress syndrome (ARDS) survivors often experience post-intensive care syndrome (PICS), is defined as new or worsened impairments in physical, cognitive and/or mental health status persisting beyond hospital discharge. These impairments negatively impact survivors' quality of life and their return to work or usual activities. Moreover, family members are also impacted as recognized by the term, PICS-Family (PICS-F). PICS poses an increased burden on the health care system and has a negative societal impact. There are ongoing efforts to understand risk factors for PICS-related impairments; design and evaluate interventions for specific impairments (including the use of an ARDS survivorship core outcome set); and refine and evaluate ICU recovery clinics to support and treat survivors and their families.

Two-year prospective cohort of intensive care survivors enrolled on a digitally enabled recovery pathway focussed on individualised recovery goal attainment

BACKGROUND

Despite substantial evidence documenting physical, psychological, and cognitive problems experienced by intensive care unit (ICU) survivors, few studies explore interventions supporting recovery after hospital discharge. Individualised recovery goal setting, the standard of care across many rehabilitation areas, is rarely used for ICU survivors. Digital health technologies may help to address current service fragmentation and gaps. We developed and implemented a digital ICU recovery pathway using the aTouchaway e-health platform.

OBJECTIVES

The objective of this study was to explore recovery barriers and challenges; recovery goals set and achieved; self-reported patient outcomes; and healthcare costs of patients enrolled on a 12-week digital ICU recovery pathway after hospital discharge.

METHODS

We conducted a prospective observational single-centre cohort study (June 2021 to May 2023) at a 90-bed tertiary critical care service in London, UK. We enrolled adults ventilated for ≥3 days who were able to participate in recovery activities. We ascertained baseline recovery challenges and identified recovery goals and achievement over 12 weeks. We collected patient-reported outcomes at 2-4, 12-14, 26-28 weeks and healthcare utilisation monthly for 28 weeks.

RESULTS

We enrolled 105 participants (35% of eligible patients). Common rehabilitation challenges were standing balance (60%), walking indoors (56%), and washing (64%) and dressing (47%) abilities. Of 522 home recovery goals, 63% weekly, 48% monthly, and 38% aspirational goals were achieved. Most goals related to self-care: ability to move outside (91 goals, 55% achieved) and inside (45 goals, 47% achieved) the home and community access (65 goals, 48% achieved). Nottingham Extended Activities of Daily Living Scale scores improved from timepoints 1 to 2 (median [interquartile range]: 15 [7, 19] versus 19 [15, 21], P = 0.01). Total healthcare costs were £240,017 (median [interquartile range] cost per patient: £784 [£125, £4419]).

CONCLUSIONS

This study found multiple ongoing functional deficits, challenges achieving recovery goals, and limited improvements in self-reported outcomes, with moderate healthcare costs after hospital discharge indicate substantial ongoing rehabilitative needs.

Prescription of potentially inappropriate medications after an intensive care unit stay for acute respiratory failure

BACKGROUND

Among survivors of critical illness, prescription of potentially inappropriate medications (PIM) at hospital discharge is thought to be an important, modifiable patient safety concern. To date, there are little empirical data evaluating this issue.

RESEARCH QUESTION

The objective of this study was to determine the frequency of PIM prescribed to survivors of acute respiratory failure (ARF) at hospital discharge and explore their association with readmissions or death within 90 days of hospital discharge.

STUDY DESIGN AND METHODS

Prospective multicenter cohort study of ARF survivors admitted to ICUs and discharged home. Prospective of new PIMs with a high-adverse-effect profile ("high impact") at discharge was the primary exposure. Potential inappropriateness was determined by a structured consensus process using Screening Tool of Older Persons' Prescriptions-Screening Tool to Alert to Right Treatment, Beers' criteria, and clinical context of prescriptions by a multidisciplinary team. Covariate balancing propensity score was used for the primary analysis.

RESULTS

Of the 195 Addressing Post Intensive Care Syndrome-01 (APICS-01) patients, 169 (87%) had ≥1 new medications prescribed at discharge, with 154 (91.1%) prescribed with one or more high-impact (HI) medications. Patients were prescribed a median of 5 [3-7] medications, of which 3 [1-4] were HI. Twenty percent of HI medications were potentially inappropriate. Medications with significant central nervous system side-effects were most prescribed potentially inappropriately. Forty-six (30%) patients experienced readmission or death within 90 days of hospital discharge. After adjusting for prespecified covariates, the association between prescription of potentially inappropriate HI medications and the composite primary outcome did not meet the prespecified threshold for statistical significance (risk ratio: 0.54; 0.26-1.13; p = 0.095) or with the constituent endpoints: readmission (risk ratio: 0.57, 0.27-1.11) or death (0.7, 0.05-9.32).

CONCLUSION

At hospital discharge, most ARF survivors are prescribed medications with a high-adverse-effect profile and approximately one-fifth are potentially inappropriate. Although prescription of such medications was not associated with 90-day readmissions and mortality, these results highlight an area for additional investigation.

Do critical illness survivors with multimorbidity need a different model of care?

There is currently a lack of evidence on the optimal strategy to support patient recovery after critical illness. Previous research has largely focussed on rehabilitation interventions which aimed to address physical, psychological, and cognitive functional sequelae, the majority of which have failed to demonstrate benefit for the selected outcomes in clinical trials. It is increasingly recognised that a person's existing health status, and in particular multimorbidity (usually defined as two or more medical conditions) and frailty, are strongly associated with their long-term outcomes after critical illness. Recent evidence indicates the existence of a distinct subgroup of critical illness survivors with multimorbidity and high healthcare utilisation, whose prior health trajectory is a better predictor of long-term outcomes than the severity of their acute illness. This review examines the complex relationships between multimorbidity and patient outcomes after critical illness, which are likely mediated by a range of factors including the number, severity, and modifiability of a person's medical conditions, as well as related factors including treatment burden, functional status, healthcare delivery, and social support. We explore potential strategies to optimise patient recovery after critical illness in the presence of multimorbidity. A comprehensive and individualized approach is likely necessary including close coordination among healthcare providers, medication reconciliation and management, and addressing the physical, psychological, and social aspects of recovery. Providing patient-centred care that proactively identifies critical illness survivors with multimorbidity and accounts for their unique challenges and needs is likely crucial to facilitate recovery and improve outcomes.

Digital solutions and the future of recovery after critical illness

PURPOSE OF REVIEW

Digital technologies may address known physical and psychological barriers to recovery experienced by intensive care survivors following hospital discharge and provide solutions to care fragmentation and unmet needs. The review highlights recent examples of digital technologies designed to support recovery of survivors of critically illness.

RECENT FINDINGS

Despite proliferation of digital technologies supporting health in the community, there are relatively few examples for intensive care survivors. Those we identified included web-based, app-based or telemedicine-informed recovery clinics or pathways offering services, including informational resources, care planning and navigation support, medication reconciliation, and recovery goal setting. Digital interventions supporting psychological recovery included apps providing adaptive coping skills training, mindfulness, and cognitive behavioural therapy. Efficacy data are limited, although feasibility and acceptability have been established for some. Challenges include difficulties identifying participants most likely to benefit and delivery in a format easily accessible to all, with digital exclusion a resultant risk.

SUMMARY

Digital interventions supporting recovery comprise web or app-based recovery clinics or pathways and digital delivery of psychological interventions. Understanding of efficacy is relatively nascent, although several studies demonstrate feasibility and acceptability. Future research is needed but should be mindful of the risk of digital exclusion.

Anaemia in the first week may be associated with long-term mortality among critically ill patients: propensity score-based analyses

BACKGROUND

Anaemia is highly prevalent in critically ill patients; however, the long-term effect on mortality remains unclear.

METHODS

We retrospectively included patients admitted to the medical intensive care units (ICUs) during 2015-2020 at the Taichung Veterans General Hospital. The primary outcome of interest was one-year mortality, and hazard ratios (HRs) with 95% confidence intervals (CIs) were determined to assess the association. We used propensity score matching (PSM) and propensity score matching methods, including inverse probability of treatment weighting (IPTW) as well as covariate balancing propensity score (CBPS), in the present study.

RESULTS

A total of 7,089 patients were eligible for analyses, and 45.0% (3,189/7,089) of them had anaemia, defined by mean levels of haemoglobin being less than 10 g/dL. The standardised difference of covariates in this study were lower than 0.20 after matching and weighting. The application of CBPS further reduced the imbalance among covariates. We demonstrated a similar association, and adjusted HRs in original, PSM, IPTW and CBPS populations were 1.345 (95% CI 1.227-1.474), 1.265 (95% CI 1.145-1.397), 1.276 (95% CI 1.142-1.427) and 1.260 (95% CI 1.125-1.411), respectively.

CONCLUSIONS

We used propensity score-based analyses to identify that anaemia within the first week was associated with increased one-year mortality in critically ill patients.

Association Between Unmet Nonmedication Needs After Hospital Discharge and Readmission or Death Among Acute Respiratory Failure Survivors: A Multicenter Prospective Cohort Study

OBJECTIVES

To characterize early unmet nonmedication discharge needs (UDNs), classified as durable medical equipment (DME), home health services (HHS), and follow-up medical appointments (FUAs) and explore their association with 90-day readmission and mortality among survivors of acute respiratory failure (ARF) who were discharged home.

DESIGN

Prospective multicenter cohort study.

SETTING

Six academic medical centers across United States.

PARTICIPANTS

Adult survivors of ARF who required an ICU stay and were discharged home from hospital.

INTERVENTIONS

None. Exposure of interest was the proportion of UDN for the following categories: DME, HHS, and FUA ascertained within 7-28 days after hospital discharge.

MEASUREMENTS AND MAIN RESULTS

Two hundred eligible patients were recruited between January 2019 and August 2020. One-hundred ninety-five patients were included in the analytic cohort: 118 were prescribed DME, 134 were prescribed HHS, and 189 needed at least one FUA according to discharge plans. 98.4% (192/195) had at least one identified nonmedication need at hospital discharge. Median (interquartile range) proportion of unmet needs across three categories were 0 (0-15%) for DME, 0 (0-50%) for HHS, and 0 (0-25%) for FUA, and overall was 0 (0-20%). Fifty-six patients (29%) had 90-day death or readmission. After adjusting for prespecified covariates, having greater than the median level of unmet needs was not associated with an increased risk of readmission or death within 90 days of discharge (risk ratio, 0.89; 0.51-1.57; p = 0.690). Age, hospital length of stay, Acute Physiology and Chronic Health Evaluation II severity of illness score, and Multidimensional Scale Perceived Social Support score were associated with UDN.

CONCLUSIONS

UDN were common among survivors of ARF but not significantly associated a composite outcome of 90-day readmission or death. Our results highlight the substantial magnitude of UDN and identifies areas especially vulnerable to lapses in healthcare coordination.

Week-One Anaemia was Associated with Increased One-Year Mortality in Critically Ill Surgical Patients

BACKGROUND

Anaemia has a deleterious effect on surgical patients, but the long-term impact of anaemia in critically ill surgical patients remains unclear.

METHODS

We enrolled consecutive patients who were admitted to surgical intensive care units (ICUs) at a tertiary referral centre in central Taiwan between 2015 and 2020. We used both Cox proportional hazards analysis and propensity score-based analyses, including propensity score matching (PSM), inverse probability of treatment weighting (IPTW), and covariate balancing propensity score (CBPS) to determine hazard ratios (HRs) and 95% confidence intervals (CIs) for one-year mortality.

RESULTS

A total of 7,623 critically ill surgical patients were enrolled, and 29.9% (2,280/7,623) of them had week-one anaemia (haemoglobin <10 g/dL). We found that anaemia was independently associated with an increased risk of one-year mortality after adjustment for relevant covariates (aHR, 1.170; 95% CI, 1.045-1.310). We further identified a consistent strength of association between anaemia and one-year mortality in propensity score-based analyses, with the adjusted HRs in the PSM, IPTW, and CBPS were 1.164 (95% CI 1.025-1.322), 1.179 (95% CI 1.030-1.348), and 1.181 (1.034-1.349), respectively.

CONCLUSIONS

We identified the impact on one-year mortality of anaemia in critically ill surgical patients, and more studies are needed to validate our findings.