Prolonged Mechanical Ventilation Often Results in Profound Disability

Patients receiving prolonged mechanical ventilation have multiple transitions of care, resulting in substantial health care costs and persistent, profound disability; family members should be informed of this when they are considering a course of prolonged life support, recommends a new study.

Researchers at Duke University (Durham, NC, USA) conducted a one-year prospective cohort study at five intensive care units (ICUs) at Duke University Medical Center (Durham, NC, USA). In all, 126 patients receiving prolonged mechanical ventilation, which was defined as ventilation for over 4 days with tracheostomy placement, or ventilation for over 21 days without tracheostomy; 126 surrogates and 54 intensive care unit physicians were also enrolled in the study. The patients and surrogates were interviewed in the hospital, as well as at 3 and 12 months after discharge, to determine patient survival, functional status, and facility type and duration of postdischarge care; the physicians were interviewed in the hospital to elicit prognoses. Institutional billing records were used to assign costs for acute care, outpatient care, and interfacility transportation. Medicare claims data were used to assign costs for post-acute care.

The results showed that 103 (82%) of the hospital survivors had 457 separate transitions in postdischarge care location, including 68 patients (67%) who were readmitted at least once. Patients spent an average of 74% of all days alive in a hospital or postacute care facility or receiving home health care. At one year, 11 patients (9%) had a good outcome (alive with no functional dependency), 33 (26%) had a fair outcome (alive with moderate dependency), and 82 (65%) had a poor outcome (either alive with complete functional dependency, or dead). The patients with poor outcomes were older, had more comorbid conditions, and they were more frequently discharged to a postacute care facility than patients with either fair or good outcomes were. The mean cost per patient was US$306,135, and the total cohort cost was $38.1 million, giving an estimated $3.5 million per independently functioning survivor at one year. The study was published in the August 3, 2010, issue of the Annals of Internal Medicine.

"Growing numbers of critically ill patients receive prolonged mechanical ventilation,” concluded lead author Mark Unroe, M.D., and colleagues. "Decision makers' hope for patient survival coupled with an incomplete understanding of the specific implications for providing prolonged mechanical ventilation may contribute to the increasing incidence.”

The researchers recommend that in the context of prolonged mechanical ventilation, physicians not only discuss long-term outcomes with surrogates in terms that they can easily understand, but also explicitly convey the probable demands of treatment, monetary costs, and the future functional dependence patients will probably have, since those patients that survive rarely improve over time. In spite of their decision makers' initial optimism, the patients frequently cycle between post-acute care facilities and hospitals.

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