haines- developing puzzle icu outcomes

The Developing Puzzle of ICU Outcomes

Kimberley HainesPhD, Senior ICU PhysiotherapistAllied Health Research LeadWestern Health

Austin Health Medical Research Foundation@HainesKimber

ley

ICU Outcomes – Presentation Outline

• The context• The patient

perspective• The family perspective• International

outcomes• Local outcomes

The context – declining mortality

Kaukonen et al 2014 JAMA

The context – increasing survivorship

Iwashyna et al 2012 JAGS

The patient’s perspective - Gratitude

“For what I went through, it was severe, it’s marvellous I’m still here, what was done for me… I’m very grateful for everything that was done for me” Participant 1

“Being alive is incredible.” Participant 4

“I’m very grateful, I don’t feel I deserve it” Participant 10

“I’m home again, I’ve survived” Participant 22

Resolution of recovery

“I’m enjoying good health and family life, I’m totally recovered” Participant 23

“Getting back to fitness, getting back to normal and enjoying life” Participant 42

“I’ve been able to travel overseas, I feel normal” Participant 18

“A thousand miles better” Participant 50

Loss and acceptance

“Most of my life I can do normally – walking, hurrying, lifting… I can function within limits, beyond that I can’t do…” Participant 2

“…it’s not too bad a quality of life, it’s the best Qol they could have given me” Participant 3

“I can’t do gardening like I used to as I get breathless and tired and I miss playing soccer and sports” Participant 45

“…losing my singing voice as I was a singer… sooo sad for me” Participant 53

Resilience“It’s only in the mind, if your will is strong enough you can beat anything!” Participant 8

“I recognised my own capacity and resilience” Participant 50

“I worry less about things now” Participant 10

“…being determined and achieving and getting back to what looks like a normal life to most. A hard fight.” Participant 1

Impact on family

“Mental aspects for my family is the part of my life that has been most affected” Participant 23

“My family life has been affected, and it was a struggle for my family whilst I was in ICU” Participant 45

Impact on family

Van Pelt et al 2010 Chest

The context

Improved survival

Increased focus on quality of survival

Longer term recovery?

ANZICs Adult Database 2007, Kaukonen 2014 Needham et al. 2011, Williams et al. 2011

WHAT DO WE KNOW ABOUT INTERNATIONAL OUTCOMES?

Physical functionHRQoL Psychology Cognition


12 months 5 years


6 months

Outcomes over time

Time

Short term 3-6 monthsPhysical functionHRQoL Psychology Cognition

6 months

Physical function1, 2 • 32-48% disability ADLS• 26% disability in IADLS

HRQoL1

• 27% HRQoL poor/fair

Psychology2, 3

• 44% PTSD• 37% Mild depression

Cognition 3 months4

• 40% cognitive impairment

1Garland 2004 Chest2Jackson 2014 Lancet Respir Med3Parker 2015 CCM4Pandharipande 2013 NEJM

Medium term 12 months


12 months

Physical function1, 2 • 27% disability in ADLs• 23% disability in IADLS• 66% predicted 6MWD

HRQoL2, 3

• SF36 domain scores <population norms

Psychology1,4

• 34% PTSD symptoms• 33% mild depression

Cognition5

• 34% cognitive impairment

1Jackson 2014 Lancet Respir Med2Herridge 2003 NEJM3Cuthberston 2010 Crit Care4Parker 2015 CCM5Pandharipande 2013 NEJM

Outcomes over time - cognition

Iwashyna et al 2010 JAMA

Long term 5 years

2010 Crit Care


5 years

Physical function1

• 79% independent living• 13% return to work

HRQoL1, 2

• SF36 similar to pop norms

Psychology• ???

Cognition3

• 25% impairment at 6 years

1Graf 2005 CCM2Cuthbertson 2010 Crit Care3Rothenhausler 2001 Gen Hosp Psych

Long term 5 years

Hofhuis et al 2015 ICM

HRQoL domains for SF36

PF = Physical functionRP = Role physicalBP = Bodily painGH = General healthVT = VitalitySF = Social functioningRE = Role emotionalMH = Mental health

Score 0-100Higher score = greater HRQoL

Long term 5 years

2011 NEJM

Long term 5 years


5 years

Physical function1

• 79% independent living• 13% return to work

HRQoL1, 2

• SF36 similar to pop norms

Psychology• ???

Cognition3

• 25% impairment at 6 years

1Graf 2005 CCM2Cuthbertson 2010 Crit Care3Rothenhausler 2001 Gen Hosp Psych

Summary of international outcomes

OUTCOME SHORT TERM3-6 MONTHS

MEDIUM TERM12 MONTHS

LONG TERM5 YEARS

Physical function

32-48% disability ADLS26% disability in IADLS

27% disability in ADLs23% disability in IADLS66% predicted 6MWD

79% independent living

76% predicted 6MWDHRQoL 27% HRQoL poor/fair SF36 domain scores

<population normsSF36 similar to population norms

Psychology 7-44% PTSD37% mild depression

7% PTSD symptoms33% mild depression

???

Cognition 40% cognitive impairment 34% cognitive impairment

???

WHAT DO WE KNOW ABOUT LOCAL RECOVERY?

Short term 6 month outcomes


6 months

HRQoL2, 3

• Mixed resultsPhysical function1

• 38% mod-severe disability ADLs

Psychology1

• 39% mod-severe anxiety, depression

Cognition• ???

1Hodgson 2015 Crit Care2Skinner 2011 CCM3Hodgson 2012 Crit Care

Medium term outcomes 12 months

2013 Crit Care


12 months

Physical function • 6MWD below pop

norms

HRQoL• Close to population

normals

Psychology• ???

Cognition• ???

Denehy 2013 Crit Care

Longer term 5 years

What are the physical function, health-related quality of life and mortality outcomes in patients four to five years following intensive care discharge?

What is the long-term prevalence of anxiety, depression and post-traumatic stress disorder?

Austin Health Medical Research Foundation

MethodsProspective observational longitudinal cohort study

Original RCT1 2007-2010, n = 150 cohort

Long term outcome study 2012-2013, Estimated n = 100

1Denehy et al, 2013 – conducted 2007-2010


Outcome Measures

Enright et al 1998, Baldwin et al 2012, Radloff et al 1977, Zigmond et al 1983, Horowitz et al 1979, Ware et al 2000, Hawthorne et al 1999

OUTCOME OUTCOME MEASURE

Physical Function Six Minute Walk Test (6MWT)Timed Up and Go (TUG)

Hand grip dynamometry* Health-Related Quality of

LifeShort Form 36 v2(SF36 v2)

Assessment of Quality of Life (AQoL) Psychological Function Impact of Events Scale (IES)

Centre for Epidemiological Studies-Depression (CES-D)

Hospital Anxiety and Depression Scale (HADS)Employment status Return to work


Results: Participant follow up150 participants screened

56 participants included in follow up study

84 participants

68 participants

58 participants 2 (1%) unable to consent in nursing homes

10 (7%) declined

16 (11%) lost to follow up

66 (44%) deceased


Results: DemographicsWhole Cohort n=150 Survivors n = 56 Deceased n = 66

Age at recruitment (years) mean (SD) 61 (15.8) 59 ( 14.1), 64 (14.2) at 4-5yrs

67 (14.6)

Male n (%) 94 (62) 34 (61) 44 (66)

APACHE II mean (SD) 20 (7) 18 (6) 22 (7.9)

ICU Diagnosis (%)

Pneumonia 17 13 21

Cardiac 39 43 33

Other surgery 15 16 14

Liver disease/transplant 10 13 9

Sepsis 8 5 12

Other 8 10 11

>1 Comorbidity n (%) 53 (35%) 17 (30%) 30 (46%)

MV hours median (IQR) 92 (26-165) 96 (0-689) 84 (41-186)

ICU length of stay (days) median (IQR) 7 (6-11) 7 (5-11) 8 (6-11)

Mortality over timeN

umbe

r of

dea

ths

Logistic regression:

Baseline age = 0.04* APACHE II = 0.01*


Results: Independent livingn (%) Survivors

n = 56

Home and independent

56 (100%)

No caregiver requirement post hospital discharge

45 (80%)

Return to work 20 (69%)


Results: Physical Function 6MWD

1 year follow up 4-5 year follow up

0

100

200

300

400

500

600

Australian survivors

US Predicted Norms

Canadian survivors Herridge 2011

Dis

tanc

e (m

)

Enright and Sherill, 1998


Results: 1 year HR-QoL and 4-5 yearsOutcome measure mean (SD) 1 YEAR 4-5 YEARS Age-matched

normative values for 4-5 years

AQoL Health utility

Range -0.04, 1.00

0.77 (0.24) 0.74 (0.23) 0.79 (0.19)

SF36 Physical Component ScorePopulation mean (SD) = 50 (10)

46.4 (7.9) 46.9 (8.2) 46.82 (11.6)

SF36 Mental Component ScorePopulation mean (SD) = 50 (10)

48.8 (13) 49.2 (11.1) 50.1 (10.8)

SF36 Physical Function ScalePopulation mean (SD) = 50(10)

44.7 (10) 43.6 (11.6) 47.4 (10.7)

* Denehy et al 2013** Skinner et al., 2013

0.50 (0.40)*0.53 (0.33)**

Results: Psychological outcomesOutcome measure n = 56

Median (IQR)

Impact of Events Scale score Trigger = >19* clinically significant symptoms PTSD

1 (0 - 11)

Hospital Anxiety and Depression Scale – AnxietyTrigger = >8** clinically significant symptoms

3 (1 - 6)

Hospital Anxiety and Depression Scale – DepressionTrigger = >8** clinically significant symptoms

1 (0 - 4)


* Horowitz et al., 1979** Zigmond et al., 1983

Results: Hospital Anxiety and Depression Scale

86%

9%

4% 1%

Depression %

NoneMildModerateSevere

80%

16%

2% 2%

Anxiety %

NoneMildModerateSevere


What do we know at 5 years?First longitudinal Australian data

Survivor bias

High mortality rate

Limitations and strengths


Summary of local outcomesOUTCOME SHORT TERM

3-6 MONTHSMEDIUM TERM12 MONTHS

LONG TERM5 YEARS

Physical function 38% mod-severe disability ADLs 6MWD below pop norms 6MWD improves but below pop norms

HRQoL Mixed results Close to population normal

Same as population normal

Psychology 39% mod-severe anxiety, depression

??? 80-86% no anxiety or depression

Cognition ??? ??? ???

Discussion

Differences between local and international contexts

Challenges in outcome measurement and reporting

Differing trajectories of recovery

Lessons to be learnt from other survivor cohorts

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