One-year trajectories of care and resource utilization for recipients of prolonged mechanical ventilation: a cohort study

Abstract

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.

Figure 1. Trajectories of care for prolonged mechanical ventilation cohort members over the first year post-discharge

126 patients are depicted entering the hospital, with 99 (79%) discharges (23 died and one patient remained in the hospital) then experiencing 457 transitions in care location during follow up. Arrows between care locations depict both the direction of patient transitions as well as the total number of patients transferred over one year between locations. Bold lines represent initial transitions between the hospital and other locations. Dashed lines represent subsequent hospital readmissions and discharges involving post-discharge care locations. Red lines represent transitions among post-discharge care locations, including home. Within each box representing a location of care, a summary is provided of the total numbers of both readmissions and patients admitted, as well as how many remained or had died in each at one year. *One skilled nursing facility to skilled nursing facility transition not shown. **Seven transitions to inpatient hospice (and death) not shown graphically (three from the acute hospitalization and one each from home, long-term acute care facility, skilled nursing facility, hospital readmission).

Figure 2. One-year patient trajectories by health outcomes groupings

Each bar chart shows patients at 3- and 12-month intervals grouped by survival and number of functional limitations in basic activities of daily living in three categories (good outcome: alive with no activities of daily living dependencies [white boxes]; fair outcome: alive but with 1–5 dependencies in activities of daily living [boxes with wavy lines]; and poor outcome: either alive and completely dependent or dead [boxes for those alive with cross-hatches and black boxes for those dead]). The arrows depict group members’ subsequent longitudinal transitions to other health outcomes. For example, between 3 and 12 months, 34 patients with a fair 3-month outcome improved to a good outcome (n=5), remained as fair (n=18), or worsened to a poor outcome (2 patients with a fair outcome and 1 with a poor outcome). Percentages in both 3-and 12-month outcomes categories are calculated by including 36 (29%) patients (not shown) who were dead at 3 months. * Designates the 23 (18%) patients who improved or remained in the good outcome grouping between 3 and 12 months.