Effects on health-related quality of life of interventions affecting survival in critically ill patients: a systematic review

Missing data and long-term outcomes from nutrition research in the critically ill

PURPOSE OF REVIEW

The use of functional outcomes in critical care nutrition research is increasingly advocated; however, this inevitably gives rise to missing data. Consequently there is a need to adopt modern approaches to the foreseeable problem of missing functional and survival outcomes in research trials.

RECENT FINDINGS

Analyses that ignore unobserved or missing data will often return biased effect estimates. An improved approach is to routinely anticipate the types and extent of missing data, and consider the likely mechanisms of that missingness. The researcher and their statistical advisor may then choose from a number of modern strategies to assess the sensitivity of the research conclusions to the patterns of missingness contained in these research data. Methods widely employed include multiple imputation of missing observations, mixed regression models, use of composite outcome variables with patients who die being attributed a value reflecting the lack of ability to function, and selected Bayesian methodology.

SUMMARY

Conclusions from clinical research in critical care nutrition will become more clinically interpretable and generalizable with the adoption of modern methods for the statistical handling of missing data.

Composite Primary Outcomes Reported in Studies of Critical Care: A Scoping Review

OBJECTIVE

Composite primary outcomes (CPO) (incorporating both mortality and non-mortality outcomes) offer several advantages over mortality as an outcome for critical care research. Our objective was to explore and map the literature to report on CPO evaluated in critical care research.

DATA SOURCES

PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, Scopus, and Cochrane Library from January 2000 to January 2024.

STUDY SELECTION

All studies (both non-randomized controlled trial [RCT] and RCT) conducted in ICUs treating adult patients (18 yr old or older) that described CPOs and their definitions, were included for mapping, reporting, and analyzing CPOs without any restrictions.

DATA EXTRACTION

Independent double-screening of abstracts/full texts and data extraction was performed using a pilot-tested extraction template. The data collected included characteristics of CPO, definitions, trends, and death handling techniques used while reporting the CPO.

DATA SYNTHESIS

Seventeen CPOs were extracted from 71 studies, predominantly reported in the setting of pharmaceutical studies (48/71, 67.6%), used RCT methodology (60/71, 84.5%), and were mostly single-center studies (55/71, 77.5%). Ventilator-free days were the most commonly reported CPO (29/71, 40.8%) with marked variability in the definition used and death handling (0 d in 33 studies and -1 d in 7 studies). The most common statistical paradigm used was frequentist (63/71, 88.7%) and the study follow-up time was 90 days with 28 studies using this timeline (28/71, 39.4%). Narrative synthesis highlighted the variability in defining CPO.

CONCLUSIONS

CPOs are an emerging set of outcomes increasingly reported in critical care research. There was significant heterogeneity in definitions used, follow-up times, and reporting trends.

Quality of Life as a Non-mortality Patient-centred Outcome in the Critically Ill: A Retrospective Analysis

Objectives

Mortality is a common gauged endpoint in critically ill patients. Reduced quality of life is an aligned repercussion of protracted critical illness. Baseline status, severity of illness and its trajectory influence the outcomes. Patient-oriented outcomes are those that matter the most to a patient. However, quite often, family approves of trade-offs with survivorship in the Indian context. We looked at non-mortality outcomes in patients on high-intensity life-sustaining interventions admitted to the intensive care unit (ICU) despite poor prognosis and died on full support or survived to be completely dependent.

Materials and Methods

In this retrospective chart review study, we studied patients (1) who spent more than 1 month in the hospital enduring a myriad of distressing physical and psychological vicissitudes, (2) whose primary illness was fairly advanced (3) and either succumbed or survived to be impeded in their response to cognitive assessment and with severe functional impairment. Patient demographics, comorbidities, pre-morbid functional status, burden of critical illness, use of life-sustaining therapies, functional dependence in the last week of ICU stay, best neurological status in the last week pre-death or discharge, dying trajectories and economic analysis were noted.

Results

Trends of clinical progress of 23 patients were deliberated. The mean age of males was 65 years and 61 years for females. Five patients had a Barthel index score of 10-20, indicating total dependency and two patients had a score of 21-60, indicating severe dependency. Two patients were cognitively impaired at baseline. The worst neurological status in the week before death or discharge was eye1, motor1, and verbaltracheostomised. Thirteen patients succumbed during ongoing treatment.

Conclusion

Daily discussions on the dynamics of illness progression need to take place with family on a regular basis for patients managed in ICU. Realistic perceptions and grounded expectations from the families and caregivers are necessary for patient-centred outcomes.

Effect of high versus standard protein provision on functional recovery in people with critical illness (PRECISe): an investigator-initiated, double-blinded, multicentre, parallel-group, randomised controlled trial in Belgium and the Netherlands

BACKGROUND

Increased protein provision might ameliorate muscle wasting and improve long-term outcomes in critically ill patients. The aim of the PRECISe trial was to assess whether higher enteral protein provision (ie, 2·0 g/kg per day) would improve health-related quality of life and functional outcomes in critically ill patients who were mechanically ventilated compared with standard enteral protein provision (ie, 1·3 g/kg per day).

METHODS

The PRECISe trial was an investigator-initiated, double-blinded, multicentre, parallel-group, randomised controlled trial in five Dutch hospitals and five Belgian hospitals. Inclusion criteria were initiation of invasive mechanical ventilation within 24 h of intensive care unit (ICU) admission and an expected duration of invasive ventilation of 3 days or longer. Exclusion criteria were contraindications for enteral nutrition, moribund condition, BMI less than 18 kg/m2, kidney failure with a no dialysis code, or hepatic encephalopathy. Patients were randomly assigned to one of four randomisation labels, corresponding with two study groups (ie, standard or high protein; two labels per group) in a 1:1:1:1 ratio through an interactive web-response system. Randomisation was done via random permuted-block randomisation in varying block sizes of eight and 12, stratified by centre. Participants, care providers, investigators, outcome assessors, data analysts, and the independent data safety monitoring board were all blinded to group allocation. Patients received isocaloric enteral feeds that contained 1·3 kcal/mL and 0·06 g of protein/mL (ie, standard protein) or 1·3 kcal/mL and 0·10 g of protein/mL (ie, high protein). The study-nutrition intervention was limited to the time period during the patient's ICU stay in which they required enteral feeding, with a maximum of 90 days. The primary outcome was EuroQoL 5-Dimension 5-level (EQ-5D-5L) health utility score at 30 days, 90 days, and 180 days after randomisation, adjusted for baseline EQ-5D-5L health utility score. This trial was registered with ClinicalTrials.gov (NCT04633421) and is closed to new participants.

FINDINGS

Between Nov 19, 2020, and April 14, 2023, 935 patients were randomly assigned. 335 (35·8%) of 935 patients were female and 600 (64·2%) were male. 465 (49·7%) of 935 were assigned to the standard protein group and 470 (50·3%) were assigned to the high protein group. 430 (92·5%) of 465 patients in the standard protein group and 419 (89·1%) of 470 patients in the high protein group were assessed for the primary outcome. The primary outcome, EQ-5D-5L health utility score during 180 days after randomisation (assessed at 30 days, 90 days, and 180 days), was lower in patients allocated to the high protein group than in those allocated to the standard protein group, with a mean difference of -0·05 (95% CI -0·10 to -0·01; p=0·031). Regarding safety outcomes, the probability of mortality during the entire follow-up was 0·38 (SE 0·02) in the standard protein group and 0·42 (0·02) in the high protein group (hazard ratio 1·14, 95% CI 0·92 to 1·40; p=0·22). There was a higher incidence of symptoms of gastrointestinal intolerance in patients in the high protein group (odds ratio 1·76, 95% CI 1·06 to 2·92; p=0·030). Incidence of other adverse events did not differ between groups.

INTERPRETATION

High enteral protein provision compared with standard enteral protein provision resulted in worse health-related quality of life in critically ill patients and did not improve functional outcomes during 180 days after ICU admission.

FUNDING

Netherlands Organisation for Healthcare Research and Development and Belgian Health Care Knowledge Centre.

Is comorbidity alone responsible for changes in health-related quality of life among critical care survivors? A purpose-specific review

BACKGROUND

Health-related quality of life (HRQoL) is one of the most important outcome variables for assessing the effectiveness of intensive care, together with mortality and survival, where comorbidity is suggested to have high impact. However, studies are lacking that examine to what extent HRQoL is affected after a general ICU period, beyond that of the effects that may be claimed to be due to comorbidities.

DESIGN

Purpose-specific literature review including literature searches in PubMed, Cinahl, Scopus, and Cochrane library between 2010 and 2021.

MEASUREMENTS AND RESULTS

This Purpose-specific, i.e., task focused review examines HRQoL (assessed by either SF-36 or EQ-5D, > 30 days after leaving the hospital) in adult patients (≥ 18 years) having an ICU length of stay > 24 h. Further, the HRQoL comparisons were adjusted for age or comorbidity. A total of 11 publications were found. A majority comprised observational, prospective cohort studies, except three that were either case-control, cross-sectional comparison, or retrospective cohort studies. A total of 18,566 critically ill patients were included, and the response rate ranged from 16 to 94%. In all studies, a recurrent relevant finding was that HRQoL after ICU care was affected by pre-ICU comorbidities. In three studies (n = 3), which included a comorbidity adjusted control group, there were no effect of the critical care period itself on the registered HRQoL after the critical care period.

CONCLUSION

Health-Related Quality of Life (HRQoL) in former ICU patients appears to be primarily influenced by comorbidity. A notable limitation in this field of research is the high heterogeneity observed in the studies reviewed, particularly in terms of the HRQoL measurement tool employed, the duration of follow-up, the methodology for comorbidity assessment, and the adjustments for age and sex. Despite these variations and the limited number of studies in the review, the findings suggest a minimal HRQoL impact beyond the effects of comorbidity. Given the significant dearth of comprehensive studies in this domain, there is an escalating call for more thorough and detailed research endeavours.

Foot drop in critically ill patients: a narrative review of an elusive complication with intricate implications for recovery and rehabilitation

Foot drop is a condition characterized by the inability to lift the foot upwards towards the shin bone. This condition may affect a proportion of critically ill patients, impacting on their recovery after the acute phase of the illness. The occurrence of foot drop in critical care patients may result from various underlying causes, including neurological injuries, muscular dysfunction, nerve compression, or vascular compromise. Understanding the etiology and assessing the severity of foot drop in these patients is essential for implementing appropriate management strategies and ensuring better patient outcomes. In this comprehensive review, we explore the complexities of foot drop in critically ill patients. We search for the potential risk factors that contribute to its development during critical illness, the impact it has on patients' functional abilities, and the various diagnostic techniques adopted to evaluate its severity. Additionally, we discuss current treatment approaches, rehabilitation strategies, and preventive measures to mitigate the adverse effects of foot drop in the critical care setting. Furthermore, we explore the roles of critical care physical therapists, neurologists, and other healthcare professionals in the comprehensive care of patients with foot drop syndrome and in such highlighting the importance of a multidisciplinary approach.

Non-pharmacological interventions to prevent PICS in critically ill adult patients: a protocol for a systematic review and network meta-analysis

BACKGROUND

Postintensive care syndrome (PICS) is common in critically ill adults who were treated in the intensive care unit (ICU). Although comparative analyses between types of non-pharmacological measures and usual care to prevent PICS have been performed, it remains unclear which of these potential treatments is the most effective for prevention.

METHODS

To obtain the best evidence for non-pharmaceutical interventions in preventing PICS, a systematic review and Bayesian network meta-analyses (NMAs) will be conducted by searching nine electronic databases for randomized controlled trials (RCTs). Two reviewers will carefully screen the titles, abstracts, and full-text papers to identify and extract relevant data. Furthermore, the research team will meticulously check the bibliographic references of the selected studies and related reviews to discover any articles pertinent to this research. The primary focus of the study is to examine the prevalence and severity of PICS among critically ill patients admitted to the ICU. The additional outcomes encompass patient satisfaction and adverse effects related to the preventive intervention. The Cochrane Collaboration's risk-of-bias assessment tool will be utilized to evaluate the risk of bias in the included RCTs. To assess the efficacy of various preventative measures, traditional pairwise meta-analysis and Bayesian NMA will be used. To gauge the confidence in the evidence supporting the results, we will utilize the Confidence in NMA tool.

DISCUSSION

There are multiple non-pharmacological interventions available for preventing the occurrence and development of PICS. However, most approaches have only been directly compared to standard care, lacking comprehensive evidence and clinical balance. Although the most effective care methods are still unknown, our research will provide valuable evidence for further non-pharmacological interventions and clinical practices aimed at preventing PICS. The research is expected to offer useful data to help healthcare workers and those creating guidelines decide on the most effective path of action for preventing PICS in adult ICU patients.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42023439343.

Long-term outcomes with haloperidol versus placebo in acutely admitted adult ICU patients with delirium

PURPOSE

We assessed long-term outcomes in acutely admitted adult patients with delirium treated in intensive care unit (ICU) with haloperidol versus placebo.

METHODS

We conducted pre-planned analyses of 1-year outcomes in the Agents Intervening against Delirium in the ICU (AID-ICU) trial, including mortality and health-related quality of life (HRQoL) assessed by Euroqol (EQ) 5-dimension 5-level questionnaire (EQ-5D-5L) index values and EQ visual analogue scale (EQ VAS) (deceased patients were assigned the numeric value zero). Outcomes were analysed using logistic and linear regressions with bootstrapping and G-computation, all with adjustment for the stratification variables (site and delirium motor subtype) and multiple imputations for missing HRQoL values.

RESULTS

At 1-year follow-up, we obtained vital status for 96.2% and HRQoL data for 83.3% of the 1000 randomised patients. One-year mortality was 224/501 (44.7%) in the haloperidol group versus 251/486 (51.6%) in the placebo group, with an adjusted absolute risk difference of - 6.4%-points (95% confidence interval [CI] - 12.8%-points to - 0.2%-points; P = 0.045). These results were largely consistent across the secondary analyses. For HRQoL, the adjusted mean differences were 0.04 (95% CI - 0.03 to 0.11; P = 0.091) for EQ-5D-5L-5L index values, and 3.3 (95% CI - 9.3 to 17.5; P = 0.142) for EQ VAS.

CONCLUSIONS

In acutely admitted adult ICU patients with delirium, haloperidol treatment reduced mortality at 1-year follow-up, but did not statistically significantly improve HRQoL.

Subjective Ratings of Mental and Physical Health Correlate With EQ-5D-5L Index Values in Survivors of Critical Illness: A Construct Validity Study

OBJECTIVES

Survivors of critical illness commonly show impaired health-related quality of life (HrQoL). We investigated if HrQoL can be approximated by brief, easily applicable items to be used in primary care.

DESIGN

Secondary analysis of data from the multicenter, cluster-randomized controlled Enhanced Recovery after Intensive Care trial ( ClinicalTrials.gov : NCT03671447) and construct validity study.

SETTING

Ten participating clusters of ICUs in the metropolitan area of Berlin, Germany.

PATIENTS

Eight hundred fifty ICU survivors enrolled in a mixed, medical or surgical ICU when they had an expected ICU length of stay of at least 24 hours, were at least 18 years old, and had statutory health insurance coverage.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patients received follow-ups scheduled 3 and 6 months after ICU discharge. HrQoL was assessed with the EuroQol 5-Dimension 5-Level (EQ-5D-5L), and patients were asked to rate their current mental and physical health state from 0 (worst) to 10 (best). We fitted prediction models for the EQ-5D-5L index value using these two items and additional covariates, applying stepwise regression and adaptive lasso. Subjective mental health (Spearman: 0.59) and subjective physical health (Spearman: 0.68) correlated with EQ-5D-5L index values and were better predictors of EQ-5D-5L index values in the two-item regression (normalized root mean squared error [nRMSE] 0.164; normalized mean absolute error [nMAE] 0.118; R2adj 0.43) than the EQ-5D Visual Analog Scale (nRMSE 0.175; nMAE 0.124; R2adj 0.35). Stepwise regression with additional covariates further increased prediction performance (nRMSE 0.133; nMAE 0.1; R2adj 0.51).

CONCLUSIONS

Asking patients to rate their subjective mental and physical health can be an easily applicable tool for a first impression of the HrQoL in primary care settings.

The impact of age on intensive care

Caring for the elderly has always been challenging for the intensive care unit (ICU) physician. Concerns like frailty, comorbidities, polypharmacy and advanced directives come up even before admission into the unit. The COVID-19 pandemic has put forward a variety of issues concerning elderly populations, making the topic more relevant than ever. Admittance to the ICU, an unequivocally multifactorial decision, requires special consideration from the side of the physician when caring for an elderly person. Patients' wishes are to be respected and thus given priority. Triage assessment must also account for age-related physiological alterations and functional status. Once in the ICU, special attention should be given to age-related specificities, such as therapeutic interventions' controversial role, infection susceptibility, and post-operative care, that could potentially alter the course of hospitalization and affect outcomes. Following ICU discharge, ensuring proper rehabilitation for both survivors and their caregivers can improve long-term outcomes and subsequent quality of life. The pandemic and its implications may limit the standard of care for the elderly requiring ICU support. Socioeconomic factors that further perplex the situation must be addressed. Elderly patients currently represent a vast expanding population in ICU. Tailoring safe treatment plans to match patients' wishes, and personalized needs will guide critical care for the elderly from this time forward.

Long-term (180-Day) Outcomes in Critically Ill Patients With COVID-19 in the REMAP-CAP Randomized Clinical Trial

Importance

The longer-term effects of therapies for the treatment of critically ill patients with COVID-19 are unknown.

Objective

To determine the effect of multiple interventions for critically ill adults with COVID-19 on longer-term outcomes.

Design, Setting, and Participants

Prespecified secondary analysis of an ongoing adaptive platform trial (REMAP-CAP) testing interventions within multiple therapeutic domains in which 4869 critically ill adult patients with COVID-19 were enrolled between March 9, 2020, and June 22, 2021, from 197 sites in 14 countries. The final 180-day follow-up was completed on March 2, 2022.

Interventions

Patients were randomized to receive 1 or more interventions within 6 treatment domains: immune modulators (n = 2274), convalescent plasma (n = 2011), antiplatelet therapy (n = 1557), anticoagulation (n = 1033), antivirals (n = 726), and corticosteroids (n = 401).

Main Outcomes and Measures

The main outcome was survival through day 180, analyzed using a bayesian piecewise exponential model. A hazard ratio (HR) less than 1 represented improved survival (superiority), while an HR greater than 1 represented worsened survival (harm); futility was represented by a relative improvement less than 20% in outcome, shown by an HR greater than 0.83.

Results

Among 4869 randomized patients (mean age, 59.3 years; 1537 [32.1%] women), 4107 (84.3%) had known vital status and 2590 (63.1%) were alive at day 180. IL-6 receptor antagonists had a greater than 99.9% probability of improving 6-month survival (adjusted HR, 0.74 [95% credible interval {CrI}, 0.61-0.90]) and antiplatelet agents had a 95% probability of improving 6-month survival (adjusted HR, 0.85 [95% CrI, 0.71-1.03]) compared with the control, while the probability of trial-defined statistical futility (HR >0.83) was high for therapeutic anticoagulation (99.9%; HR, 1.13 [95% CrI, 0.93-1.42]), convalescent plasma (99.2%; HR, 0.99 [95% CrI, 0.86-1.14]), and lopinavir-ritonavir (96.6%; HR, 1.06 [95% CrI, 0.82-1.38]) and the probabilities of harm from hydroxychloroquine (96.9%; HR, 1.51 [95% CrI, 0.98-2.29]) and the combination of lopinavir-ritonavir and hydroxychloroquine (96.8%; HR, 1.61 [95% CrI, 0.97-2.67]) were high. The corticosteroid domain was stopped early prior to reaching a predefined statistical trigger; there was a 57.1% to 61.6% probability of improving 6-month survival across varying hydrocortisone dosing strategies.

Conclusions and Relevance

Among critically ill patients with COVID-19 randomized to receive 1 or more therapeutic interventions, treatment with an IL-6 receptor antagonist had a greater than 99.9% probability of improved 180-day mortality compared with patients randomized to the control, and treatment with an antiplatelet had a 95.0% probability of improved 180-day mortality compared with patients randomized to the control. Overall, when considered with previously reported short-term results, the findings indicate that initial in-hospital treatment effects were consistent for most therapies through 6 months.

Patient-Important Outcomes Other Than Mortality in Contemporary ICU Trials: A Scoping Review

OBJECTIVES

Randomized clinical trials (RCTs) conducted in adult ICU patients increasingly include patient-important outcomes other than mortality. This comes with challenges regarding outcome choices/definitions, handling of deceased patients and missing data in analyses, and choices of effect measures and statistical methods due to complex distributions. This scoping review aimed to characterize how these challenges are handled in relevant contemporary RCTs.

DATA SOURCES

We systematically searched 10 selected journals for RCTs conducted primarily in adult ICU patients published between 1 January 2018 and 5 May 2022 reporting at least one patient-important outcome other than mortality, including "days alive without"…-type outcomes, functional/cognitive/neurologic outcomes, health-related quality of life (HRQoL) outcomes, and ordinal/other outcomes.

STUDY SELECTION

Abstracts and full-texts were assessed independently and in duplicate by two reviewers.

DATA EXTRACTION

Data were extracted independently and in duplicate by two reviewers using predefined and pilot-tested extraction forms and subsequently categorized to facilitate analysis.

DATA SYNTHESIS

We included 687 outcomes from 167 RCTs, with 32% of RCTs using a patient-important outcome other than mortality as a (co-)primary outcome, most frequently "days alive without"…-type outcomes. Many different functional/cognitive/neurologic (103) and HRQoL (29) outcomes were reported. Handling of deceased patients varied, with analyses frequently restricted to survivors only for functional/cognitive/neurologic (62%) and HRQoL (89%) outcomes. Follow-up was generally longer and missing data proportions higher for functional/cognitive/neurologic and HRQoL outcomes. Most outcomes were analyzed using nonparametric tests (31%), linear regression/ t tests (27%), chi-square-like tests (12%), and proportional odds logistic regression (9%), often without presentation of actual treatment effects estimates (38%).

CONCLUSIONS

In this sample of RCTs, substantial variation in practice and suboptimal methodological choices were observed. This calls for increased focus on standardizing outcome choices and definitions, adequate handling of missing data and deceased patients in analyses, and use of statistical methods quantifying effect sizes.

Discomfort improvement for critically ill patients using electronic relaxation devices: results of the cross-over randomized controlled trial E-CHOISIR (Electronic-CHOIce of a System for Intensive care Relaxation)

Purpose

To assess the impact of different electronic relaxation devices on common stressful patient symptoms experienced in intensive care unit (ICU).

Methods

Sixty critically ill patients were enrolled in four relaxation sessions using a randomized cross-over design: standard relaxation (TV/radio), music therapy (MUSIC-CARE©), and two virtual reality systems using either real motion pictures (DEEPSEN©) or synthetic motion pictures (HEALTHY-MIND©). The goal was to determine which device was the best to reduce overall patient discomfort intensity (0–10 Numeric Rating Scale (NRS); primary endpoint). Secondary endpoints were specific stressful symptoms (pain, anxiety, dyspnea, thirst, and lack of rest feeling) and stress response measured by Analgesia/Nociception Index (ANI). Multivariate mixed-effect analysis was used, taking into account patient characteristics and multiple measurements.

Results

Fifty patients followed the full research protocol, and ten patients did at least one research planned session of relaxation. HEALTHY-MIND© was associated with a significant decrease in overall discomfort, the primary endpoint (median NRS = 4[2–6] vs. 2[0–5]; p = 0.01, mixed-effect model), accompanied by a significant decrease in stress response (increase in ANI, secondary endpoint; p < 0.01). Regarding other secondary endpoints, each of the two virtual reality systems was associated with a decrease in anxiety (p < 0.01), while HEALTHY-MIND© was associated also with a decrease in pain (p = 0.001) and DEEPSEN© with a decrease in lack of rest (p = 0.01). Three incidents (claustrophobia/dyspnea/agitation) were reported among 109 virtual reality sessions. Cybersickness was rare (NRS = 0[0–0]).

Conclusion

Electronic relaxation therapy is a promising, safe, and effective non-pharmacological solution that can be used to improve overall discomfort in alert and non-delirious ICU patients. Its effectiveness depends on technical characteristics (virtual reality using a synthetic imagined world versus a real world or music therapy alone without virtual reality), as well as the type of symptoms.

Electronic relaxation therapies are effective supportive care tools for improving stressful symptoms in ICU patients.

Effectiveness depends on the type of symptom and the characteristics of the devices.

Overall discomfort and adrenergic stress response are more significantly improved by virtual reality using a synthetic imagined world than using a real world or music therapy alone.