Am J Respir Crit Care Med 14 March 2016

1. The RECOVER Program: Disability Risk Groups and One Year Outcome After > 7 Days of Mechanical Ventilation Am J RespirCrit Care Med 14 March 2016

2. INTRODUCTION • Patients who survive critical illness have important long-term disability • Functional • Neuropsychological • Unclear whether there are unifying predictors for all medical and surgical critically ill patients • ?Transcending diagnosis

3. ARDS patients have been the focus of the most detailed studies • Often younger and with fewer comorbidities than other patients

4. Herridge, 2011

5. May not be generalisable to mixed populations • Medical? Surgical? • Older? Sicker? • The ability to predict longer term functional outcome may influence decision making during and after ICU stay

6. Structured early discharge planning • Nurse led and self-directed home rehab • Disease management approach • Home based exercise with PT home visits • Televisits • Hospital based rehab • Starting rehab in the ICU

7. No Substantial Improvement in Outcome

8. Why? • The patient sample is heterogenous • Applying a generic intervention to all patients • Rehab based on targeting muscle strength in isolation • Isolated use of specific domains of HRQOL or muscle strength as outcome measure • No inclusion of family caregiver or recognition of their potential role as risk-modifier

9. OBJECTIVES • Identify novel disability risk groups and their recovery trajectories based on FIM – Functional Independence Measure • Characterize in detail the first year for a heterogenous population • Understand functional dependencies • Define independent predictors of ICU and 1yr mortality in diverse population

10. METHOD • RECOVER program initiated in 2007 as a multi-phase project designed to determine risk strata to tailor ICU follow up care to improve outcome for patients AND families • Phase 1 – multi-centre prospective cohort study 2/07-3/14 • Screened eligble patients on day 7 of MV

11. INCLUSION • 16yrs+ • Requiring mechanical ventilation on ICU for 7 days+

12. EXCLUSION • Neurological injury such that pt couldn’t complete a questionnaire • Neuromuscular disease • Non-ambulatory before critical illness • Anticipated death/WLST within 48hrs of enrolment • Psychiatric illness/cognitive impairment • Not fluid in English/French • Lived >300km from referral centre • Physician/patient/surrogate consent refusal

14. BASELINE CHARACTERISTICS

16. FOLLOW UP PROTOCOL • Evaluated patients on the ward 7 days after ICU discharge or immediately before hospital discharge • RECOVER clinic 3/6/12 months after discharge • Home visits (upto 10hrs travel) where necessary • At each visit, patient interviewed, underwent physical exam and completed outcome measures

17. OUTCOME MEASURES • FIM – patient centred measure of functional disability that captures burden of care required by pt on daily basis motor and cognitive. Predicts disability in diverse populations Function • 6MWT Exercise Capacity • MRC score Muscle Strength • SF-36 HRQoL • IES-R and BDI-II Neuropsychological • Pattern of Post-hospital discharge healthcare utilisation Healthcare Utilisation

18. RESULTS • At day 7, all pts reported weakness and functional limitations • Majority (60%) were unable to walk • Median total FIM score was 54 – consistent with a need for a moderate level of assistance

20. Disability risk groups were generated by a recursive partitioning model and based on the total FIM at 7 days after ICU discharge • Only risk factors specified a priori were patient age and LOS

22. 4 Groups Characterised • Young short LOS (<42yrs, <2wk LOS) • Mid age, variable LOS (>42, <2wk LOS AND <45, >2wk LOS) • Older Long LOS (45-66, >2wk LOS) • Oldest Long LOS (>66, >2wk LOS)

23. Each group distinct in outcome and ICU and post-ICU healthcare utilisation • EVEN though spectrum of admitting diagnoses and severity of illness measures (APACHE II, MODS) were similar

24. Patients in the Young Short LOS group had the best outcomes. • Also had the smallest number of pts who required RRT, tracheostomy and who were unable to walk on day 7 • 68% of this group were discharged home directly from hospital

25. Patients in the Oldest Long LOS group had worst outcomes. • Had a greater burden of comorbid disease and underwent tracheostomy more often. • 77% were unable to walk 6 days after ICU discharge • Only 19% were discharged directly home

26. Mid Age Variable LOS and Older Long LOS showed similar mortality • Differences in specific functional disabilities over time

27. Functional Dependencies • Degree of dependency varied by task and risk group • Motor tasks dependent on shoulder and hip girdle power and intact co-ordination were most affected • Cognitive dysfunction including problem solving and memory were affected more uniformly

30. Mortality and Disposition

31. DISCUSSION • Can divide critically ill medical and surgical patients who survive >7 days into 4 discrete disability risk groups used on age and LOS based on total FIM • The degree of disability will determine 1yr mortality • AND recovery trajectory including ICU and hospital readmission and specialty use in first year after discharge

32. This diverse group of survivors has important functional and neuropsychological disability • Complex pattern of subsequent healthcare use • May be helpful during family communication during a protracted ICU stay • But also serve to inform discharge planning etc.

33. Strengths • Prospective multi-centre longitudinal design • Heterogenous case mix • Broad eligibility criteria • Acceptable rate of loss to FU at 1yr • Strengths of the recursive partitioning tree approach

34. Limitations • No knowledge of the pre-ICU trajectory • Relied on disposition and work status to make inferences about health • Not a natural history study since patients and families were followed closely and offered education, counselling and psychiatric referrals

35. Implications • Clinical management during the critical illness • Future clinical trial designs – treatment or intervention may have different effect in different disability group • Conversation about what it means to survive critical illness • Timing/intensity/nature of rehab programs

36. “Doctor - If (s)he survives this, what will life be like?”