Health care resource use and costs of two-year survivors of acute lung injury. An observational cohort study

Factors influencing the hospitalization cost for stroke patients in J district, Shanghai

OBJECTIVES

Stroke is the main cause of death in Chinese residents, bringing a heavy economic burden to patients. This study aims to explore the characteristics and the factors influencing the hospitalization cost for stroke, and to provide scientific evidence for reducing the economic burden on stroke patients.

METHODS

The data were mainly obtained from the Shanghai Statistics Center for Health. Using the coding system of International Classification of Diseases (ICD)-10, we retrospectively collected the stroke-related first hospitalization records of stroke patients in J district, Shanghai during January 1, 2016 to December 31, 2019 whose main diagnostic disease codes were I61-I63. After cleaning and arranging the data, we counted the first hospitalization cost and length of hospital stay (LOS) of the patients. Univariate analysis was performed using non-parametric tests, and the factors influencing stroke hospitalization cost were further analyzed by multiple linear regression fitting path model.

RESULTS

A total of 3 901 stroke patients were included. Ischemic and hemorrhagic stroke patients accounted for 92.59% and 7.41%, respectively, of which the mean hospitalization cost per patient were 12 397.35 yuan and 28 814.72 yuan, respectively, and the mean LOS per patient were 13 days and 19 days, respectively. Hospitalization cost for ischemic stroke mainly consisted of medicine fees, diagnosis fees, and service fees, accounting for 44.70%, 29.92%, and 15.42%, respectively, and hospitalization cost for hemorrhagic stroke mainly consisted of medicine fees, diagnosis fees, consumables fees, and service fees, accounting for 38.76%, 18.33%, 17.59%, and 15.38%, respectively. From 2016 to 2019, the proportion of medicine fees for ischemic stroke was decreased by 19.38 percentage points, and the diagnosis fees and service fees were increased by 8.43 percentage points and 9.04 percentage points, respectively; the proportions of medicine fees and consumables fees for hemorrhagic stroke were decreased by 7.54 percentage points and 13.43 percentage points, respectively, and the proportions of diagnostic fees and service fees were increased by 6.87 percentage points and 10.15 percentage points, respectively. Path analysis results showed that the main direct factors influencing hospitalization cost were the LOS, hospital level, operation, and year, and the main indirect factors were age and hospital level (all P<0.05).

CONCLUSIONS

The cost burden of stroke patients in Shanghai is relatively heavy, and we should continue to promote the medical reform policy and consolidate the achievements of medical reform. Hospitals should strengthen clinical pathway management and patient health education to improve medical efficiency and reduce invalid hospitalization days. Government departments should continue to improve the medical insurance system, enhance the supervision to medical insurance, and promote health equity.

Hospital re-admission after critical care survival: a systematic review and meta-analysis

Survivors of critical illness frequently require increased healthcare resources after hospital discharge. We undertook a systematic review and meta-analysis to assess hospital re-admission rates following critical care admission and to explore potential re-admission risk factors. We searched the MEDLINE, Embase and CINAHL databases on 05 March 2020. Our search strategy incorporated controlled vocabulary and text words for hospital re-admission and critical illness, limited to the English language. Two reviewers independently applied eligibility criteria and assessed quality using the Newcastle Ottawa Score checklist and extracted data. The primary outcome was acute hospital re-admission in the year after critical care discharge. Of the 8851 studies screened, 87 met inclusion criteria and 41 were used within the meta-analysis. The analysis incorporated data from 3,897,597 patients and 741,664 re-admission episodes. Pooled estimates for hospital re-admission after critical illness were 16.9% (95%CI: 13.3-21.2%) at 30 days; 31.0% (95%CI: 24.3-38.6%) at 90 days; 29.6% (95%CI: 24.5-35.2%) at six months; and 53.3% (95%CI: 44.4-62.0%) at 12 months. Significant heterogeneity was observed across included studies. Three risk factors were associated with excess acute care rehospitalisation one year after discharge: the presence of comorbidities; events during initial hospitalisation (e.g. the presence of delirium and duration of mechanical ventilation); and subsequent infection after hospital discharge. Hospital re-admission is common in survivors of critical illness. Careful attention to the management of pre-existing comorbidities during transitions of care may help reduce healthcare utilisation after critical care discharge. Future research should determine if targeted interventions for at-risk critical care survivors can reduce the risk of subsequent rehospitalisation.

BMI1 Silencing Induces Mitochondrial Dysfunction in Lung Epithelial Cells Exposed to Hyperoxia

Acute Lung Injury (ALI), characterized by bilateral pulmonary infiltrates that restrict gas exchange, leads to respiratory failure. It is caused by an innate immune response with white blood cell infiltration of the lungs, release of cytokines, an increase in reactive oxygen species (ROS), oxidative stress, and changes in mitochondrial function. Mitochondrial alterations, changes in respiration, ATP production and the unbalancing fusion and fission processes are key events in ALI pathogenesis and increase mitophagy. Research indicates that BMI1 (B cell-specific Moloney murine leukemia virus integration site 1), a protein of the Polycomb repressive complex 1, is a cell cycle and survival regulator that plays a role in mitochondrial function. BMI1-silenced cultured lung epithelial cells were exposed to hyperoxia to determine the role of BMI1 in mitochondrial metabolism. Its expression significantly decreases in human lung epithelial cells (H441) following hyperoxic insult, as determined by western blot, Qrt-PCR, and functional analysis. This decrease correlates with an increase in mitophagy proteins, PINK1, Parkin, and DJ1; an increase in the expression of tumor suppressor PTEN; changes in the expression of mitochondrial biomarkers; and decreases in the oxygen consumption rate (OCR) and tricarboxylic acid enzyme activity. Our bioinformatics analysis suggested that the BMI1 multifunctionality is determined by its high level of intrinsic disorder that defines the ability of this protein to bind to numerous cellular partners. These results demonstrate a close relationship between BMI1 expression and mitochondrial health in hyperoxia-induced acute lung injury (HALI) and indicate that BMI1 is a potential therapeutic target to treat ALI and Acute Respiratory Distress Syndrome.

Socio-Ecologic Perspective: Barriers Complicating Post-Intensive Care Syndrome Mitigation

Objective:Post-intensive care syndrome (PICS) is a phenomenon whereby survivors of an intensive care unit (ICU) admission subsequently experience issues with physical, cognitive, or mental health status persisting beyond the acute hospitalization. Risk factors for developing PICS include prolonged mechanical ventilation with sedation and immobility. PICS is a devastating illness that negatively alters the life path of many individuals with tremendous economic impact. Methods: This qualitative study employed a grounded theory approach to understand the systemic barriers blocking mitigation and treatment of PICS in all seven ICUs across Essex County, New Jersey (NJ) through semi-scripted interviews conducted with 11 members of the healthcare teams with at least one from each site. Thematic analysis was performed with open, axial, and selective coding. Results: Applying socio-ecologic viewpoint to data illustrate significant barriers on both an interpersonal and organizational level that decrease the operationalization of PICS mitigation measures as identified by healthcare providers. Of those interviewed, eight (73%) were physicians and the remaining were nurses. Significant thematic issues included understanding the risk factors of PICS but feeling powerless to institute mitigation efforts; experiencing lack of enthusiasm due to the absence of institutionalized mitigation protocols; noting frustration about closing the gap between academic recommendations and the ability to operationalize these appropriately; and feeling unable to effectuate meaningful change. Conclusion: Providing education to the target population and healthcare provider stakeholders regarding the barriers against PICS mitigation can alter the status quo.

Clinical and economic benefits of lenzilumab plus standard of care compared with standard of care alone for the treatment of hospitalized patients with COVID-19 in the United States from the hospital perspective

AIMS

Estimate the clinical and economic benefits of lenzilumab plus standard of care (SOC) compared with SOC alone in the treatment of patients hospitalized with COVID-19 pneumonia from the United States (US) hospital perspective.

MATERIALS AND METHODS

A per-patient cost calculator was developed to report the clinical and economic benefits associated with adding lenzilumab to SOC in newly hospitalized COVID-19 patients over 28 days. Clinical inputs were based on the LIVE-AIR trial, including failure to achieve survival without ventilation (SWOV), mortality, time to recovery, intensive care unit (ICU) admission, and invasive mechanical ventilation (IMV) use. Base case costs included the anticipated list price of lenzilumab, drug administration, and hospital resource costs based on the level of care required. A scenario analysis examined projected one-year rehospitalization costs.

RESULTS

In the base case and all scenarios, lenzilumab plus SOC improved all specified clinical outcomes relative to SOC alone. Lenzilumab plus SOC resulted in estimated cost savings of $3,190 per patient in a population aged <85 years with C-reactive protein (CRP) levels <150 mg/L and receiving remdesivir (base case). Per-patient cost savings were observed in the following scenarios: (1) aged <85 years with CRP <150 mg/L, with or without remdesivir ($1,858); (2) Black and African American patients with CRP <150 mg/L ($13,154); and (3) Black and African American patients from the full population, regardless of CRP level ($2,763). In the full modified intent-to-treat population, an additional cost of $4,952 per patient was estimated. When adding rehospitalization costs to the index hospitalization, a total per-patient cost savings of $5,154 was estimated.

CONCLUSIONS

The results highlight the clinical benefits for SWOV, ventilator use, time to recovery, mortality, time in ICU, and time on IMV, in addition to an economic benefit from the US hospital perspective associated with adding lenzilumab to SOC for COVID-19 patients.

The Cost of ARDS: A Systematic Review

BACKGROUND

ARDS is an inflammatory condition of the lungs and is a common condition in adult ICUs. The resources required and costs of care for patients with ARDS are significant because of the severity of the illness and extended ICU lengths of stay.

RESEARCH QUESTION

What are the costs associated with ARDS?

STUDY DESIGN AND METHODS

We systematically searched the literature through April 29, 2021, for articles relevant to ARDS and costs. MEDLINE, Embase, Central, and EconLit databases were searched, and articles that reported on cost data from an original publication in adult patients with ARDS were included. Two authors independently assessed articles for inclusion and extracted data elements related to costs, methodology, health-care system type, economic perspective, and clinical data. Publication quality was assessed using a modified version of the Quality of Health Economic Studies Instrument.

RESULTS

Four thousand six hundred sixty-three publications were found, of which 110 were included for full-text review (κ = 0.72). A total of 22 publications (49,483 patients) were suitable for data extraction. The publications represented a broad range of health-care systems, economic perspectives, costing methodology, and time frames. Mean inpatient costs ranged from $8,476 (2021 US dollars [USD]) to $547,974 (2021 USD) and were highest in publications of lower quality and in American health systems and were associated with trauma cohorts. Outpatient costs were highest in publications with higher readmission rates, longer durations of follow-up, and in American health systems.

INTERPRETATION

A wide range of costing data is available for ARDS. A comprehensive synthesis of this literature frames the reasons for this and allows estimates to reflect the context in which they were assessed. This information will be of value to researchers and administrators interested in the economics of caring for patients with ARDS.

TRIAL REGISTRY

PROSPERO; No.: CRD42020192487.

Costs and Cost-Utility of Critical Care and Subsequent Health Care: A Multicenter Prospective Study

OBJECTIVES

The number of critical care survivors is growing, but their long-term outcomes and resource use are poorly characterized. Estimating the cost-utility of critical care is necessary to ensure reasonable use of resources. The objective of this study was to analyze the long-term resource use and costs, and to estimate the cost-utility, of critical care.

DESIGN

Prospective observational study.

SETTING

Seventeen ICUs providing critical care to 85% of the Finnish adult population.

PATIENTS

Adult patients admitted to any of 17 Finnish ICUs from September 2011 to February 2012, enrolled in the Finnish Acute Kidney Injury (FINNAKI) study, and matched hospitalized controls from the same time period.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We primarily assessed total 3-year healthcare costs per quality-adjusted life-years at 3 years. We also estimated predicted life-time quality-adjusted life-years and described resource use and costs. The costing year was 2016. Of 2,869 patients, 1,839 (64.1%) survived the 3-year follow-up period. During the first year, 1,290 of 2,212 (58.3%) index episode survivors were rehospitalized. Median (interquartile range) 3-year cumulative costs per patient were $49,200 ($30,000-$85,700). ICU costs constituted 21.4% of the total costs during the 3-year follow-up. Compared with matched hospital controls, costs of the critically ill remained higher throughout the follow-up. Estimated total mean (95% CI) 3-year costs per 3-year quality-adjusted life-years were $46,000 ($44,700-$48,500) and per predicted life-time quality-adjusted life-years $8,460 ($8,060-8,870). Three-year costs per 3-year quality-adjusted life-years were $61,100 ($57,900-$64,400) for those with an estimated risk of in-hospital death exceeding 15% (based on the Simplified Acute Physiology Score II).

CONCLUSIONS

Healthcare resource use was substantial after critical care and remained higher compared with matched hospital controls. Estimated cost-utility of critical care in Finland was of high value.

Protocol for a multicentre longitudinal mixed-methods study: feeding and survivorship outcomes in previously healthy young paediatric Intensive care survivors (the PIES Study)

INTRODUCTION

An admission to paediatric intensive care unit (PICU) is associated with multiple physical and environmental stressors, often involving many negative and painful oral experiences. Evidence from children with complex medical conditions suggests that feeding difficulties post-PICU stay are common, causing significant parental anxiety. Adult intensive care unit (ICU) survivor studies suggest feeding issues lasting up to 3 months post-discharge from ICU. There is, however, a paucity of evidence regarding feeding outcomes for previously healthy children following a PICU admission and whether painful oral experiences during an admission contribute to feeding difficulties post-discharge, negatively impacting on parental/caregiver anxiety.

METHODS AND ANALYSIS

This longitudinal mixed-methods study will explore the impact of feeding difficulties, identifying any clinical risk factors during the first 6 months of PICU discharge in previously healthy young children (≤4 years). Parents/caregivers of children will be asked to complete questionnaires relating to: feeding difficulties, parental/caregiver stress, and child and parental/caregivers' feeding behaviours at the point of PICU discharge, 1, 3 and 6 months post-discharge. Parents/caregivers will be invited to participate in qualitative semistructured interviews at 3 and 6 months post-PICU discharge exploring parental/caregiver experiences of feeding their child after PICU. Statistical analysis of the survey data will consist of descriptive and inferential statistics, plus qualitative analysis of any free text comments using thematic analysis.

ETHICS AND DISSEMINATION

This study will provide an insight and increase our understanding of the prevalence of feeding difficulties in previously healthy children admitted to PICU and parental/caregiver experiences. Multiple methods will be used to ensure that the findings are effectively disseminated to service users, clinicians, policy and academic audiences. The study has full ethical approval from the National Health Service Research Ethics Committee (Ref: 20/YH/0160) and full governance clearance.

Evaluating the association between unmet healthcare needs and subsequent clinical outcomes: protocol for the Addressing Post-Intensive Care Syndrome-01 (APICS-01) multicentre cohort study

INTRODUCTION

As short-term mortality declines for critically ill patients, a growing number of survivors face long-term physical, cognitive and/or mental health impairments. After hospital discharge, many critical illness survivors require an in-depth plan to address their healthcare needs. Early after hospital discharge, numerous survivors experience inadequate care or a mismatch between their healthcare needs and what is provided. Many patients are readmitted to the hospital, have substantial healthcare resource use and experience long-lasting morbidity. The objective of this study is to investigate the gap in healthcare needs occurring immediately after hospital discharge and its association with hospital readmissions or death for survivors of acute respiratory failure (ARF).

METHODS AND ANALYSIS

In this multicentre prospective cohort study, we will enrol 200 survivors of ARF in the intensive care unit (ICU) who are discharged directly home from their acute care hospital stay. Unmet healthcare needs, the primary exposure of interest, will be evaluated as soon as possible within 1 to 4 weeks after hospital discharge, via a standardised telephone assessment. The primary outcome, death or hospital readmission, will be measured at 3 months after discharge. Secondary outcomes (eg, quality of life, cognitive impairment, depression, anxiety and post-traumatic stress disorder) will be measured as part of 3-month and 6-month telephone-based follow-up assessments. Descriptive statistics will be reported for the exposure and outcome variables along with a propensity score analysis, using inverse probability weighting for the primary exposure, to evaluate the relationship between the primary exposure and outcome.

ETHICS AND DISSEMINATION

The study received ethics approval from Vanderbilt University Medical Center Institutional Review Board (IRB) and the University of Utah IRB (for the Veterans Affairs site). These results will inform both clinical practice and future interventional trials in the field. We plan to disseminate the results in peer-reviewed journals, and via national and international conferences.

TRIAL REGISTRATION DETAILS

ClinicalTrials.gov (NCT03738774). Registered before enrollment of the first patient.

Approaches to Addressing Post-Intensive Care Syndrome among Intensive Care Unit Survivors. A Narrative Review

Critical illness can be lethal and devastating to survivors. Improvements in acute care have increased the number of intensive care unit (ICU) survivors. These survivors confront a range of new or worsened health states that collectively are commonly denominated post-intensive care syndrome (PICS). These problems include physical, cognitive, psychological, and existential aspects, among others. Burgeoning interest in improving long-term outcomes for ICU survivors has driven an array of potential interventions to improve outcomes associated with PICS. To date, the most promising interventions appear to relate to very early physical rehabilitation. Late interventions within aftercare and recovery clinics have yielded mixed results, although experience in heart failure programs suggests the possibility that very early case management interventions may help improve intermediate-term outcomes, including mortality and hospital readmission. Predictive models have tended to underperform, complicating study design and clinical referral. The complexity of the health states associated with PICS suggests that careful and rigorous evaluation of multidisciplinary, multimodality interventions-tied to the specific conditions of interest-will be required to address these important problems.

Impact of Critical Illness on Resource Utilization: A Comparison of Use in the Year Before and After ICU Admission

Supplemental Digital Content is available in the text.

Increasingly, patients admitted to an ICU survive to hospital discharge; many with ongoing medical needs. The full impact of an ICU admission on an individual’s resource utilization and survivorship trajectory in the United States is not clear. We sought to compare healthcare utilization among ICU survivors in each year surrounding an ICU admission.

Home and Community-Based Physical Therapist Management of Adults With Post-Intensive Care Syndrome

More than 4 million adults survive a stay in the intensive care unit each year, with many experiencing new or worsening physical disability, mental health problems, and/or cognitive impairments, known as post-intensive care syndrome (PICS). Given the prevalence and magnitude of physical impairments after critical illness, many survivors, including those recovering from COVID-19, could benefit from physical therapist services after hospital discharge. However, due to the relatively recent recognition and characterization of PICS, there may be limited awareness and understanding of PICS among physical therapists practicing in home health care and community-based settings. This lack of awareness may lead to inappropriate and/or inadequate rehabilitation service provision. While this perspective article provides information relevant to all physical therapists, it is aimed toward those providing rehabilitation services outside of the acute and postacute inpatient settings. This article reports the prevalence and clinical presentation of PICS and provides recommendations for physical examination and outcomes measures, plan of care, and intervention strategies. The importance of providing patient and family education, coordinating community resources including referring to other health care team members, and community-based rehabilitation service options is emphasized. Finally, this perspective article discusses current challenges for optimizing outcomes for people with PICS and suggests future directions for research and practice.

The Cost-Effectiveness of Interventions to Increase Utilization of Prone Positioning for Severe Acute Respiratory Distress Syndrome

OBJECTIVES

Despite strong evidence supporting proning in acute respiratory distress syndrome, few eligible patients receive it. This study determines the cost-effectiveness of interventions to increase utilization of proning for severe acute respiratory distress syndrome.

DESIGN

We created decision trees to model severe acute respiratory distress syndrome from ICU admission through death (societal perspective) and hospital discharge (hospital perspective). We assumed patients received low tidal volume ventilation. We used short-term outcome estimates from the PROSEVA trial and longitudinal cost and benefit data from cohort studies. In probabilistic sensitivity analyses, we used distributions for each input that included the fifth to 95th percentile of its CI.

SETTING

ICUs that care for patients with acute respiratory distress syndrome.

SUBJECTS

Patients with moderate to severe acute respiratory distress syndrome.

INTERVENTIONS

The implementation of a hypothetical intervention to increase the appropriate utilization of prone positioning.

MEASUREMENTS AND MAIN RESULTS

In the societal perspective model, an intervention that increased proning utilization from 16% to 65% yielded an additional 0.779 (95% CI, 0.088-1.714) quality-adjusted life years at an additional long-term cost of $31,156 (95% CI, -$158 to $92,179) (incremental cost-effectiveness ratio = $38,648 per quality-adjusted life year [95% CI, $1,695-$98,522]). If society was willing to pay $100,000 per quality-adjusted life year, any intervention costing less than $51,328 per patient with moderate to severe acute respiratory distress syndrome would represent good value. From a hospital perspective, the intervention yielded 0.072 (95% CI, 0.008-0.147) more survivals-to-discharge at a cost of $5,242 (95% CI, -$19,035 to $41,019) (incremental cost-effectiveness ratio = $44,615 per extra survival [95% CI, -$250,912 to $558,222]). If hospitals were willing to pay $100,000 per survival-to-discharge, any intervention costing less than $5,140 per patient would represent good value.

CONCLUSIONS

Interventions that increase utilization of proning would be cost-effective from both societal and hospital perspectives under many plausible cost and benefit assumptions.

Identifying Barriers to Nurse-Facilitated Patient Mobility in the Intensive Care Unit

BACKGROUND

Nurse-facilitated mobility of patients in the intensive care unit can improve outcomes. However, a gap exists between research findings and their implementation as part of routine clinical practice. Such a gap is often attributed, in part, to the barrier of lack of time. The Translating Evidence Into Practice model provides a framework for research implementation, including recommendations for identifying barriers to implementation via direct observation of clinical care.

OBJECTIVES

To report on design, implementation, and outcomes of an approach to identify and understand lack of time as a barrier to nurse-facilitated mobility in the intensive care unit.

METHODS

An interprofessional team designed the observational process and evaluated the resulting data by using qualitative content analysis.

RESULTS

During three 4-hour observations of 2 nurses and 1 nursing technician, 194 distinct tasks were performed (ie, events). A total of 4 categories of nurses' work were identified: patient care (47% of observation time), provider communication (25%), documentation (18%), and down time (10%). In addition, 3 types of potential mobility events were identified: in bed, edge of bed, and out of bed. The 194 observed events included 34 instances (18%) of potential mobility events that could be implemented: in bed (53%), edge of bed (6%), and out of bed (41%).

CONCLUSIONS

Nurses have limited time for additional clinical activities but may miss potentially important opportunities for facilitating patient mobility during existing patient care. The proposed method is feasible and helpful in empirically investigating barriers to nurse-facilitated patient mobility in the intensive care unit.

The association of intensive care with utilization and costs of outpatient healthcare services and quality of life

Background

Little is known about outpatient health services use following critical illness and intensive care. We examined the association of intensive care with outpatient consultations and quality of life in a population-based sample.

Methods

Cross-sectional analysis of data from 6,686 participants of the Study of Health in Pomerania (SHIP), which consists of two independent population-based cohorts. Statistical modeling was done using Poisson regression, negative binomial and generalized linear models for consultations, and a fractional response model for quality of life (EQ-5D-3L index value), with results expressed as prevalence ratios (PR) or percent change (PC). Entropy balancing was used to adjust for observed confounding.

Results

ICU treatment in the previous year was reported by 139 of 6,686 (2,1%) participants, and was associated with a higher probability (PR 1.05 [CI:1.03;1.07]), number (PC +58.0% [CI:22.8;103.2]) and costs (PC +64.1% [CI:32.0;103.9]) of annual outpatient consultations, as well as with a higher number of medications (PC +37.8% [CI:17.7;61.5]). Participants with ICU treatment were more likely to visit a specialist (PR 1.13 [CI:1.09; 1.16]), specifically internal medicine (PR 1.67 [CI:1.45;1.92]), surgery (PR 2.42 [CI:1.92;3.05]), psychiatry (PR 2.25 [CI:1.30;3.90]), and orthopedics (PR 1.54 [CI:1.11;2.14]). There was no significant effect regarding general practitioner consultations. ICU treatment was also associated with lower health-related quality of life (EQ-5D index value: PC -13.7% [CI:-27.0;-0.3]). Furthermore, quality of life was inversely associated with outpatient consultations in the previous month, more so for participants with ICU treatment.

Conclusions

Our findings suggest that ICU treatment is associated with an increased utilization of outpatient specialist services, higher medication intake, and impaired quality of life.

Understanding patient-important outcomes after critical illness: a synthesis of recent qualitative, empirical, and consensus-related studies

Purpose of review

Patients surviving critical illness frequently experience long-lasting morbidities. Consequently, researchers and clinicians are increasingly focused on evaluating and improving survivors’ outcomes after hospital discharge. This review synthesizes recent research aimed at understanding the postdischarge outcomes that patients consider important (i.e., patient-important outcomes) for the purpose of advancing future clinical research in the field.

Recent findings

Across multiple types of studies, patients, family members, researchers, and clinicians have consistently endorsed physical function, cognition, and mental health as important outcomes to evaluate in future research. Aspects of social health, such as return to work and changes in interpersonal relationships, also were noted in some research publications. Informed by these recent studies, an international Delphi consensus process (including patient and caregiver representatives) recommended the following core set of outcomes for use in all studies evaluating acute respiratory failure survivors after hospital discharge: survival, physical function (including muscle/nerve function and pulmonary function), cognition, mental health, health-related quality of life, and pain. The Delphi panel also reached consensus on recommended measurement instruments for some of these core outcomes.

Summary

Recent studies have made major advances in understanding patient-important outcomes to help guide future clinical research aimed at improving ICU survivors’ recovery.

Nutrition and Exercise in Critical Illness Trial (NEXIS Trial): a protocol of a multicentred, randomised controlled trial of combined cycle ergometry and amino acid supplementation commenced early during critical illness

INTRODUCTION

Survivors of critical illness often experience significant morbidities, including muscle weakness and impairments in physical functioning. This muscle weakness is associated with longer duration mechanical ventilation, greater hospital costs and increased postdischarge impairments in physical function, quality of life and survival. Compared with standard of care, the benefits of greater protein intake combined with structured exercise started early after the onset of critical illness remain uncertain. However, the combination of protein supplementation and exercise in other populations has demonstrated positive effects on strength and function. In the present study, we will evaluate the effects of a combination of early implementation of intravenous amino acid supplementation and in-bed cycle ergometry exercise versus a 'usual care' control group in patients with acute respiratory failure requiring mechanical ventilation in an intensive care unit (ICU).

METHODS AND ANALYSIS

In this multicentre, assessor-blinded, randomised controlled trial, we will randomise 142 patients in a 1:1 ratio to usual care (which commonly consists of minimal exercise and under-achievement of guideline-recommended caloric and protein intake goals) versus a combined intravenous amino acid supplementation and in-bed cycle ergometery exercise intervention. We hypothesise that this novel combined intervention will (1) improve physical functioning at hospital discharge; (2) reduce muscle wasting with improved amino acid metabolism and protein synthesis in-hospital and (3) improve patient-reported outcomes and healthcare resource utilisation at 6 months after enrolment. Key cointerventions will be standardised. In-hospital outcome assessments will be conducted at baseline, ICU discharge and hospital discharge. An intent-to-treat analysis will be used to analyse all data with additional per-protocol analyses.

ETHICS AND DISSEMINATION

The trial received ethics approval at each institution and enrolment has begun. These results will inform both clinical practice and future research in the area. We plan to disseminate trial results in peer-reviewed journals, at national and international conferences, and via nutritional and rehabilitation-focused electronic education and knowledge translation platforms.

TRIAL REGISTRATION NUMBER

NCT03021902; Pre-results.

The Use of Volatile Anesthetics as Sedatives for Acute Respiratory Distress Syndrome

Acute respiratory distress syndrome (ARDS) remains to pose a high morbidity and mortality without any targeted therapies. Sedation, usually given intravenously, is an important part of clinical practice in intensive care unit (ICU), and the effect of sedatives on patients’ outcomes has been studied intensively. Although volatile anesthetics are not routine sedatives in ICU, preclinical and clinical studies suggested their potential benefit in pulmonary pathophysiology. This review will summarize the current knowledge of ARDS and the role of volatile anesthetic sedation in this setting from both clinical and mechanistic standpoints. In addition, we will review the infrastructure to use volatile anesthetics.

Habilitation of very preterm infants at a Post Acute Care Inpatient Rehabilitation (PACIR) center after neonatal intensive care unit (NICU) discharge

OBJECTIVE

To investigate whether Post-Acute Care Inpatient Rehabilitation (PACIR) admission after NICU stay affects the total length of stay (LOS) of very preterm (VPT: ≤30 weeks of gestation) infants.

METHODS

A retrospective case control study of VPT infants d/c'd from the NICU at Maria Fareri Children's Hospital (MFCH) to either a PACIR (Blythedale Children's Hospital: BH) for convalescent care (cases) or directly home (controls).

RESULTS

35 cases and 70 controls. Total LOS (MFCH + BH) was longer for cases [196 vs. 97 days]. At the time of d/c from MFCH, Special Health Care Needs (SHCN) amongst cases were greater than controls, however, became similar at the time of home d/c. The majority of cases achieved habilitation goals at the PACIR.

CONCLUSIONS

Although LOS was longer for patients transferred to a PACIR, habilitation at BH Hospital reduced the SHCN at the time of home d/c amongst cases.

Inflammatory lung edema correlates with echocardiographic estimation of capillary wedge pressure in newly diagnosed septic patients

PURPOSE

Lung ultrasound is an accurate and accessible tool to quantify lung edema. Furthermore, left ventricle filling pressures (LVFP) can be assessed with transthoracic echocardiography (TTE) by the E/e' ratio (E/e'). The present study aimed to assess the correlation between E/e' and lung edema quantified by a simplified lung ultrasound score (LUS) in newly admitted septic patients.

MATERIALS AND METHODS

In this prospective observational cohort, septic adult patients admitted at the emergency department of a tertiary hospital were included. LUS consisted of four different patterns of lung edema (from normal aeration to parenchymal consolidation). To compare lung edema with LVFP, E/e' was calculated immediately before or within 5min of fluid therapy.

RESULTS

Fifty patients were enrolled in 3months. The LUS correlated with E/e' (r=0.58, P<0.0001). The LUS also increased among E/e' quartiles (Q) (Q1: E/e'≤4.49; Q2: 4.49<E/e'≤5.49; Q3: 5.49<E/e'≤7.11; Q4: >7.11; P=0.0003 for Q1 and 4; 2 and 4); and LUS was significantly higher in abnormal (≥8) vs. normal (<8) values of E/e' (11.29 vs 8.49, P=0.007).

CONCLUSION

In newly admitted septic patients, lung edema is positively correlated with LVFP prior to fluid therapy. This finding might help find future targets for fluid resuscitation in sepsis.

Joblessness and Lost Earnings after Acute Respiratory Distress Syndrome in a 1-Year National Multicenter Study

RATIONALE

Following acute respiratory distress syndrome (ARDS), joblessness is common but poorly understood.

OBJECTIVES

To evaluate the timing of return to work after ARDS, and associated risk factors, lost earnings, and changes in healthcare coverage Methods: Over 12-month longitudinal follow-up, ARDS survivors from 43 U.S. ARDSNet hospitals provided employment and healthcare coverage data via structured telephone interviews. Factors associated with the timing of return to work were assessed using Fine and Gray regression analysis. Lost earnings were estimated using Bureau of Labor Statistics data.

MEASUREMENTS AND MAIN RESULTS

Of 922 consenting survivors, 386 (42%) were employed before ARDS (56% male; mean ± SD age, 45 ± 13 yr), with seven dying by 12-month follow-up. Of 379 previously employed 12-month survivors, 166 (44%) were jobless at 12-month follow-up. Accounting for competing risks of death and retirement, half of enrolled and previously employed survivors returned to work by 13 weeks after hospital discharge, with 68% ever returning by 12 months. Delays in return to work were associated with longer hospitalization and older age among nonwhite survivors. Over 12-month follow-up, 274 (71%) survivors accrued lost earnings, averaging $26,949 ± $22,447 (60% of pre-ARDS annual earnings). Jobless survivors experienced a 14% (95% confidence interval, 5-22%; P = 0.002) absolute decrease in private health insurance (from 44% pre-ARDS) and a 16% (95% confidence interval, 7-24%; P < 0.001) absolute increase in Medicare and Medicaid (from 33%).

CONCLUSIONS

At 12 months after ARDS, nearly one-half of previously employed survivors were jobless. Post-ARDS joblessness is associated with readily identifiable patient and hospital variables and accompanied by substantial lost earnings and a shift toward government-funded healthcare coverage.

Return to work and lost earnings after acute respiratory distress syndrome: a 5-year prospective, longitudinal study of long-term survivors

BACKGROUND

Delayed return to work is common after acute respiratory distress syndrome (ARDS), but has undergone little detailed evaluation. We examined factors associated with the timing of return to work after ARDS, along with lost earnings and shifts in healthcare coverage.

METHODS

Five-year, multisite prospective, longitudinal cohort study of 138 2-year ARDS survivors hospitalised between 2004 and 2007. Employment and healthcare coverage were collected via structured interview. Predictors of time to return to work were evaluated using Fine and Grey regression analysis. Lost earnings were estimated using Bureau of Labor Statistics data.

RESULTS

Sixty-seven (49%) of the 138 2-year survivors were employed prior to ARDS. Among 64 5-year survivors, 20 (31%) never returned to work across 5-year follow-up. Predictors of delayed return to work (HR (95% CI)) included baseline Charlson Comorbidity Index (0.77 (0.59 to 0.99) per point; p=0.04), mechanical ventilation duration (0.67 (0.55 to 0.82) per day up to 5 days; p<0.001) and discharge to a healthcare facility (0.49 (0.26 to 0.93); p=0.03). Forty-nine of 64 (77%) 5-year survivors incurred lost earnings, with average (SD) losses ranging from US$38 354 (21,533) to US$43 510 (25,753) per person per year. Jobless, non-retired survivors experienced a 33% decrease in private health insurance and concomitant 37% rise in government-funded coverage.

CONCLUSIONS

Across 5-year follow-up, nearly one-third of previously employed ARDS survivors never returned to work. Delayed return to work was associated with patient-related and intensive care unit/hospital-related factors, substantial lost earnings and a marked rise in government-funded healthcare coverage. These important consequences emphasise the need to design and evaluate vocation-based interventions to assist ARDS survivors return to work.

Five-Year Mortality and Hospital Costs Associated with Surviving Intensive Care

RATIONALE

Survivors of critical illness experience significant morbidity, but the impact of surviving the intensive care unit (ICU) has not been quantified comprehensively at a population level.

OBJECTIVES

To identify factors associated with increased hospital resource use and to ascertain whether ICU admission was associated with increased mortality and resource use.

METHODS

Matched cohort study and pre/post-analysis using national linked data registries with complete population coverage. The population consisted of patients admitted to all adult general ICUs during 2005 and surviving to hospital discharge, identified from the Scottish Intensive Care Society Audit Group registry, matched (1:1) with similar hospital control subjects. Five-year outcomes included mortality and hospital resource use. Confounder adjustment was based on multivariable regression and pre/post within-individual analyses.

MEASUREMENTS AND MAIN RESULTS

Of 7,656 ICU patients, 5,259 survived to hospital discharge (5,215 [99.2%] matched to hospital control subjects). Factors present before ICU admission (comorbidities/pre-ICU hospitalizations) were stronger predictors of hospital resource use than acute illness factors. In the 5 years after the initial hospital discharge, compared with hospital control subjects, the ICU cohort had higher mortality (32.3% vs. 22.7%; hazard ratio, 1.33; 95% confidence interval, 1.22-1.46; P < 0.001), used more hospital resources (mean hospital admission rate, 4.8 vs. 3.3/person/5 yr), and had 51% higher mean 5-year hospital costs ($25,608 vs. $16,913/patient). Increased resource use persisted after confounder adjustment (P < 0.001) and using pre/post-analyses (P < 0.001). Excess resource use and mortality were greatest for younger patients without significant comorbidity.

CONCLUSIONS

This complete, national study demonstrates that ICU survivorship is associated with higher 5-year mortality and hospital resource use than hospital control subjects, representing a substantial burden on individuals, caregivers, and society.

Feasibility of Continuous Actigraphy in Patients in a Medical Intensive Care Unit

BACKGROUND

Poor sleep and immobility are common in patients in the medical intensive care unit (MICU) and are associated with adverse outcomes. Interventions to promote sleep and mobilization in the MICU are gaining popularity, but feasible instruments to measure their effectiveness are lacking. Actigraphy may be useful for large-scale, continuous measurement of sleep and activity, but its feasibility in MICU patients has not been rigorously evaluated.

OBJECTIVE

To evaluate the feasibility of continuous actigraphy measurement in consecutive MICU patients.

METHODS

Wrist and ankle actigraphy data were collected for 48 hours in consenting MICU patients. Actigraphy-based measures of estimated sleep and activity were summarized by using descriptive statistics. Agreement between wrist and ankle measurements was evaluated using Cohen κ statistics (for sleep quantity) and intraclass correlation coefficients (for activity).

RESULTS

Overall, 35 of 48 (73%) eligible patients were enrolled, including 10 requiring mechanical ventilation. Of these patients, 34 (97%) completed the 48-hour actigraphy period; 20 (57%) found the devices comfortable. Wrist devices logged a mean (SD) of 33.4 (8.8) hours of estimated sleep (72% [19%] of recording period) and 19.6 (17.2) movements per 30-second epoch. Ankle devices recorded 43.2 (4.1) hours of estimated sleep (93% [7%] of recording period) and 5.1 (6.0) movements per 30 seconds.

CONCLUSIONS

Uninterrupted actigraphy is feasible and generally well tolerated by MICU patients and may be considered for future large-scale studies. Wrist and ankle actigraphy measurements of sleep and activity in this setting agree poorly and cannot be used interchangeably.

Nucleated red blood cells, critical illness survivors and postdischarge outcomes: a cohort study

Background

Little is known about risk factors associated with out-of-hospital outcomes in survivors of critical illness. We hypothesized that the presence of nucleated red blood cells in patients who survived critical care would be associated with adverse outcomes following hospital discharge.

Methods

We performed a two-center observational cohort study of patients treated in medical and surgical intensive care units in Boston, Massachusetts. All data were obtained from the Research Patient Data Registry at Partners HealthCare. We studied 2878 patients, age ≥ 18 years, who received critical care between 2011 and 2015 and survived hospitalization. The exposure of interest was nucleated red blood cells occurring from 2 days prior to 7 days after critical care initiation. The primary outcome was mortality in the 90 days following hospital discharge. Secondary outcome was unplanned 30-day hospital readmission. Adjusted odds ratios were estimated by multivariable logistic regression models with inclusion of covariate terms thought to plausibly interact with both nucleated red blood cells and outcome. Adjustment included age, race (white versus nonwhite), gender, Deyo–Charlson Index, patient type (medical versus surgical), sepsis and acute organ failure.

Results

In patients who received critical care and survived hospitalization, the absolute risk of 90-day postdischarge mortality was 5.9%, 11.7%, 15.8% and 21.9% in patients with 0/μl, 1–100/μl, 101–200/μl and more than 200/μl nucleated red blood cells respectively. Nucleated red blood cells were a robust predictor of postdischarge mortality and remained so following multivariable adjustment. The fully adjusted odds of 90-day postdischarge mortality in patients with 1–100/μl, 101–200/μl and more than 200/μl nucleated red blood cells were 1.77 (95% CI, 1.23–2.54), 2.51 (95% CI, 1.36–4.62) and 3.72 (95% CI, 2.16–6.39) respectively, relative to patients without nucleated red blood cells. Further, the presence of nucleated red blood cells is a significant predictor of the odds of unplanned 30-day hospital readmission.

Conclusion

In critically ill patients who survive hospitalization, the presence of nucleated red blood cells is a robust predictor of postdischarge mortality and unplanned hospital readmission.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-017-1724-z) contains supplementary material, which is available to authorized users.

Core Domains for Clinical Research in Acute Respiratory Failure Survivors: An International Modified Delphi Consensus Study

OBJECTIVES

To identify the "core domains" (i.e., patient outcomes, health-related conditions, or aspects of health) that relevant stakeholders agree are essential to assess in all clinical research studies evaluating the outcomes of acute respiratory failure survivors after hospital discharge.

DESIGN

A two-round consensus process, using a modified Delphi methodology, with participants from 16 countries, including patient and caregiver representatives. Prior to voting, participants were asked to review 1) results from surveys of clinical researchers, acute respiratory failure survivors, and caregivers that rated the importance of 19 preliminary outcome domains and 2) results from a qualitative study of acute respiratory failure survivors' outcomes after hospital discharge, as related to the 19 preliminary outcome domains. Participants also were asked to suggest any additional potential domains for evaluation in the first Delphi survey.

SETTING

Web-based surveys of participants representing four stakeholder groups relevant to clinical research evaluating postdischarge outcomes of acute respiratory failure survivors: clinical researchers, clinicians, patients and caregivers, and U.S. federal research funding organizations.

SUBJECTS

None.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Survey response rates were 97% and 99% in round 1 and round 2, respectively. There were seven domains that met the a priori consensus criteria to be designated as core domains: physical function, cognition, mental health, survival, pulmonary function, pain, and muscle and/or nerve function.

CONCLUSIONS

This study generated a consensus-based list of core domains that should be assessed in all clinical research studies evaluating acute respiratory failure survivors after hospital discharge. Identifying appropriate measurement instruments to assess these core domains is an important next step toward developing a set of core outcome measures for this field of research.

Healthcare Resource Use and Costs in Long-Term Survivors of Acute Respiratory Distress Syndrome: A 5-Year Longitudinal Cohort Study

OBJECTIVE

To evaluate the time-varying relationship of annual physical, psychiatric, and quality of life status with subsequent inpatient healthcare resource use and estimated costs.

DESIGN

Five-year longitudinal cohort study.

SETTING

Thirteen ICUs at four teaching hospitals.

PATIENTS

One hundred thirty-eight patients surviving greater than or equal to 2 years after acute respiratory distress syndrome.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Postdischarge inpatient resource use data (e.g., hospitalizations, skilled nursing, and rehabilitation facility stays) were collected via a retrospective structured interview at 2 years, with prospective collection every 4 months thereafter, until 5 years postacute respiratory distress syndrome. Adjusted odds ratios for hospitalization and relative medians for estimated episode of care costs were calculated using marginal longitudinal two-part regression. The median (interquartile range) number of inpatient admission hospitalizations was 4 (2-8), with 114 patients (83%) reporting greater than or equal to one hospital readmission. The median (interquartile range) estimated total inpatient postdischarge costs over 5 years were $58,500 ($19,700-157,800; 90th percentile, $328,083). Better annual physical and quality of life status, but not psychiatric status, were associated with fewer subsequent hospitalizations and lower follow-up costs. For example, greater grip strength (per 6 kg) had an odds ratio (95% CI) of 0.85 (0.73-1.00) for inpatient admission, with 23% lower relative median costs, 0.77 (0.69-0.87).

CONCLUSIONS

In a multisite cohort of long-term acute respiratory distress syndrome survivors, better annual physical and quality of life status, but not psychiatric status, were associated with fewer hospitalizations and lower healthcare costs.

Recovery from Dysphagia Symptoms after Oral Endotracheal Intubation in Acute Respiratory Distress Syndrome Survivors. A 5-Year Longitudinal Study

RATIONALE

Nearly 60% of patients who are intubated in intensive care units (ICUs) experience dysphagia after extubation, and approximately 50% of them aspirate. Little is known about dysphagia recovery time after patients are discharged from the hospital.

OBJECTIVES

To determine factors associated with recovery from dysphagia symptoms after hospital discharge for acute respiratory distress syndrome (ARDS) survivors who received oral intubation with mechanical ventilation.

METHODS

This is a prospective, 5-year longitudinal cohort study involving 13 ICUs at four teaching hospitals in Baltimore, Maryland. The Sydney Swallowing Questionnaire (SSQ), a 17-item visual analog scale (range, 0-1,700), was used to quantify patient-perceived dysphagia symptoms at hospital discharge, and at 3, 6, 12, 24, 36, 48, and 60 months after ARDS. An SSQ score greater than or equal to 200 was used to indicate clinically important dysphagia symptoms at the time of hospital discharge. Recovery was defined as an SSQ score less than 200, with a decrease from hospital discharge greater than or equal to 119, the reliable change index for SSQ score. Fine and Gray proportional subdistribution hazards regression analysis was used to evaluate patient and ICU variables associated with time to recovery accounting for the competing risk of death.

MEASUREMENTS AND MAIN RESULTS

Thirty-seven (32%) of 115 patients had an SSQ score greater than or equal to 200 at hospital discharge; 3 died before recovery. All 34 remaining survivors recovered from dysphagia symptoms by 5-year follow-up, 7 (23%) after 6 months. ICU length of stay was independently associated with time to recovery, with a hazard ratio (95% confidence interval) of 0.96 (0.93-1.00) per day.

CONCLUSIONS

One-third of orally intubated ARDS survivors have dysphagia symptoms that persist beyond hospital discharge. Patients with a longer ICU length of stay have slower recovery from dysphagia symptoms and should be carefully considered for swallowing assessment to help prevent complications related to dysphagia.

Perioperative "remote" acute lung injury: recent update

Perioperative acute lung injury (ALI) is a syndrome characterised by hypoxia and chest radiograph changes. It is a serious post-operative complication, associated with considerable mortality and morbidity. In addition to mechanical ventilation, remote organ insult could also trigger systemic responses which induce ALI. Currently, there are limited treatment options available beyond conservative respiratory support. However, increasing understanding of the pathophysiology of ALI and the biochemical pathways involved will aid the development of novel treatments and help to improve patient outcome as well as to reduce cost to the health service. In this review we will discuss the epidemiology of peri-operative ALI; the cellular and molecular mechanisms involved on the pathological process; the clinical considerations in preventing and managing perioperative ALI and the potential future treatment options.

Physical declines occurring after hospital discharge in ARDS survivors: a 5-year longitudinal study

PURPOSE

Survivors of acute respiratory distress syndrome (ARDS) are at high risk for new or ongoing physical declines after hospital discharge. The objective of our study was to evaluate the epidemiology of physical declines over 5-year follow-up and identify patients at risk for decline.

METHODS

This multi-site prospective cohort study evaluated ARDS survivors who completed a physical status assessment at 3 or 6 months post-discharge. Three measures were evaluated: muscle strength (Medical Resource Council sumscore); exercise capacity [6-min walk test (6MWT)]; physical functioning [36-Item Short Form Health Survey (SF-36 survey)]. Patients were defined as "declined" if a comparison of their current and prior score showed a decrease that was greater than the Reliable Change Index-or if the patient died. Risk factors [pre-ARDS baseline status, intensive care unit (ICU) illness severity, and other intensive care variables] were evaluated using longitudinal, generalized linear regression models for each measure.

RESULTS

During the follow-up of 193 ARDS survivors (55 % male; median age 49 years), 166 (86 %) experienced decline in ≥1 physical measure (including death) and 133 (69 %) experienced a physical decline (excluding death). For all measures, age was a significant risk factor [odds ratios (OR) 1.34-1.69 per decade; p < 0.001]. Pre-ARDS comorbidity (Charlson Index) was independently associated with declines in strength and exercise capacity (OR 1.10 and 1.18, respectively; p < 0.02), and organ failure [maximum daily Sequential Organ Failure Assessment (SOFA) score in ICU] was associated with declines in strength (OR 1.06 per 1 point of SOFA score; p = 0.02).

CONCLUSIONS

Over the follow-up period, the majority of ARDS survivors experienced a physical decline, with older age and pre-ICU comorbidity being important risk factors for this decline.