Can patient-reported outcome measures change delivery of intensive care?

1. Can patient-reported outcome measures change delivery of intensive care? Cristina Granja EmergencyandIntensiveMedicineDepartment Hospital Pedro Hispano BiostatisticsandMedicalInformaticsDepartment FacultyofMedicineof Porto Portugal

2. 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?

3. Follow up clinic: from real patients to outcome studies ICU Follow-up Clinic Hospital Pedro Hispano Begin in 1997

4. Follow up clinic: from real patients to outcome studies

5. Follow up clinic: from real patients to outcome studies Outcomesaftercriticalcare Ridley & Young, Intensive Care After Care, Butterworth Heinemann,2002

6. What have we learned: Consequences of critical illness and critical care

7. What have we learned: Consequences of critical illness and critical care • Ongoing increased mortality • Physical Disability • Neuropsychological Disability • Health-Related Quality of Life

8. Consequences of critical illness and critical care • Ongoing increased mortality

10. Consequences of critical illness and critical care • Physical Disability: • Pulmonary • Lung function impairments • Extra-Pulmonary • Weight loss/ICU- acquired weakness • Critical illness polyneuropathy

11. Consequences of critical illness and critical care • Lung function impairments Herridge M et al , NEJM 2003 Granja et al, Intensive Care Med 2003

12. Consequences of critical illness and critical care • Weight loss/ICU-acquired weakness Herridge M et al , NEJM 2003

13. Consequences of critical illness and critical care • Weight loss/ICU-acquired weakness Griffiths & Jones, Intensive Care After Care, 2002

14. Consequences of critical illness and critical care • Critical illness polyneuropathy

16. Consequences of critical illness and critical care • Neuropsychological Disability: • Cognitiveimpairment • Delirium • Anxiety, Depression • PTSD/PTSS

17. Consequences of critical illness and critical care • Cognitiveimpairment

19. Delirium

21. Consequences of critical illness and critical care • Anxiety, Depression BDI-II - Beck Depression Inventory II 41% moderate/severe depression (BDI-II >20)

22. Consequences of critical illness and critical care • PTSD/PTSS Schelling et al, Crit Care Med 1998

27. Consequences of critical illness and critical care • Health-Related Quality of Life

29. 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 lowerHRQOL 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.

30. Consequences of critical illness and critical care • Health-Related Quality of Life – studies with EQ-5D

31. Health-Related Quality of Life – studies with EQ-5D • In all ICU survivors Granja et al, Intensive Care Med 2002 • In cardiac arrest ICU survivorsGranja et al, Resuscitation 2002 • In ARDS ICU survivorsGranja et al, Intensive Care Med 2003 • In severe sepsis ICU survivorsGranja 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.

32. 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 ALI/ARDS and its treatment Steroids Neuroendocrine Stress Frightening Memories Delirium Bed rest Immobility Hypoxia Hypotension Sedation Medications Cognitive Dysfunction Caregiver burden Psychiatric or Mood disorders Poor HRQOL Financial Loss Physical Impairment Reduction in Employment Wilcox et al, Semin Resp Crit Care Med 2010

33. Consequences of critical illness and critical care

34. Recollection of stressful experiences lived in the ICU

35. Have you had many dreams and nightmares during ICU stay? (n= 352)

36. Report of No problems

37. Outcome Studies Clinical Interventions in the ICU

41. Can patient-reported outcome measures change delivery of intensive care? 1 – Muscle weakness 2 – Cognitive dysfunction /Delirium 3 – PTSD/PTSS 4 – HRQOL

42. 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

43. 1 - Muscle weakness

44. 1 - Muscle weakness

47. 2 – Brain Dysfunction/Delirium

50. 3 – PTSD/PTSS