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What outcome measures are important?

Todd Fraser on 30-04-2011

This month, the Archives of Surgery published a paper examining the longer term quality of life in patients admitted to a surgical ICU. The results were profound. The authors found that a great percentage of patients reported restriction in their quality of life, even 6-11 years after the admission to ICU. 52% described issues with mobility, 57% had pain or discomfort, 43% reported cognitive issues, and 52% were limited in their normal activities. These findings were worse than historically matched controls. This study is obviously bound by issues such as recall bias and a lack of QOL assessment prior to illness. Nonetheless, the results are striking. Survival to ICU discharge is an easy endpont to measure, but may not be the information we are after. Is more work required in this area? Surely we need better information on this to fully explain to patients the implications of our treatments.


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Todd Fraser wrote 10-24-2011 08:33:20 am
Check out today's newly released Vodcast by Neil Orford. He discusses the need for further research into why ICU patients do so badly in the 12 months following their admission to ICU.

Its a fascinating interview



Alex McKenzie wrote 10-28-2011 10:26:13 pm
What a fascinating perspective. Many trials seem to be reporting significant mortality after ICU admission - in the range of 10-20%. I had always thought this was just that they were often a sicker group who got into trouble (ie they were older, had significant co-morbidities like COPD etc). It hadn't occured to me that there might be reversable pathology accounting for it.

It will be interesting to see what is turned up in this area.



Alex McKenzie wrote 06-21-2011 10:10:45 am
One of the problems is defining an acceptable outcome. I know there are outcomes from ICU that I would not want for myself, but others would take with both hands. It seems that research is best applied when there is a hard end-point - some of the outcomes suggested for this area are grey to say the least.

By the way, fantastic work with the podcast by Charlie Corke - summed up my feelings on this in a nutshell.



Anthony Tzannes wrote 05-09-2011 12:14:17 am
I agree with Todd, having data about functional outcomes in survivors of ICU is of immense value. Not only will families/patients have a better idea on the implications of decisions, ICU staff will have a better idea of who should be accepted to ICU.

We have had a recent run of older patients with abdo disasters (severe pancreatitis etc) most of these survived their 2+ months in ICU only to end up being palliated (at their request) on the ward and dying after their 5th , 6th...27th complication. I don't think anyone would call 3+ months of pain and procedures prior to dying while still an inpatient a good outcome. But if one only looks at ICU mortality figures then these patients were all "wins"

If one looks at the role of the Intensivist in regards to being the gatekeeper to ICU and their responsibility to society on how to utilise this limited resource, functional outcome measures are of even greater import



Benjamin Moran wrote 05-10-2011 08:22:29 pm
I agree, Anthony. It seems that one of the most important questions we ask prior to a patient's admission to ICU, "What is their quality of life like at home?" is a scant outcome in the majority of intensive care studies. I understand the difficulties about designing and implementing a study where there is a functional primary outcome (death is an easily defined parameter), but these are important outcomes that may clearly influence decision-making. Some recent studies (SAFE-TBI and DECRA) have utilised functional outcomes in their analyses, and these have proved beneficial in treatment effects beyond mortality.

The obvious caveat to this argument is standardising functional outcome. What one patient deems a poor quality of life may be the El Dorado of another. It is not an easy outcome to measure, and there may be reluctance to fund studies which such ambiguous endpoints. That said, more studies that utilise these outcomes could only benefit us in our quest for delivering appropriate health care to the critically ill.



Todd Fraser wrote 05-16-2011 11:00:51 am
Thanks Anthony and Ben for your comments.

Agreed, there is clearly a need for these types of endpoints. I guess the question is, which endpoint do we turn to? Is there validation studies of these tools?

In the March 2011 edition of Critical Care and Resuscitation, Dennis et al look at the use of the FIM (Functional Independence Measure). They found 50% of ICU survivors returned to work and 76% of drivers returned to driving at 6 months, if they'd been ventilated >48 hours.

Other studies have used Glasgow Outcome Score, others Rankin score. So, much like measuring sedation, without agreed endpoints, even when studies are done, translation to clinical practice may lag significantly behind. It would be nice to have clear agreed apon outcome measures prior to doing the research.



Cameron Knott wrote 05-17-2011 01:52:43 pm
Interesting comments. Having worked in rehabilitation for some part of my medical training, it is interesting to see how patients rarely recover to 100% of their previous functional state. The FIM score is a well validated score and widely used score for rehabilitation. What is needed is an integrated database system that allows tracking of patients from hospital to rehabilitation (and beyond) to allow feedback into the decision-making processes for ICU - at admission and during admission. There is already a 'screening process' at admission (which varies across organisations), but information about QOL and recovery of function could assist in fine-tuning selection, particularly with an expected rise in the number of patients expected in the coming years. This is the core of the new push to patient-centred outcomes in research. Information assisting with the distributive justice question could only help the intensivist in the important 'resource gatekeeper' role.



Todd Fraser wrote 10-07-2012 10:47:48 am
Neil's podcast interview can be found here - http://crit-iq.com/index.php/podcast



 

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