Transcript Can patient-reported outcome measures change delivery of

, epe
Unidade Local de Saúde de Matosinhos
Can patient-reported outcome measures
change delivery of intensive care?
Cristina Granja
Emergency and Intensive Medicine Department
Hospital Pedro Hispano
Biostatistics and Medical Informatics Department
Faculty of Medicine of Porto
Portugal
Can patient-reported outcome measures change delivery of
intensive care?
•
Follow up clinic: from real patients to outcome studies
•
What we have learned: Consequences of critical illness and critical
care
•
From outcome studies to clinical interventions
•
Can patient-reported outcome measures change delivery of
intensive care?
Follow up clinic: from real patients to outcome studies
ICU Follow-up Clinic
Hospital Pedro Hispano
Begin in
1997
Follow up clinic: from real patients to outcome studies
Follow up clinic: from real patients to outcome studies
Outcomes after critical care
Ridley & Young, Intensive Care After Care,
Butterworth Heinemann,2002
What have we learned: Consequences of critical illness and critical care
What have we learned: Consequences of critical illness and critical care
• Ongoing increased mortality
• Physical Disability
• Neuropsychological Disability
• Health-Related Quality of Life
Consequences of critical illness and critical care
• Ongoing increased mortality
Consequences of critical illness and critical care
• Physical Disability:
– Pulmonary
• Lung function impairments
– Extra-Pulmonary
• Weight loss/ICU- acquired weakness
• Critical illness polyneuropathy
Consequences of critical illness and critical care
•
Lung function impairments
Herridge M et al , NEJM 2003
Granja et al, Intensive Care Med 2003
Consequences of critical illness and critical care
• Weight loss/ICU-acquired weakness
Herridge M et al , NEJM 2003
Consequences of critical illness and critical care
• Weight loss/ICU-acquired weakness
Griffiths & Jones, Intensive Care After Care, 2002
Consequences of critical illness and critical care
•
Critical illness polyneuropathy
Consequences of critical illness and critical care
• Neuropsychological Disability:
– Cognitive impairment
– Delirium
– Anxiety, Depression
–
PTSD/PTSS
Consequences of critical illness and critical care
•
Cognitive impairment
•
Delirium
Consequences of critical illness and critical care
•
Anxiety, Depression
BDI-II - Beck Depression Inventory II
41% moderate/severe depression (BDI-II >20)
Consequences of critical illness and critical care
• PTSD/PTSS
Schelling et al, Crit Care Med 1998
Consequences of critical illness and critical care
• Health-Related Quality of Life
Report of moderate and extreme problems (%)
100%
80%
60%
46%
37%
40%
54%
45%
22%
20%
on
re
ss
i
De
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An
xie
ty
/
Pa
in
/D
Ac
tiv
su
al
U
is
iti
co
m
fo
rt
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lf
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Se
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ob
ilit
y
0%
•
21 independent studies with 7320 patients were reviewed
•
SF-36, EuroQol-5D, Sickness Impact Profile or Nottingham Health Profile in
representative populations of adult ICU survivors
•
Compared with the general population ICU survivors report lower HRQOL prior to
ICU admission
•
After hospital discharge, HRQOL in ICU survivors improves but remains lower than
general population levels.
•
Age and severity of illness were predictors of physical functioning: Physical
functioning showed rapid improvement and was associated with age and severity of
illness, whereas mental health shows no improvement and was independent of
baseline characteristics.
Consequences of critical illness and critical care
• Health-Related Quality of Life – studies with EQ-5D
Health-Related Quality of Life – studies with EQ-5D
•
In all ICU survivors Granja et al, Intensive Care Med 2002
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In cardiac arrest ICU survivors Granja et al, Resuscitation 2002
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In ARDS ICU survivors Granja et al, Intensive Care Med 2003
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In severe sepsis ICU survivors Granja et al, Crit Care 2004
No significant differences in HRQOL,
when compared with other ICU survivors
with similar age, gender, previous health
state and severity of disease at admission.
 HRQOL of ICU survivors seems depend less on specific diagnosis,
and more on the typical residual of any severe, critical illness.
Premorbid Status
Age
Gender
Pre-existing medical disease
Prior psychopathology. Family history of psychiatric disease
Cognitive impairment , dementia, previous TBI or anoxic brain injury
Genetic predisposition
Social support network
Pain
Altered sensorium
ICU LOS
Hospital LOS
Duration of MV
Steroids
Neuroendocrine Stress
Frightening Memories
Delirium
ALI/ARDS and its treatment
Hypoxia
Hypotension
Bed rest
Immobility
Cognitive
Dysfunction
Caregiver burden
Financial Loss
Reduction in
Employment
Sedation
Medications
Psychiatric or
Mood disorders
Poor HRQOL
Physical Impairment
Wilcox et al,
Semin Resp Crit Care Med 2010
Consequences of critical illness and critical care
Recollection of stressful experiences lived in the ICU
Tracheal tube aspiration
Nose tube
Family worries
Pain
Bedridden
Fear of dying, uncertain in the future
Daily needle punctures
Communication difficulties
Ventilator dependence
General discomfort
Bladder tube
Noisy and bad sleeping nights
Remember
With Stress
Without Stress
n (%)
n (%)
113 (81)
26 (19)
127 (75)
42 (25)
129 (71)
53 (29)
121 (64)
69 (36)
129 (64)
73 (36)
110 (64)
62 (36)
114 (61)
72 (39)
111 (59)
78 (41)
93 (58)
68 (42)
98 (58)
71 (42)
90 (56)
72 (44)
83 (54)
71 (46)
Have you had many dreams and nightmares during ICU stay? (n= 352)
Yes
51%
No
49%
No
Yes
Currently, do you think that those dreams and nigthmares disturb your daily life?
100%
80%
p=0.042
p=0.084
p<0.001
p=0.183
p=0.009
60%
40%
20%
0%
Mobility
Self-Care
Usual Activities
No (n=146)
Yes (n=23)
Report of No problems
Pain/Disconfort
Anxiety/Depression
Outcome Studies
Clinical Interventions in the ICU
Can patient-reported outcome measures change delivery of intensive care?
1 – Muscle weakness
2 – Cognitive dysfunction /Delirium
3 – PTSD/PTSS
4 – HRQOL
1 - Muscle weakness
Intervention – early exercise and mobilisation (physical and occupational therapy)
during periods of daily interruption of sedation
Vs
Control – daily interruption of sedation with therapy as ordered by the primary care team
1 - Muscle weakness
1 - Muscle weakness
2 – Brain Dysfunction/Delirium
3 – PTSD/PTSS
4 – HRQOL
Recollection of stressful experiences lived in the ICU
Tracheal tube aspiration
Nose tube
Family worries
Pain
Bedridden
Fear of dying, uncertain in the future
Daily needle punctures
Communication difficulties
Ventilator dependence
General discomfort
Bladder tube
Noisy and bad sleeping nights
Remember
With Stress
Without Stress
n (%)
n (%)
113 (81)
26 (19)
127 (75)
42 (25)
129 (71)
53 (29)
121 (64)
69 (36)
129 (64)
73 (36)
110 (64)
62 (36)
114 (61)
72 (39)
111 (59)
78 (41)
93 (58)
68 (42)
98 (58)
71 (42)
90 (56)
72 (44)
83 (54)
71 (46)
• What was changed inside the ICU (2007)
– Tracheal aspiration technique was improved
– Set of letters and pictures for patients to facilitate communication
– More time for relatives to be inside the ICU, improvement in communication with
relatives (66% of relatives did not understood the information provided by physicians)
– Analgesia (epidural)
– Early evaluation and treatment of delirium (CAM-ICU)
– Daily reduction of sedation
– Earlier rehabilitation inside the ICU
– Keeping the cycle day/night inside the ICU
– …
What was changed at the Follow-Up Clinic :
Follow-up: ward (first week) - 6 weeks - 6 months
• Functional Sequelae: N
- Critical illness polyneuropathy
rehabilitation
- Respiratory evaluation
rehabilitation
- Neurologic evaluation
rehabilitation
- Other sequelae:
weight loss; nutritional status; joint stiffness; decubitus ulcer
• Psychological Sequelae: Psicologia
- PTSD/PTSS
ICU diaries
- Anxiety/depression (HAD)
psychological/psichiatric follow-up; early medication
4 – HRQOL
Follow-up was changed from 6 months to: 6 days - 6 weeks - 6 months
Self care
Mobility
20%
20%
Usual
activities
Pain/Disco
mfort
20%
20%
10%
10%
Anxiety/D
epression
20%
10%
10%
10%
0%
0%
Extreme Problems
Before
After
Extreme
Problems
(unable to
wash or
dress my
self)
Before
After
0%
Extreme Problems
(I am unable to
perform my usual
activities)
Before
After
0%
0%
I have extreme
pain or
discomfort
Before
After
I have extreme
anxiety or
depression
Before
After
Before : Follow up at 6 months
After: Follow up at 6 days, 6 weeks and 6 months
Earlier follow up and earlier interventions
Reduction in extreme problems at 6 months
Thank You