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August - 2017

   

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The impact of disability in survivors of critical illness

C Hodgson, A Udy, M Bailey, et al Int Care Med, 2017, 43(7);992-1001

Comment

Our exploration of long-term outcomes after critical illness is evolving. We know survivors often experience long-term physical, cognitive and mental health impairments known as post-intensive care syndrome. We also know we are limited in our understanding of this by the tools we use to measure outcomes. 

To start with, loss to follow-up is a major issue. Also, the relationship between what we measure, and what matters to our patients, remains an issue. We know about readmission, healthcare costs, and health-related quality of life. However we are increasingly recognising the value of patient related outcome measures (PROMs), measuring what matters most to our patients, their experiences of disability, functioning and health-related quality of life, including participation and limitations in activities.

So, how can we align what we measure with what matters to our patients? 

World Health Organisation’s International Classification defines disability as "difficulties  in any area of functioning as they relate to environmental and personal factors”. It separates the measurement of disability and functioning from health-related quality of life. World Health Organisation’s Disability Assessment Schedule 2.0 (WHODAS) was developed to measure disability cross-culturally and for disease-related states across six major life domains: cognition, mobility, self-care, interpersonal relationships, work and household roles, and participation in society. It has been tested for concurrent validity against the Functional Independence Measure (FIM), SF-36 and the WHOQoL and used to assess disability following trauma, stroke, surgery, post traumatic stress in veterans and in chronic diseases.

This multicentre, prospective cohort study aimed to measure key components of WHODAS in survivors of critical illness using patient centred outcomes. So what did they do?

  • Enrolled adult patients in 5 ICUs, ventilated for 24hr or more and surviving to hospital discharge, and followed them for 6-months
  • At 6-months they underwent a telephone interview, and information collected included global function and disability (WHODAS II, 12 item) [19], health status EQ-5D-5L, cognitive function (TICS), anxiety and depression (HADS), PTSD (IES-R), and return to work (WHODAS II)
  • All these are converted to scores, and patients were categorised as no, mild, moderate, severe, or disability free vs non-disability free. 
  • Multivariable logistic regression was used to identify factors independently associated with moderate to severe disability with results reported as odds ratios (95% CI)

They found;

  • low levels of comorbidity in the enrolled group (median =0)
  • WHODAS 6-month disability - 25% reported no disability (score 0–4%), 50% mild disability (score 5–24%) and 25% reported moderate to severe disability (score 25–95%). No patients reported complete disability (score 96–100%). After multivariable analysis, predictors of moderate to severe disability included a history of anxiety and/or depression, being separated or divorced, longer duration of mechanical ventilation and not being discharged to home from the acute hospital. 
  • EQ5D (health-related quality of life) was worse at 6 months after critical illness compared to the month prior to the illness as retrospectively recalled. Patients with a moderate to severe disability had a significant decrease in health status in all domains compared to patients with no disability at 6 month
  • At 6 months anxiety was reported in 21%, depression in 17% and depression and/or anxiety in 22%. Patients with moderate to severe disability reported significantly greater anxiety and depression symptoms 
  • At 6 months after ICU, 60% had not returned to work or studies because of their health. There was a significant difference in the number of patients who reported being unemployed as a result of their health with a moderate to severe disability compared to none or mild disability

Disability measured using patient-reported outcomes was prevalent at 6 months after critical illness in survivors and was associated with both reduced health-related quality of life and poor return to work due to result of health. There is a lot of work to be done.

 

Abstract

Purpose

To use the World Health Organisation’s International Classification of Functioning to measure disability following critical illness using patient-reported outcomes.

Methods

A prospective, multicentre cohort study conducted in five metropolitan intensive care units (ICU). Participants were adults who had been admitted to the ICU, received more than 24 h of mechanical ventilation and survived to hospital discharge. The primary outcome was measurement of disability using the World Health Organisation’s Disability Assessment Schedule 2.0. The secondary outcomes included the limitation of activities and changes to health-related quality of life comparing survivors with and without disability at 6 months after ICU.

Results

We followed 262 patients to 6 months, with a mean age of 59 ± 16 years, and of whom 175 (67%) were men. Moderate or severe disability was reported in 65 of 262 (25%). Predictors of disability included a history of anxiety/depression [odds ratio (OR) 1.65 (95% confidence interval (CI) 1.22, 2.23), P = 0.001]; being separated or divorced [OR 2.87 (CI 1.35, 6.08), P = 0.006]; increased duration of mechanical ventilation [OR 1.04 (CI 1.01, 1.08), P = 0.03 per day]; and not being discharged to home from the acute hospital [OR 1.96 (CI 1.01, 3.70) P = 0.04]. Moderate or severe disability at 6 months was associated with limitation in activities, e.g. not returning to work or studies due to health (P < 0.002), and reduced health-related quality of life (P < 0.001).

Conclusion

Disability measured using patient-reported outcomes was prevalent at 6 months after critical illness in survivors and was associated with reduced health-related quality of life. Predictors of moderate or severe disability included a prior history of anxiety or depression, separation or divorce and a longer duration of mechanical ventilation.

August


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