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Differences in one-year health outcomes and resource utilization by definition of prolonged mechanical ventilation: a prospective cohort study.

Cox CE, Carson SS, Lindquist JH, Olsen MK, Govert JA, Chelluri L, Quality of Life After Mechanical Ventilation in the Aged (QOL-MV) Investigato - Crit Care (2007)

Bottom Line: To better understand the implications of PMV provision, we compared one-year health outcomes between two common definitions of PMV as well as between PMV patients and those ventilated for shorter periods of time.Contrasting definitions of PMV capture significantly different patient populations, with > or = 21 days of ventilation specifying the most resource-intensive recipients of critical care.PMV patients, particularly the elderly, suffer from a significant burden of costly, chronic critical illness and are at high risk for death throughout the first year after intensive care.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Medicine, Division of Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina 27710, USA. christopher.cox@duke.edu

ABSTRACT

Introduction: The outcomes of patients ventilated for longer than average are unclear, in part because of the lack of an accepted definition of prolonged mechanical ventilation (PMV). To better understand the implications of PMV provision, we compared one-year health outcomes between two common definitions of PMV as well as between PMV patients and those ventilated for shorter periods of time.

Methods: We conducted a secondary analysis of prospectively collected data from medical and surgical intensive care units at an academic tertiary care medical center. The study included 817 critically ill patients ventilated for > or = 48 hours, 267 (33%) of whom received PMV based on receipt of a tracheostomy and ventilation for > or = 96 hours. A total of 114 (14%) patients met the alternate definition of PMV by being ventilated for > or = 21 days. Survival, functional status, and costs were measured at baseline and at 2, 6, and 12 months after discharge. Of one-year survivors, 71 (17%) were lost to follow up.

Results: PMV patients ventilated for > or = 21 days had greater costs ($140,409 versus $143,389) and higher one-year mortality (58% versus 48%) than did PMV patients with tracheostomies who were ventilated for > or = 96 hours. The majority of PMV deaths (58%) occurred after hospital discharge whereas 67% of PMV patients aged 65 years or older had died by one year. At one year PMV patients on average had limitations in two basic and five instrumental elements of functional status that exceeded both their pre-admission status and the one-year disability of those ventilated for < 96 hours. Costs per one-year survivor were $423,596, $266,105, and $165,075 for patients ventilated > or = 21 days, > or = 96 hours with a tracheostomy, and < 96 hours, respectively.

Conclusion: Contrasting definitions of PMV capture significantly different patient populations, with > or = 21 days of ventilation specifying the most resource-intensive recipients of critical care. PMV patients, particularly the elderly, suffer from a significant burden of costly, chronic critical illness and are at high risk for death throughout the first year after intensive care.

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Survival by age group among DRG 541/542 patients. Kaplan-Meier plot demonstrating one-year survival stratified by age group among DRG 541/542 patients. Patients aged < 55 years have noticeably better overall survival than do older patients. Those < 55 years old also experience very low mortality rates after two months, whereas other age groups continue to die at relatively constant rates. P < 0.01 for comparisons between 65–74, 75–84, and ≥ 85 year age groups by logistic regression and adjusted for day one APS, preadmission IADLs, admission source, admitting diagnostic group, and preadmission Charlson score; P > 0.05 for comparisons between other age groups. APS, Acute Physiology Score; DRG, diagnosis related group; IADL, instrumental activity of daily living.
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Figure 2: Survival by age group among DRG 541/542 patients. Kaplan-Meier plot demonstrating one-year survival stratified by age group among DRG 541/542 patients. Patients aged < 55 years have noticeably better overall survival than do older patients. Those < 55 years old also experience very low mortality rates after two months, whereas other age groups continue to die at relatively constant rates. P < 0.01 for comparisons between 65–74, 75–84, and ≥ 85 year age groups by logistic regression and adjusted for day one APS, preadmission IADLs, admission source, admitting diagnostic group, and preadmission Charlson score; P > 0.05 for comparisons between other age groups. APS, Acute Physiology Score; DRG, diagnosis related group; IADL, instrumental activity of daily living.

Mentions: DRG 541/542 patients had significantly lower in-hospital mortality (20% versus 43%; P < 0.0001) and one-year mortality (48% versus 59%) compared with short-term ventilation patients (Table 2). Considering DRG 541/542 patients alone, mortality increased with patient age (Figure 2), although there were statistically significant adjusted one-year mortality differences only between patients in the 65–74, 75–84, and ≥ 85 year age groups (all P < 0.01). In-hospital and one-year mortality appeared higher for those ventilated for ≥ 21 days than for DRG 541/542 patients (statistical comparison not performed because of overlap between the groups). Mortality did not differ significantly between patient age strata (P = 0.30 by log-rank test) for patients ventilated ≥ 21 days. Patients ventilated for ≥ 21 days who did not receive a tracheostomy had particularly high mortality (Figure 3).


Differences in one-year health outcomes and resource utilization by definition of prolonged mechanical ventilation: a prospective cohort study.

Cox CE, Carson SS, Lindquist JH, Olsen MK, Govert JA, Chelluri L, Quality of Life After Mechanical Ventilation in the Aged (QOL-MV) Investigato - Crit Care (2007)

Survival by age group among DRG 541/542 patients. Kaplan-Meier plot demonstrating one-year survival stratified by age group among DRG 541/542 patients. Patients aged < 55 years have noticeably better overall survival than do older patients. Those < 55 years old also experience very low mortality rates after two months, whereas other age groups continue to die at relatively constant rates. P < 0.01 for comparisons between 65–74, 75–84, and ≥ 85 year age groups by logistic regression and adjusted for day one APS, preadmission IADLs, admission source, admitting diagnostic group, and preadmission Charlson score; P > 0.05 for comparisons between other age groups. APS, Acute Physiology Score; DRG, diagnosis related group; IADL, instrumental activity of daily living.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2147069&req=5

Figure 2: Survival by age group among DRG 541/542 patients. Kaplan-Meier plot demonstrating one-year survival stratified by age group among DRG 541/542 patients. Patients aged < 55 years have noticeably better overall survival than do older patients. Those < 55 years old also experience very low mortality rates after two months, whereas other age groups continue to die at relatively constant rates. P < 0.01 for comparisons between 65–74, 75–84, and ≥ 85 year age groups by logistic regression and adjusted for day one APS, preadmission IADLs, admission source, admitting diagnostic group, and preadmission Charlson score; P > 0.05 for comparisons between other age groups. APS, Acute Physiology Score; DRG, diagnosis related group; IADL, instrumental activity of daily living.
Mentions: DRG 541/542 patients had significantly lower in-hospital mortality (20% versus 43%; P < 0.0001) and one-year mortality (48% versus 59%) compared with short-term ventilation patients (Table 2). Considering DRG 541/542 patients alone, mortality increased with patient age (Figure 2), although there were statistically significant adjusted one-year mortality differences only between patients in the 65–74, 75–84, and ≥ 85 year age groups (all P < 0.01). In-hospital and one-year mortality appeared higher for those ventilated for ≥ 21 days than for DRG 541/542 patients (statistical comparison not performed because of overlap between the groups). Mortality did not differ significantly between patient age strata (P = 0.30 by log-rank test) for patients ventilated ≥ 21 days. Patients ventilated for ≥ 21 days who did not receive a tracheostomy had particularly high mortality (Figure 3).

Bottom Line: To better understand the implications of PMV provision, we compared one-year health outcomes between two common definitions of PMV as well as between PMV patients and those ventilated for shorter periods of time.Contrasting definitions of PMV capture significantly different patient populations, with > or = 21 days of ventilation specifying the most resource-intensive recipients of critical care.PMV patients, particularly the elderly, suffer from a significant burden of costly, chronic critical illness and are at high risk for death throughout the first year after intensive care.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Medicine, Division of Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina 27710, USA. christopher.cox@duke.edu

ABSTRACT

Introduction: The outcomes of patients ventilated for longer than average are unclear, in part because of the lack of an accepted definition of prolonged mechanical ventilation (PMV). To better understand the implications of PMV provision, we compared one-year health outcomes between two common definitions of PMV as well as between PMV patients and those ventilated for shorter periods of time.

Methods: We conducted a secondary analysis of prospectively collected data from medical and surgical intensive care units at an academic tertiary care medical center. The study included 817 critically ill patients ventilated for > or = 48 hours, 267 (33%) of whom received PMV based on receipt of a tracheostomy and ventilation for > or = 96 hours. A total of 114 (14%) patients met the alternate definition of PMV by being ventilated for > or = 21 days. Survival, functional status, and costs were measured at baseline and at 2, 6, and 12 months after discharge. Of one-year survivors, 71 (17%) were lost to follow up.

Results: PMV patients ventilated for > or = 21 days had greater costs ($140,409 versus $143,389) and higher one-year mortality (58% versus 48%) than did PMV patients with tracheostomies who were ventilated for > or = 96 hours. The majority of PMV deaths (58%) occurred after hospital discharge whereas 67% of PMV patients aged 65 years or older had died by one year. At one year PMV patients on average had limitations in two basic and five instrumental elements of functional status that exceeded both their pre-admission status and the one-year disability of those ventilated for < 96 hours. Costs per one-year survivor were $423,596, $266,105, and $165,075 for patients ventilated > or = 21 days, > or = 96 hours with a tracheostomy, and < 96 hours, respectively.

Conclusion: Contrasting definitions of PMV capture significantly different patient populations, with > or = 21 days of ventilation specifying the most resource-intensive recipients of critical care. PMV patients, particularly the elderly, suffer from a significant burden of costly, chronic critical illness and are at high risk for death throughout the first year after intensive care.

Show MeSH
Related in: MedlinePlus