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Costs of care in the intensive care unit are a frequent area of concern in our current health care system. Utilization of critical care services in the United States, particularly near the end of life, has been steadily increasing and will continue to do so. Acute respiratory distress syndrome (ARDS) is a common and important complication of critical illness. Patients with ARDS frequently experience prolonged hospitalizations and consume significant health care resources. Many patients are discharged with functional limitations and require significant postdischarge services. These patients have a high susceptibility to new complications which require significant additional health care resources. There is a slowly growing literature on the cost-effectiveness of the treatment of ARDS; despite its high costs, treatment remains a cost-effective intervention by most societal standards. However, when ARDS leads to prolonged mechanical ventilation, treatment may become less cost-effective. In addition, the provision of extracorporeal life support adds another layer of complexity to these cases. Small reductions in intensive care unit length of stay may benefit patients, but they do not lead to significant reductions in overall hospital costs. Early discharge to postacute care facilities can reduce hospital costs but is unlikely to significantly decrease costs for an entire episode of illness. Improved effectiveness of communication between clinicians and patients or their surrogates could help avoid costly interventions with poor expected outcomes. However, the most significant cost-saving interventions are early recognition and treatment of conditions to potentially prevent the development of this serious complication. [ABSTRACT FROM AUTHOR]

Importance: Family caregivers of patients with chronic critical illness experience significant psychological distress.Objective: To determine whether family informational and emotional support meetings led by palliative care clinicians improve family anxiety and depression.Design, Setting, and Participants: A multicenter randomized clinical trial conducted from October 2010 through November 2014 in 4 medical intensive care units (ICUs). Adult patients (aged ≥21 years) requiring 7 days of mechanical ventilation were randomized and their family surrogate decision makers were enrolled in the study. Observers were blinded to group allocation for the measurement of the primary outcomes.Interventions: At least 2 structured family meetings led by palliative care specialists and provision of an informational brochure (intervention) compared with provision of an informational brochure and routine family meetings conducted by ICU teams (control). There were 130 patients with 184 family surrogate decision makers in the intervention group and 126 patients with 181 family surrogate decision makers in the control group.Main Outcomes and Measures: The primary outcome was Hospital Anxiety and Depression Scale symptom score (HADS; score range, 0 [best] to 42 [worst]; minimal clinically important difference, 1.5) obtained during 3-month follow-up interviews with the surrogate decision makers. Secondary outcomes included posttraumatic stress disorder experienced by the family and measured by the Impact of Events Scale-Revised (IES-R; total score range, 0 [best] to 88 [worst]), discussion of patient preferences, hospital length of stay, and 90-day survival.Results: Among 365 family surrogate decision makers (mean age, 51 years; 71% female), 312 completed the study. At 3 months, there was no significant difference in anxiety and depression symptoms between surrogate decision makers in the intervention group and the control group (adjusted mean HADS score, 12.2 vs 11.4, respectively; between-group difference, 0.8 [95% CI, -0.9 to 2.6]; P = .34). Posttraumatic stress disorder symptoms were higher in the intervention group (adjusted mean IES-R score, 25.9) compared with the control group (adjusted mean IES-R score, 21.3) (between-group difference, 4.60 [95% CI, 0.01 to 9.10]; P = .0495). There was no difference between groups regarding the discussion of patient preferences (intervention, 75%; control, 83%; odds ratio, 0.63 [95% CI, 0.34 to 1.16; P = .14]). The median number of hospital days for patients in the intervention vs the control group (19 days vs 23 days, respectively; between-group difference, -4 days [95% CI, -6 to 3 days]; P = .51) and 90-day survival (hazard ratio, 0.95 [95% CI, 0.65 to 1.38], P = .96) were not significantly different.Conclusions and Relevance: Among families of patients with chronic critical illness, the use of palliative care-led informational and emotional support meetings compared with usual care did not reduce anxiety or depression symptoms and may have increased posttraumatic stress disorder symptoms. These findings do not support routine or mandatory palliative care-led discussion of goals of care for all families of patients with chronic critical illness.Trial Registration: clinicaltrials.gov Identifier: NCT01230099. [ABSTRACT FROM AUTHOR]

This article describes the increasingly common phenomenon of prolonged mechanical ventilation in the context of the transition between the acute care hospital and post--acute care. Prolonged mechanical ventilation or chronic critical illness is associated with hospital mortality in the range of 20 to 40%, with median hospital length of stay ranging from 14 to 60 days. Fewer than 10% of patients are discharged home, and most hospital survivors require institutionalized post--acute care in the form of long-term acute care, skilled nursing facilities, or inpatient rehabilitation. Acute hospital readmission is common. Because of prolonged functional disabilities and multiple underlying co morbid conditions, overall 1 year mortality for prolonged mechanical ventilation patients ranges from 50 to 60%. Survivors experience significant functional limitations. The prolonged institutional care and poor long-term outcomes of these patients bring into question the cost-effectiveness of prolonged mechanical ventilation after acute illness, especially for patients with poor long-term prognoses. New measures to facilitate assessments of long-term prognosis and improve communication with surrogate decision makers may reduce the amount of ineffective care for some patients requiring prolonged mechanical ventilation. [ABSTRACT FROM AUTHOR]

The article focuses on a study which analyzed a simplified prognostic scoring rule (ProVent score) prediction model for patients requiring prolonged ventilation. The study included 260 adult patients who received at least 21 days of mechanical ventilation following an acute illness. It concluded that the ProVent probability model can accurately identity patients requiring prolonged mechanical ventilation and are at high risk of one-year mortality.

The article discusses the development and verification of a printed information brochure for families of chronically critically ill patients through cognitive testing via interviews. A printed information brochure that may enhance family understanding of chronic critical illnesses and its outcomes was developed and validated. The described structed process can function as a template for developing other information aids for use with seriously ill populations.

Patients requiring prolonged mechanical ventilation (PMV) are a subset of critically ill patients with high resource utilization and poor long-term outcomes. We sought to develop an algorithm for identifying patients receiving PMV, defined as either 14 or 21 days of mechanical ventilation, in administrative and claims data. The algorithm was derived in mechanically ventilated patients at an academic medical center ( n = 1,500) and validated in patients with community-acquired pneumonia in a multi-center clinical registry ( n = 20,370), with further evaluation in the Pennsylvania discharge database ( n = 62,383). The final algorithm combined the International Classification of Diseases codes for mechanical ventilation, diagnosis related groups for ventilation and tracheostomy, and intensive care unit length of stay. In the derivation dataset the algorithm was highly sensitive (14 days = 92.4%; 21 days = 97.6%) and specific (14 days = 91.6%, 21 days = 92.1%). The definition continued to perform well in the validation dataset (14 days: sensitivity = 87.6%, specificity = 88.5%). In both the derivation and validation datasets the negative predictive value was over 95% and positive predictive values ranged from 60% to 70%. In state discharge data the algorithm identified a cohort of patients with high costs and frequent discharge to skilled care facilities. Administrative data can be used to accurately identify populations of patients receiving PMV. [ABSTRACT FROM AUTHOR]

The article develops and validates a prognostic model for one-year mortality in patients ventilated for 21 days or more. The researchers conducted a prospective cohort study. It shows the simple clinical variables measured on day 21 of mechanical ventilation can identify patients at highest and lowest risk of death from prolonged ventilation.

The article discusses the role of long-term care hospitals (LTCHs) in managing patients requiring prolonged mechanical ventilation after acute illness. LTCHs focus on the successful weaning of patients requiring PMV by providing a rehabilitation-based approach to care. As compared to the acute hospital intensive care units, the cost savings in LTCHs are due to lower intensity nursing and due to more efficient movement through the rehabilitation process.

The number of critical care beds in the United States has been increasing considerably, but it is unclear how these additional beds have been used. Mechanical ventilation for acute respiratory failure almost always demands ICU care and is likely to be a reliable indicator of critical care resource requirements on a population level. The objective of this study was to measure changes in the yearly incidence of mechanical ventilation in a statewide population. The North Carolina Hospital Discharge Database contains data on all discharges from nonfederal, nonpsychiatric hospitals in North Carolina. Authors extracted data on adult patients with International Classification of Diseases, 9tb Revision, Clinical Modification procedure codes for mechanical ventilation from 1996 to 2002. The incidence of mechanical ventilation for adults grew from 284/100 000 population in 1996 to 314/100 000 in 2002, an increase of 11% (P < .05). While patients aged >64 had the highest age-specific incidence of mechanical ventilation each year, the greatest increase in incidence occurred in younger age groups (119% increase for age 18–64 vs 4% increase for age >64). The mean Charlson score increased from 1.76 ± 1.73 to 1.89 ± 1.86 (P < .001). Renal disease became more prevalent among patients requiring mechanical ventilation (17% of patients in 1996 vs 24% in 2002). Hospital charges adjusted for the medical consumer price index increased by 12%. The proportion of patients discharged to home declined from 45.4% to 34.4%, and discharges to nursing homes grew from 7.3% to 10.7%. The incidence of mechanical ventilation is increasing, and the increase is associated with a higher burden of comorbidities and fewer discharges to home. [ABSTRACT FROM AUTHOR]

Study objectives: Investigators have been using severity-of-illness indexes such as APACHE II (acute physiology and chronic health evaluation score II) to describe patients with prolonged critical illness. However, little is known about the utility of these indexes for this patient population. We evaluated the ability of four severity-of-illness indexes to predict mortality rates in 182 patients with prolonged critical illness. Design: Retrospective inception cohort study. Setting: A single, urban, long-term, acute-care hospital in Chicago. Patients: One hundred eighty-two patients transferred from 37 acute-care hospital ICUs. Measurements and results: We assessed four indexes: the acute physiology and chronic health evaluation II, the simplified acute physiology score II, the mortality prediction model II, and the logistic organ dysfunction system using variables measured on admission to the long-term acute-care hospital ICU. We found that none of these indexes distinguished well between the patients who lived and the patients who died (area under ROC [receiver operating characteristics] curve < 0.70 for all), nor did they assign correct probabilities of death to individual patients (Hosmer-Lemeshow goodness-of-fit statistics, p < 0.01 for all). Conclusions: Investigators and clinicians should use caution in using severity-of-illness measures developed for acutely ill patients to describe critically ill patients admitted to long-term care units. As clinical practice and research focus more on these latter patients, development of adequately performing severity-of-illness measures appropriate to this patient population will be needed. [ABSTRACT FROM AUTHOR]

Offers results of a study, the objective of which was to compare the effects of change from an open to a closed intensive care unit format on clinical outcomes, resource utilization, teaching, and perceptions regarding quality of care. Design; Setting; Patients; Main outcome measures; Conclusions.

The article offers insights on a study which examined the clinical significance of new-onset atrial fibrilation (AF) in a severe sepsis setting published in this issue. It notes that the sensitivity analyses used in this study were able to support its findings that there is an association between AF in patients with severe sepsis and increased risk of stroke or hospital mortality. It cites factors that can help assess whether causal inferences can be drawn from observational data.

Prostacyclin therapy is a mainstay of the management of pulmonary arterial hypertension (PAH). Inhaled prostacyclins present safe and effective options for the management of PAH that limit systemic side effects. We describe the first reported case of life‐threatening bronchospasm and acute respiratory failure associated with inhaled prostacyclin administration. [ABSTRACT FROM AUTHOR]

A response from the authors of the article "Effect of Palliative Care-Led Meetings for Families of Patients With Chronic Critical Illness: A Randomized Clinical Trial" in a previous 2016 issue is presented.

The author reflects on best practice in long-term acute care hospitals (LTACHs), facilities specializing in the care of patients with persistent respiratory failure and other complex conditions. He mentions that the use of LTACHs has increased substantially in recent years due to rise in aging population, increased survival following critical illness, and hospital reimbursement models. Further he emphasizes on the need to rectify payment models of LTACHs to control the expenditure.

Background: Although trust is central to successful clinician-family relationships in intensive care units (ICUs), little is known about how to promote surrogates' trust of ICU clinicians in this setting.Research Question: Does the conduct of family conferences and clinicians' use of shared decision-making (SDM) within family conferences impact surrogates' trust in the clinician?Study Design and Methods: Mixed methods secondary analysis of a multi-center prospective cohort study of 369 surrogate decision-makers of 204 decisionally incapacitated patients at high risk of death or severe functional impairment within 13 ICUs at 6 U.S. medical centers between 2008 and 2012. Surrogates completed the Abbreviated Wake Forest Physician Trust Scale (range 5-25) before and after an audio-recorded family conference conducted within 5 days of ICU admission. We qualitatively coded transcribed conferences to determine clinicians' use of 5 SDM behaviors: discussing surrogate's role, explaining medical condition and prognosis, providing emotional support, assessing understanding, and eliciting patient's values and preferences. Using multivariable linear regression with adjustment for clustering, we assessed whether surrogates' trust in the physician increased after the family meeting; we also examined whether the number of SDM behaviors used by clinicians during the family meeting impacted trust scores.Results: In adjusted models, conduct of a family meeting was associated with increased trust (average change pre-to-post: 0.91-points (95% CI 0.4-1.4, P-value<0.01)). Every additional element of SDM used during the family meeting, including discussing surrogate's role, providing emotional support, assessing understanding, and eliciting patient's values and preferences, was associated with a 0.37-point increase in trust (95% CI 0.08-0.67, P-value=0.01). If all 4 elements were used trust increased by 1.48-points. Explaining medical condition or prognosis was observed in nearly every conference (98.5%) and excluded from the final model.Interpretation: The conduct of family meetings and clinicians' use of SDM behaviors during meetings were both associated with increases in surrogates' trust in the treating clinician. [ABSTRACT FROM AUTHOR]

The number of chronically critically ill patients requiring prolonged mechanical ventilation and receiving a tracheostomy is steadily increasing. Early tracheostomy in patients requiring prolonged mechanical ventilation has been proposed to decrease duration of mechanical ventilation and intensive care unit stay, reduce mortality, and improve patient comfort. However, these benefits have been difficult to demonstrate in clinical trials. So how does one determine the appropriate timing for tracheostomy placement in your patient? Here we review the potential benefits and consequences of tracheostomy, the available evidence for tracheostomy timing, communication surrounding the tracheostomy decision, and a patient-centered approach to tracheostomy. Patients requiring > 10 days of mechanical ventilation who are expected to survive their hospitalization likely benefit from tracheostomy, but protocols involving routine early tracheostomy placement do not improve patient outcomes. However, patients with neurologic injury, provided they have a good prognosis for meaningful recovery, may benefit from early tracheostomy. In chronically critically ill patients with poor prognosis, tracheostomy is unlikely to provide benefit and should only be pursued if it is consistent with the patient's values, goals, and preferences. In this setting, communication with patients and surrogates regarding tracheostomy and prognosis becomes paramount. For the foreseeable future, decisions surrounding tracheostomy will remain relevant and challenging. [ABSTRACT FROM AUTHOR]

Context: Outcomes after cardiopulmonary resuscitation (CPR) remain poor. We have spent 10 years investigating an "informed assent" (IA) approach to discussing CPR with chronically ill patients/families. IA is a discussion framework whereby patients extremely unlikely to benefit from CPR are informed that unless they disagree, CPR will not be performed because it will not help achieve their goals, thus removing the burden of decision-making from the patient/family, while they retain an opportunity to disagree.Objectives: Determine the acceptability and efficacy of IA discussions about CPR with older chronically ill patients/families.Methods: This multi-site research occurred in three stages. Stage I determined acceptability of the intervention through focus groups of patients with advanced COPD or malignancy, family members, and physicians. Stage II was an ambulatory pilot randomized controlled trial (RCT) of the IA discussion. Stage III is an ongoing phase 2 RCT of IA versus attention control in in patients with advanced chronic illness.Results: Our qualitative work found the IA approach was acceptable to most patients, families, and physicians. The pilot RCT demonstrated feasibility and showed an increase in participants in the intervention group changing from "full code" to "do not resuscitate" within two weeks after the intervention. However, Stages I and II found that IA is best suited to inpatients. Our phase 2 RCT in older hospitalized seriously ill patients is ongoing; results are pending.Conclusions: IA is a feasible and reasonable approach to CPR discussions in selected patient populations. [ABSTRACT FROM AUTHOR]

Context: Severe Acute Brain Injury (SABI) is neurologically devastating, and surrogates for these patients may struggle with particularly complex decisions due to substantial prognostic uncertainty.Objectives: To compare anxiety and depression symptoms over time between SABI surrogates and non-SABI surrogates for patients requiring prolonged mechanical ventilation (PMV).Methods: We conducted a secondary analysis of the data from a multicenter randomized trial of a decision aid intervention for surrogates of adults experiencing PMV. Eligible patients were enrolled from medical, surgical, trauma, cardiac, and neurologic intensive care units (ICUs). ICU admitting diagnoses were used to identify patients experiencing SABI. We compared anxiety and depression symptoms as measured by the Hospital Anxiety and Depression Scale score 6 months after trial enrollment between surrogates of patients with SABI and surrogates of patients experiencing PMV for other reasons.Results: Our analysis included 206 patients, 60 (29%) with SABI and 146 (71%) without SABI, and their primary surrogate decision makers. After adjusting for potential confounders including surrogate demographics, surrogate financial distress, patient severity of illness baseline GCS, and patient health status at 6 months, we found that surrogates of patients experiencing SABI had higher symptoms of anxiety and depression than surrogates of non-SABI patients (adjusted mean difference 3.6, 95% CI 1.2-6.0).Conclusion: Surrogates of PMV patients with SABI experience persistently elevated anxiety and depression symptoms over 6 months compared to surrogates of PMV patients without SABI. Further work is needed to understand contributors to prolonged distress in this higher risk population. [ABSTRACT FROM AUTHOR]

Costs of care in the intensive care unit are a frequent target for concern in the current health care system. Utilization of critical care services in the United States is increasing and will continue to do so. Acute respiratory distress syndrome (ARDS) is a common and important complication of critical illness. Patients with ARDS frequently have long hospitalizations and consume a significant amount of health care resources. Many patients are discharged with functional limitations and high susceptibility to new complications that require significant additional health care resources. There is increasing literature on the cost-effectiveness of the treatment of ARDS, and despite its high costs, treatment remains a cost-effective intervention by current societal standards. However, when ARDS leads to prolonged mechanical ventilation, treatment becomes less cost-effective. Current research seeks to find interventions that lead to reductions in duration of mechanical ventilation and intensive care unit (ICU) length of stay. Limited reductions in ICU length of stay have benefits for the patient, but they do not lead to significant reductions in overall hospital costs. Early discharge to post-acute care facilities can reduce hospital costs but are unlikely to decrease costs for an entire episode of illness. Improved effectiveness of communication between clinicians and patients or their surrogates could help avoid costly interventions with poor expected outcomes. [ABSTRACT FROM AUTHOR]

Long-term acute care hospitals (LTACs) are an increasingly common discharge destination for patients recovering from intensive care. In this article the authors use U.S. Medicare claims data to examine regional- and hospital-level variation in LTAC utilization after intensive care to determine factors associated with their use. Using hierarchical regression models to control for patient characteristics, this study found wide variation in LTAC utilization across hospitals, even controlling for LTAC access within a region. Several hospital characteristics were independently associated with increasing LTAC utilization, including increasing hospital size, for-profit ownership, academic teaching status, and colocation of the LTAC within an acute care hospital. These findings highlight the need for research into LTAC admission criteria and the incentives driving variation in LTAC utilization across hospitals. [ABSTRACT FROM PUBLISHER]

The article discusses a systematic review of studies of family-provider communication interventions that aim to improve communication quality and outcomes for patients in the intensive care unit (ICU). Data were obtained from PsychInfo and Cochrane, among others, from 1995 to 2010. Results show that patient length of stay (LOS) decreases due to the palliative care consultation. The interventions have no effect on mortality of patients.

Background: Growing numbers of critically ill patients receive prolonged mechanical ventilation. Little is known about the patterns of care as patients transition from acute care hospitals to postacute care facilities or about the associated resource utilization. Objective: To describe 1-year trajectories of care and resource utilization for patients receiving prolonged mechanical ventilation. Design: 1-year prospective cohort study. Setting: 5 intensive care units at Duke University Medical Center, Durham, North Carolina. Participants: 126 patients receiving prolonged mechanical ventilation (defined as ventilation for ≦4 days with tracheostomy placement or ventilation for ≦21 days without tracheostomy), as well as their 126 surrogates and 54 intensive care unit physicians, enrolled consecutively over 1 year. Measurements: Patients and surrogates were interviewed in the hospital, as well as 3 and 12 months after discharge, to determine patient survival, functional status, and facility type and duration of postdischarge care. 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 postacute care. Results: 103 (82%) hospital survivors had 457 separate transitions in postdischarge care location (median, 4 transitions [interquartile range, 3 to 5 transitions]), including 68 patients (67%) who were readmitted at least once. Patients spent an average of 74% (95% CI, 68% to 80%) of all days alive in a hospital or postacute care facility or receiving home health care. At 1 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 [4 patients; 21%] or dead [56 patients; 44%]). Patients with poor outcomes were older, had more comorbid conditions, and were more frequently discharged to a postacute care facility than patients with either fair or good outcomes (P < 0.05 for all). The mean cost per patient was $306 135 (SD, $285 467), and total cohort cost was $38.1 million, for an estimated $3.5 million per independently functioning survivor at 1 year. Limitation: The results of this single-center study may not be applicable to other centers. Conclusion: Patients receiving prolonged mechanical ventilation have multiple transitions of care, resulting in substantial health care costs and persistent, profound disability. The optimism of surrogate decision makers should be balanced by discussions of these outcomes when considering a course of prolonged life support. [ABSTRACT FROM AUTHOR]

The article presents a placebo-controlled trial of antipsychotics for patients in the intensive care unit (ICU) suffering from delirium and a test if antipsychotics improve days alive for patients without delirium. The study involved 101 ICU patients who received haloperidol or zipradone, or placebo. The study found the feasibility of a randomized, placebo-controlled trial of antipsychotics for delirium in ICU patients and suggests the need to examine the appropriateness of using antipsychotics.

The article aims to investigate the efficacy, effectiveness and safety of inhaled corticosteroids with respect to health outcomes in patients with chronic obstructive pulmonary disease (COPD). The findings revealed that 13 double-blinded randomized controlled trials determined the efficacy of an inhaled corticosteroid compared with placebo while 11 additional studies confirmed the safety of inhaled corticosteroid treatment in patients with asthma or COPD.

physician perceptions on information retrieval as well as favorable and unfavorable features of specific EHR screens. Transcripts were independently coded in a qualitative software management tool by at least two trained coders using a common code book. We successfully obtained vendor permission to map physicians perception’s on full Epic© screenshots. Among the 25 physician participants (13 female; 5 attending physicians, 9 fellows, 11 residents), the majority of participants reported experiencing challenges finding clinical information in the EHR. We present the most favorable and unfavorable screen-level features for four central EHR screens: Flowsheet, Notes/Chart Review, Results Review, and Vital Signs. We also compiled participants’ recommendations for a comprehensive EHR dashboard screen to better support clinical workflow and information retrieval in the medical ICU through User-Centered Design. ICU physicians demonstrated a mix of positive and negative attitudes toward specific screen-level features in a major vendor-based EHR system. Physician perceptions of information overload emerged as a theme across multiple EHR screens. Our findings underscore the importance of qualitative research and end-user feedback in EHR software design and interface optimization at both the vendor and institutional level. [ABSTRACT FROM AUTHOR]

The article discusses papers published within the issue, including one on the concept of disability and another on the pathophysiology and epidemiology of physical disability following critical illness.

Purpose: To identify specific components of ICU clinician supportive care and communication that are associated with increased post-traumatic stress disorder (PTSD) symptoms for surrogate decision makers of patients with chronic critical illness (CCI).Methods: We conducted a secondary analysis of data from a randomized controlled trial of palliative care-led meetings to provide information and support for CCI surrogates. The primary outcome for this secondary analysis was PTSD symptoms at 90 days, measured by the Impact of Event Scale-Revised (IES-R). Caregiver perceptions of clinician support and communication were assessed using a version of the After-Death Bereaved Family Member Interview (ADBFMI) instrument modified for use in non-bereaved in addition to bereaved caregivers. The association between ADBFMI items and IES-R score was analyzed using multiple linear regression.Results: Ninety-day follow up was complete for 306 surrogates corresponding to 224 patients. Seventy-one percent of surrogates were female, and the mean age was 51 years. Of the domains, negative perception of the patient's physical comfort and emotional support was associated with the greatest increase in surrogate PTSD symptoms (beta coefficient 1.74, 95% CI 0.82-2.65). The three specific preselected items associated with increased surrogate PTSD symptoms were surrogate perception that clinicians did not listen to concerns (beta coefficient 10.7, 95% CI 3.6-17.9), failure of the physician to explain how the patient's pain would be treated (beta coefficient 12.1, 95% CI 4.9-19.3), and lack of sufficient religious contact (beta coefficient 11.7, 95% CI 2-21.3).Conclusion: Modifiable deficits in ICU clinician support and communication were associated with increased PTSD symptoms among CCI surrogates. [ABSTRACT FROM AUTHOR]

Background: Treatment decisions commonly have to be made in intensive care units (ICUs). These decisions are difficult for surrogate decision makers and often lead to decisional conflict, psychological distress, and treatments misaligned with patient preferences.Objective: To determine whether a decision aid about prolonged mechanical ventilation improved prognostic concordance between surrogate decision makers and clinicians compared with a usual care control.Design: Multicenter, parallel, randomized, clinical trial. (ClinicalTrials.gov: NCT01751061).Setting: 13 medical and surgical ICUs at 5 hospitals.Participants: Adult patients receiving prolonged mechanical ventilation and their surrogates, ICU physicians, and ICU nurses.Intervention: A Web-based decision aid provided personalized prognostic estimates, explained treatment options, and interactively clarified patient values to inform a family meeting. The control group received information according to usual care practices followed by a family meeting.Measurements: The primary outcome was improved concordance on 1-year survival estimates, measured with the clinician-surrogate concordance scale (range, 0 to 100 percentage points; higher scores indicate more discordance). Secondary and additional outcomes assessed the experiences of surrogates (psychological distress, decisional conflict, and quality of communication) and patients (length of stay and 6-month mortality). Outcomes assessors were blinded to group allocation.Results: The study enrolled 277 patients, 416 surrogates, and 427 clinicians. Concordance improvement did not differ between intervention and control groups (mean difference in score change from baseline, -1.7 percentage points [95% CI, -8.3 to 4.8 percentage points]; P = 0.60). Surrogates' postintervention estimates of patients' 1-year prognoses did not differ between intervention and control groups (median, 86.0% [interquartile range {IQR}, 50.0%] vs. 92.5% [IQR, 47.0%]; P = 0.23) and were substantially more optimistic than results of a validated prediction model (median, 56.0% [IQR, 43.0%]) and physician estimates (median, 50.0% [IQR, 55.5%]). Eighty-two intervention surrogates (43%) favored a treatment option that was more aggressive than their report of patient preferences. Although intervention surrogates had greater reduction in decisional conflict than control surrogates (mean difference in change from baseline, 0.4 points [CI, 0.0 to 0.7 points]; P = 0.041), other surrogate and patient outcomes did not differ.Limitation: Contamination among clinicians could have biased results toward the null hypothesis.Conclusion: A decision aid about prolonged mechanical ventilation did not improve prognostic concordance between clinicians and surrogates, reduce psychological distress among surrogates, or alter clinical outcomes. Decision support in acute care settings may require greater individualized attention for both the cognitive and affective challenges of decision making.Primary Funding Source: National Institutes of Health. [ABSTRACT FROM AUTHOR]

Objective: Decades-old, common ICU practices including deep sedation, immobilization, and limited family access are being challenged. We endeavoured to evaluate the relationship between ABCDEF bundle performance and patient-centered outcomes in critical care.Design: Prospective, multicenter, cohort study from a national quality improvement collaborative.Setting: 68 academic, community, and federal ICUs collected data during a 20-month period.Patients: 15,226 adults with at least one ICU day.Interventions: We defined ABCDEF bundle performance (our main exposure) in two ways: 1) complete performance (patient received every eligible bundle element on any given day) and 2) proportional performance (percentage of eligible bundle elements performed on any given day). We explored the association between complete and proportional ABCDEF bundle performance and three sets of outcomes: patient-related (mortality, ICU and hospital discharge), symptom-related (mechanical ventilation, coma, delirium, pain, restraint use), and system-related (ICU readmission, discharge destination). All models were adjusted for a minimum of 18 a priori determined potential confounders.Measurements and Results: Complete ABCDEF bundle performance was associated with lower likelihood of seven outcomes: hospital death within 7 days (adjusted hazard ratio, 0.32; CI, 0.17-0.62), next-day mechanical ventilation (adjusted odds ratio [AOR], 0.28; CI, 0.22-0.36), coma (AOR, 0.35; CI, 0.22-0.56), delirium (AOR, 0.60; CI, 0.49-0.72), physical restraint use (AOR, 0.37; CI, 0.30-0.46), ICU readmission (AOR, 0.54; CI, 0.37-0.79), and discharge to a facility other than home (AOR, 0.64; CI, 0.51-0.80). There was a consistent dose-response relationship between higher proportional bundle performance and improvements in each of the above-mentioned clinical outcomes (all p < 0.002). Significant pain was more frequently reported as bundle performance proportionally increased (p = 0.0001).Conclusions: ABCDEF bundle performance showed significant and clinically meaningful improvements in outcomes including survival, mechanical ventilation use, coma, delirium, restraint-free care, ICU readmissions, and post-ICU discharge disposition. [ABSTRACT FROM AUTHOR]

Objectives: Family members commonly make medical decision for patients with chronic critical illness. This study examines how family members approach this decision-making role in real time.Design: Qualitative analysis of interviews with family members in the intervention arm of a randomized controlled communication trial.Settings: Medical ICUs at four U.S. hospitals.Participants: Family members of patients with chronic critical illness (adults mechanically ventilated for ≥ 7 d and expected to remain ventilated and survive for ≥ 72 hr) who participated in the active arm of a communication intervention study.Interventions: Family members participated in at least two content-guided, informational, and emotional support meetings led by a palliative care physician and nurse practitioner.Measurements and Main Results: Grounded theory was used for qualitative analysis of 66 audio recordings of meetings with 51 family members. Family members perceived their role in four main ways: voice of the patient, advocate for the patient, advocate for others, and advocate for oneself. Their decision-making was characterized by balancing goals, sharing their role, keeping perspective, remembering previous experiences, finding sources of strength, and coping with various burdens.Conclusions: Family members take a multifaceted approach as they participate in decision-making. Understanding how surrogates perceive and act in their roles may facilitate shared decision-making among clinicians and families during critical care. [ABSTRACT FROM AUTHOR]

Context: Patients triggering rapid response team (RRT) intervention are at high risk for adverse outcomes. Data on symptom burden of these patients do not currently exist, and current symptom management and communication practices of RRT clinicians are unknown.Objectives: We sought to identify the symptom experience of RRT patients and observe how RRT clinicians communicate with patients and their families.Methods: We conducted a prospective observational study from August to December 2015. Investigators attending RRT events measured frequencies of symptom assessment, communication, and supportive behaviors by RRT clinicians. As the rapid response event concluded, investigators measured patient-reported pain, dyspnea, and anxiety using a numeric rating scale of 0 (none) to 10 (most severe), with uncontrolled symptoms defined as numeric rating scale score of ≥4.Results: We observed a total of 52 RRT events. RRT clinicians assessed for pain during the event in 62% of alert patients, dyspnea in 38%, and anxiety in 21%. Goals of care were discussed during 3% of events and within 24 hours in 13%. For the primary outcome measure, at the RRT event conclusion, 44% of alert patients had uncontrolled pain, 39% had uncontrolled dyspnea, and 35% had uncontrolled anxiety.Conclusion: Hospitalized patients triggering RRT events have a high degree of uncontrolled symptoms that are infrequently assessed and treated. Although these patients experience an acute change in medical status and are at high risk for adverse outcomes, goals-of-care discussions with RRT patients or families are rarely documented in the period after the events. [ABSTRACT FROM AUTHOR]

Background Pulmonary arterial hypertension (PAH) is a progressive, fatal disease. Current prognostic models are not ideal, and identifying more accurate prognostic variables is needed. The objective of this study was to evaluate the relative prognostic value of the right atrial pressure/pulmonary artery wedge pressure (RAP/PAWP) ratio in PAH patients. We hypothesized that the RAP/PAWP ratio is more predictive of survival than any of the other measured or calculated hemodynamic variables. Methods We performed a secondary analysis of a PAH cohort (Cohort 1) and validated our results in a separate cohort (Cohort 2). Cohort 1 included primarily patients enrolled in prospective, short-term, randomized clinical trials and subsequently followed long term. Cohort 2 included patients prospectively enrolled in a PAH registry at a tertiary PAH referral center. Results Cohort 1 ( n = 847) and Cohort 2 ( n = 697) had a mean age of 47 and 54 years, respectively. Most were female (78% and 73%, respectively), Caucasian (83% and 82%), with advanced functional class disease status (New York Heart Association Functional Class III/IV 85% and 68%) and with significantly elevated hemodynamics (mean RAP/PAWP ratio: 1.2 and 1.0; pulmonary vascular resistance: 13.5 and 9.4 Wood units). RAP/PAWP ratio indicated a 1-year hazard ratio of 1.44 ( p = 0.0001) and 1.35, respectively ( p < 0.0001), and was the most consistently predictive hemodynamic variable across the 2 cohorts. These results remain valid even when adjusted for other covariables in multivariable regression models. Conclusions The RAP/PAWP ratio is a more specific predictor of survival than any other hemodynamic variable, and we recommend that it be used in clinical prognostication and PAH predictive models. [ABSTRACT FROM AUTHOR]

Objectives: The existing risk prediction model for patients requiring prolonged mechanical ventilation is not applicable until after 21 days of mechanical ventilation. We sought to develop and validate a mortality prediction model for patients earlier in the ICU course using data from day 14 of mechanical ventilation.Design: Multicenter retrospective cohort study.Setting: Forty medical centers across the United States.Patients: Adult patients receiving at least 14 days of mechanical ventilation.Interventions: None.Measurements and Main Results: Predictor variables were measured on day 14 of mechanical ventilation in the development cohort and included in a logistic regression model with 1-year mortality as the outcome. Variables were sequentially eliminated to develop the ProVent 14 model. This model was then generated in the validation cohort. A simplified prognostic scoring rule (ProVent 14 Score) using categorical variables was created in the development cohort and then tested in the validation cohort. Model discrimination was assessed by the area under the receiver operator characteristic curve. Four hundred ninety-one patients and 245 patients were included in the development and validation cohorts, respectively. The most parsimonious model included age, platelet count, requirement for vasopressors, requirement for hemodialysis, and nontrauma admission. The area under the receiver operator characteristic curve for the ProVent 14 model using continuous variables was 0.80 (95% CI, 0.76-0.83) in the development cohort and 0.78 (95% CI, 0.72-0.83) in the validation cohort. The ProVent 14 Score categorized age at 50 and 65 years old and platelet count at 100×10(9)/L and had similar discrimination as the ProVent 14 model in both cohorts.Conclusion: Using clinical variables available on day 14 of mechanical ventilation, the ProVent 14 model can identify patients receiving prolonged mechanical ventilation with a high risk of mortality within 1 year. [ABSTRACT FROM AUTHOR]

Objectives: The epidemiology of chronic critical illness is not well characterized. We sought to determine the prevalence, outcomes, and associated costs of chronic critical illness in the United States.Design: Population-based cohort study using data from the United States Healthcare Costs and Utilization Project from 2004 to 2009.Setting: Acute care hospitals in Massachusetts, North Carolina, Nebraska, New York, and Washington.Patients: Adult and pediatric patients meeting a consensus-derived definition for chronic critical illness, which included one of six eligible clinical conditions (prolonged acute mechanical ventilation, tracheotomy, stroke, traumatic brain injury, sepsis, or severe wounds) plus at least 8 days in an ICU.Interventions: None.Measurements and Main Results: Out of 3,235,741 admissions to an ICU during the study period, 246,151 (7.6%) met the consensus definition for chronic critical illness. The most common eligibility conditions were prolonged acute mechanical ventilation (72.0% of eligible admissions) and sepsis (63.7% of eligible admissions). Among patients meeting chronic critical illness criteria through sepsis, the infections were community acquired in 48.5% and hospital acquired in 51.5%. In-hospital mortality was 30.9% with little change over the study period. The overall population-based prevalence was 34.4 per 100,000. The prevalence varied substantially with age, peaking at 82.1 per 100,000 individuals 75-79 years old but then declining coincident with a rise in mortality before day 8 in otherwise eligible patients. Extrapolating to the entire United States, for 2009, we estimated a total of 380,001 cases; 107,880 in-hospital deaths and $26 billion in hospital-related costs.Conclusions: Using a consensus-based definition, the prevalence, hospital mortality, and costs of chronic critical illness are substantial. Chronic critical illness is particularly common in the elderly although in very old patients the prevalence declines, in part because of an increase in early mortality among potentially eligible patients. [ABSTRACT FROM AUTHOR]

Objectives: The epidemiology of chronic critical illness is not well characterized. We sought to determine the prevalence, outcomes, and associated costs of chronic critical illness in the United States. Design: Population-based cohort study using data from the United States Healthcare Costs and Utilization Project from 2004 to 2009. Setting: Acute care hospitals in Massachusetts, North Carolina, Nebraska, New York, and Washington. Patients: Adult and pediatric patients meeting a consensusderived definition for chronic critical illness, which included one of six eligible clinical conditions (prolonged acute mechanical ventilation, tracheotomy, stroke, traumatic brain injury, sepsis, or severe wounds) plus at least 8 days in an ICU. Interventions: None. Measurements and Main Results: Out of 3,235,741 admissions to an ICU during the study period, 246,151 (7.6%) met the consensus definition for chronic critical illness. The most common eligibility conditions were prolonged acute mechanical ventilation (72.0% of eligible admissions) and sepsis (63.7% of eligible admissions). Among patients meeting chronic critical illness criteria through sepsis, the infections were community acquired in 48.5% and hospital acquired in 51.5%. In-hospital mortality was 30.9% with little change over the study period. The overall population- based prevalence was 34.4 per 100,000. The prevalence varied substantially with age, peaking at 82.1 per 100,000 individuals 75-79 years old but then declining coincident with a rise in mortality before day 8 in otherwise eligible patients. Extrapolating to the entire United States, for 2009, we estimated a total of 380,001 cases; 107,880 in-hospital deaths and $26 billion in hospital-related costs. Conclusions: Using a consensus-based definition, the prevalence, hospital mortality, and costs of chronic critical illness are substantial. Chronic critical illness is particularly common in the elderly although in very old patients the prevalence declines, in part because of an increase in early mortality among potentially eligible patients. [ABSTRACT FROM AUTHOR]

Background The Patient Reported Outcomes Measurement Information System 43-item short form (PROMIS-43) and the five-level EQ-5D (EQ-5D-5 L) are recently developed measures of health-related quality of life (HRQL) that have potentially broad application in evaluating treatments and capturing burden of respiratory-related diseases. The aims of this study were: (1) to examine their psychometric properties in patients with chronic obstructive pulmonary disease (COPD), and (2) to identify dimensions of HRQL that differ and do not differ by lung function. Methods We conducted a multi-center, cross-sectional study ("COPD Outcomes-based Network for Clinical Effectiveness & Research Translation" [CONCERT]). We analyzed patients who met spirometric criteria for COPD, and completed EQ-5D-5 L and PROMIS questionnaires. Disease severity was graded based on the Global Initiative for Chronic Obstructive Lung Disease (GOLD) classification. Pulmonary function test, PROMIS-43, EQ-5D (index score and EQ-Visual Analog Scale [EQ-VAS]), six minute walk test (6MWT), and three dyspnea scales (mMRC, Borg, FACIT-Dyspnea) were administered. Validity and reliability of EQ- 5D-5 L and PROMIS-43 were examined, and differences in HRQL by GOLD grade were assessed. Results Data from 670 patients with COPD were analyzed (mean age 68.5 years; 58% male). More severe COPD was associated with more problems with mobility, self-care and usual activities (all p-values <0.01) according to EQ-5D-5 L. Related domains on EQ-5D-5 L, PROMIS and clinical measures were moderately (r = 0.30-0.49) to strongly (r = 0.50) correlated. A statistically significant trend of decreasing HRQL with more severe lung functions was observed for EQ-5D-5 L index scores, EQ-VAS scores, and PROMIS physical function and social roles. Conclusions Results supported the validity of EQ-5D-5 L and PROMIS-43 in COPD patients, and indicate that physical function and social activities decrease with level of lung function by GOLD grade, but not pain, mental health, sleep or fatigue as reported by patients. [ABSTRACT FROM AUTHOR]

A preface to "Seminars in Respiratory & Critical Care Medicine" is presented.

The article discusses a study which developed and tested a decision aid for surrogates of patients under prolonged mechanical ventilation. The study included 53 surrogate decision makers and 58 patients. Its primary outcomes include physician-surrogate discordance for expected patient survival, comprehension of medical information and communication quality. Study authors concluded that the decision aid they have developed is feasible and acceptable.

Background: Communication between families and providers in the ICU affects patient and family outcomes and use of health-care resources. Recent research studies have tested interventions designed to improve communication quality and outcomes between providers and families of patients in the ICU. We conducted a systematic review of these studies.Methods: We searched the MEDLINE, PsychInfo, Cochrane, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases from 1995 to July 2010. We included studies that reported controlled clinical interventions designed to improve communication between providers and families of patients in the ICU aged 18 years or older. We abstracted all selected studies to a standardized data collection instrument and completed a quality checklist based on recommendations from the Consolidated Standards for Reporting Trials (CONSORT) investigators.Results: In all, 2,841 articles were identified. Of those articles, 180 met the criteria for full review, and 21 articles of 16 distinct interventions met the full inclusion criteria, of which five were randomized. Interventions studied included printed information or structured family conferences, with or without additional family support. Conferences aimed to communicate the diagnosis and prognosis, elicit patient values, assess family understanding, and clarify the goals of treatment. Printed information, palliative care or ethics consultation, or regular, structured communication by the usual ICU team reduced family distress, improved comprehension, and decreased the use of intensive treatments.Conclusions: The evidence supports the use of printed information and structured communication by the usual ICU team, ethics consultation, or palliative care consultation to improve family emotional outcomes and to reduce ICU length of stay and treatment intensity. Evidence that these interventions reduce total costs is inconclusive. A comprehensive research agenda should ensure the future study of a full range of patient-centered outcomes. [ABSTRACT FROM AUTHOR]

Background: Growing numbers of critically ill patients receive prolonged mechanical ventilation. Little is known about the patterns of care as patients transition from acute care hospitals to postacute care facilities or about the associated resource utilization.Objective: To describe 1-year trajectories of care and resource utilization for patients receiving prolonged mechanical ventilation.Design: 1-year prospective cohort study.Setting: 5 intensive care units at Duke University Medical Center, Durham, North Carolina.Participants: 126 patients receiving prolonged mechanical ventilation (defined as ventilation for >or=4 days with tracheostomy placement or ventilation for >or=21 days without tracheostomy), as well as their 126 surrogates and 54 intensive care unit physicians, enrolled consecutively over 1 year.Measurements: Patients and surrogates were interviewed in the hospital, as well as 3 and 12 months after discharge, to determine patient survival, functional status, and facility type and duration of postdischarge care. 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 postacute care.Results: 103 (82%) hospital survivors had 457 separate transitions in postdischarge care location (median, 4 transitions [interquartile range, 3 to 5 transitions]), including 68 patients (67%) who were readmitted at least once. Patients spent an average of 74% (95% CI, 68% to 80%) of all days alive in a hospital or postacute care facility or receiving home health care. At 1 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 [4 patients; 21%] or dead [56 patients; 44%]). Patients with poor outcomes were older, had more comorbid conditions, and were more frequently discharged to a postacute care facility than patients with either fair or good outcomes (P < 0.05 for all). The mean cost per patient was $306,135 (SD, $285,467), and total cohort cost was $38.1 million, for an estimated $3.5 million per independently functioning survivor at 1 year.Limitation: The results of this single-center study may not be applicable to other centers.Conclusion: Patients receiving prolonged mechanical ventilation have multiple transitions of care, resulting in substantial health care costs and persistent, profound disability. The optimism of surrogate decision makers should be balanced by discussions of these outcomes when considering a course of prolonged life support.Primary Funding Source: None. [ABSTRACT FROM AUTHOR]

The article discusses a study which analyzed the temporal trends in long-term acute care hospital utilization following critical illness among fee-for-service Medicare beneficiaries aged 65 years and above in the U.S. The study utilized the Medicare Provider Analysis and Review files from 1997 to 2006. It found that during the period, utilization of age-standardized population incidence of long-term acute care increased from 38.1 per 100,000 in 1997 to 99.7 per 100,000 in 2006. It also discovered an increase in annual health care costs associated with long-term acute care admissions following critical illness. Study authors also revealed poor survival rate for Medicare beneficiaries who are transferred to long-term acute care after a critical illness.

The article focuses on a study which examined whether decline in cognitive function was greater among older individuals who experienced acute care or critical illness hospitalizations relative to those not hospitalized and determined whether the risk for incident dementia differed by the exposures. Study participants are composed of individuals 65 years and older without dementia at baseline residing in the community in the Seattle, Washington area and belonging to the Group Health Cooperative. The study found a greater likelihood of cognitive decline in older adults who experienced acute care hospitalization and critical illness hospitalization compared with those who had no hospitalization.

Objective: To demonstrate the feasibility of a placebo-controlled trial of antipsychotics for delirium in the intensive care unit and to test the hypothesis that antipsychotics would improve days alive without delirium or coma.Design: Randomized, double-blind, placebo-controlled trial.Setting: Six tertiary care medical centers in the US.Patients: One hundred one mechanically ventilated medical and surgical intensive care unit patients.Intervention: Patients were randomly assigned to receive haloperidol or ziprasidone or placebo every 6 hrs for up to 14 days. Twice each day, frequency of study drug administration was adjusted according to delirium status, level of sedation, and side effects.Measurements and Main Outcomes: The primary end point was the number of days patients were alive without delirium or coma. During the 21-day study period, patients in the haloperidol group spent a similar number days alive without delirium or coma (median [interquartile range], 14.0 [6.0-18.0] days) as did patients in the ziprasidone (15.0 [9.1-18.0] days) and placebo groups (12.5 [1.2-17.2] days; p = 0.66). No differences were found in secondary clinical outcomes, including ventilator-free days (p = .25), hospital length of stay (p = .68), and mortality (p = .81). Ten (29%) patients in the haloperidol group reported symptoms consistent with akathisia, compared with six (20%) patients in the ziprasidone group and seven (19%) patients in the placebo group (p = .60), and a global measure of extrapyramidal symptoms was similar between treatment groups (p = .46).Conclusions: A randomized, placebo-controlled trial of antipsychotics for delirium in mechanically ventilated intensive care unit patients is feasible. Treatment with antipsychotics in this limited pilot trial did not improve the number of days alive without delirium or coma, nor did it increase adverse outcomes. Thus, a large trial is needed to determine whether use of antipsychotics for intensive care unit delirium is appropriate. [ABSTRACT FROM AUTHOR]

The article presents a study which examines the prevalence of clinically applicable findings on chest computed tomographic angiograms (CTAs) that were ordered to diagnose pulmonary embolism (PE). The study analyzed 589 pulmonary CTAs that were ordered in the emergency department of a tertiary care hospital. Result shows that PE was discovered in 55 CTAs. It concludes that CTAs that are ordered in the department are more than twice as potential to find a pulmonary nodule.

The article discusses a study which compares the expectation of prolonged mechanical ventilation (PMV) decision-makers with observed outcomes and characterizes the vital elements of the surrogate-physician interaction concerning PMV provision. A total of 126 patients were interviewed about their expectations for one-year patient survival, quality of life and functional status. The findings revealed that the outcomes for PMV patients were worse than the physicians and surrogates' expectations.

The article investigates the cost-effectiveness of the most commonly used sedatives prescribed for mechanically ventilated critically ill patients. Base-case probabilistic analysis shows that propofol dominated lorazepam in 91% of simulations and, on average, was both $6,378 less expensive per patient and associated with more than three extra mechanical ventilator-free days. The probabilistic model fails to reveal differences between propofol and midazolam on costs or measures of effectiveness.

Objective: Patients who receive prolonged mechanical ventilation have high resource utilization and relatively poor outcomes, especially the elderly, and are increasing in number. The economic implications of prolonged mechanical ventilation provision, however, are uncertain and would be helpful to providers and policymakers. Therefore, we aimed to determine the lifetime societal value of prolonged mechanical ventilation.Design and Patients: Adopting the perspective of a healthcare payor, we developed a Markov model to determine the cost effectiveness of providing mechanical ventilation for at least 21 days to a 65-yr-old critically ill base-case patient compared with the provision of comfort care resulting in withdrawal of ventilation. Input data were derived from the medical literature, Medicare, and a recent large cohort study of ventilated patients.Measurements and Main Results: We determined lifetime costs and survival, quality-adjusted life expectancy, and cost effectiveness as reflected by costs per quality-adjusted life-year gained. Providing prolonged mechanical ventilation to the base-case patient cost "dollars"55,460 per life-year gained and "dollars"82,411 per quality-adjusted life-year gained compared with withdrawal of ventilation. Cost-effectiveness ratios were most sensitive to variation in age, hospital costs, and probability of readmission, although less sensitive to postacute care-facility costs. Specifically, incremental costs per quality-adjusted life-year gained by prolonged mechanical ventilation provision exceeded "dollars"100,000 with age >or=68 and when predicted 1-yr mortality was >50%.Conclusions: The cost effectiveness of prolonged mechanical ventilation provision varies dramatically based on age and likelihood of poor short- and long-term outcomes. Identifying patients likely to have unfavorable outcomes, lowering intensity of care for appropriate patients, and reducing costly readmissions should be future priorities in improving the value of prolonged mechanical ventilation. [ABSTRACT FROM AUTHOR]

Objective: Patients who require tracheostomy for prolonged mechanical ventilation have poor outcomes and high costs of care. However, recent longitudinal trends relevant to these patients and their care have not been described. We aimed to describe trends in the annual incidence and timing of tracheostomy for prolonged mechanical ventilation, as well as prolonged mechanical ventilation patient resource utilization and overall in-hospital mortality.Design and Setting: Retrospective review of the North Carolina Hospital Discharge Database, a comprehensive record of all state nonfederal, nonpsychiatric hospital discharges between 1993 and 2002.Patients: Patients were 9,794 medical and surgical patients >/=18 yrs of age with International Classification of Diseases, Ninth Revision, Clinical Modification code 96.72 (mechanical ventilation for >96 hrs) and Diagnosis Related Group code 483 (tracheostomy except for face, neck, and mouth diagnoses).Interventions: None.Measurements: Incidence rates adjusted for annual population growth, mechanical ventilation days until tracheostomy placement, length of stay, and hospital charges and payments adjusted by the medical component of the Consumer Price Index.Main Results: Between 1993 and 2002, the incidence of tracheostomy for prolonged mechanical ventilation increased across all age groups from 8.3 of 100,000 to 24.2 of 100,000 (p < .001), although most significantly among patients <55 yrs of age. During this period, a decrease was seen in mortality (from 39% to 25%), median mechanical ventilation days to tracheostomy placement (from 12 to 10 days), and median length of stay (from 47 to 33 days). By 2002, patients were almost three times less likely to be discharged to home independently although twice as likely to be sent to a skilled nursing facility. Although prolonged mechanical ventilation patients with tracheostomies represented only 7% of all who required mechanical ventilation, their total charges during the study period were 1.74 billion dollars-22% of all mechanical ventilation patient charges.Conclusion: The incidence of tracheostomy for prolonged mechanical ventilation increased by nearly 200% during the past decade in North Carolina, exceeding changes in the overall incidence of respiratory failure three-fold. Although in-hospital mortality, length of stay, and charges per patient fell over time, the overall resource utilization of prolonged mechanical ventilation patients increased dramatically. [ABSTRACT FROM AUTHOR]