COMMENTARY

What Happens to Patients After They Leave the ICU

Aaron B. Holley, MD

Disclosures

June 08, 2017

Joblessness and Lost Earnings After ARDS in a 1-Year National Multicenter Study

Kamdar BB, Huang M, Dinglas VD, et al; National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome Network
Am J Respir Crit Care Med. 2017 Apr 27. [Epub ahead of print]

Background

When designing a study in the intensive care unit (ICU) and choosing an outcome of interest, "hard" data points are popular. Think ventilator and ICU days or survival to hospital discharge. None of these are open to interpretation, and all three can be tracked. They're also appealing to ICU physicians who don't see their patients after they leave the unit. We're in the business of survival and recovery. Extubations and ward transfers make us feel like we're doing our job.

But what happens to our patients after they leave the ICU? A new study published online in the American Journal of Critical Care Medicine (AJRCCM) tracked outcomes at 6 and 12 months post ICU admission for acute respiratory distress syndrome (ARDS).[1] The measures of interest were employment and return to work, along with lost earnings and healthcare coverage. The report was part of the ARDS network (ARDSNet) long-term outcome study (ALTOS) and included data from four different ARDSNet clinical trials. For those unfamiliar, the ARDSNet has published several seminal papers on ARDS management.[2,3,4]

The Study

Not surprisingly, the socioeconomic burden from ARDS is high. The major findings from the study are as follows:

  • Among those previously employed (n=386), 49% and 44% were unemployed at 6 and 12 months, respectively.

  • Among those who did return to work after 12 months, 111 (43%) never returned to previous levels (in hours per week), 69 (27%) reported reduced effectiveness, and 62 (24%) ultimately lost their jobs.

  • Among survivors who were left unemployed or disabled, there was a shift from private insurance (40% to 30%) to Medicaid/Medicare (33% to 49%).

As a whole, the population was reasonably young. The mean age was 45 (±13) years, and only 14 (4%) were over age 65 years.

Viewpoint

Why is this study important, and what are the takeaways? First, it's part of the growing literature on post ICU ARDS outcomes published by the ARDSNet[5] and others.[6,7,8] Intensivists need to pay close attention because our day-to-day experiences offer little insight into longer-term, patient-centered outcomes. Information on the post-ICU experience might drive our clinical decision-making and family counseling sessions in new directions. Ignoring it can lead to damaging biases. As a hypothetical example, if neuromuscular blockade improves survival but leads to permanent disabilities and post-ICU posttraumatic stress disorder, we may be less likely to use it.

Second, at 12 months, most ARDS survivors suffer lingering effects from their illness. It's notable that very few of the patients studied were at retirement age (assuming 65 years old is a reasonable estimate), yet the majority was working less or not at all. The insurance burden shifted from private to public. In short, ARDS is an expensive disease with economic effects on the patient and society.

Lastly, socioeconomic data are critical for measuring the impact of disease. The data quantify the true burden to the patient, which helps hospital systems and policy makers to prioritize the use of limited resources. Data should drive decision-making at the individual physician level as well. We need more data, so the AJRCCM paper[1] is a welcome addition to the literature. In summary, the ARDSNet continues to do important work.

Abstract

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