Long-Term Outcomes for Elderly Survivors of Prolonged Ventilator Assistance

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clinical investigations in critical care

----i~IIIII;t--------------Long-Term Outcomes for Elderly Survivors of Prolonged Ventilator Assistance* fl. Elpern, R.N.; Ruth Larson, R.N.; Paula Douglass, A/.A.; Robert LJo Rosen, AI.D.; and Roger C. Bone, L\1. D.

l~:llen

Care of ventilator-dependent patients requires considerable resources, yet the long-term outcomes of this type of care have rarely been described. We retrospectively investigated the posthospital course of elderly patients who survived an episode of prolonged ventilator dependency to describe survival rates, subsequent use of health care resources, and functional abilities. Our data suggest that the use of prolonged mechanical ventilation in the elderly produces few

survivors at considerable expense. Poor overall outcomes occurred despite considerable consumption of medical and nursing resources by the survivors. (Chest 1989; 96:1120-24)

nt scientific advances have improved the outR ece look for survival of catastrophic illnesses. Since

longed mechanical ventilation. Costs of care in 1984 exceeded payments by an average of over $20,000 per ventilator patient. h,M (3) Survival to discharge in patients who undergo at least 48 h of mechanical ventilation is 50 percent or less. Factors influencing survival include age as well as type and number of disease processes. 3 ,6,k - 11 (4) Few reports have evaluated quality of life in survivors of critical illnesses. Survivors of intensive care have been characterized as having a favorable prognosis in regard to functional capacities." Studies addressing quality of life for long-term survivors of respiratory in tensive care suggest a satisfactory degree of independence in lifestyle for these patients.P-" In summary, the costs of providing acute care to long-term ventilator-dependent patients are high. Given the limited survival of these patients, the appropriateness ofsuch expenditures is under scrutiny. Reconciliation of resource utilization with the potential for beneficial results requires specific information regarding long-term outcomes for survivors of an episode of ventilator dependency. Specific aims of the present study were to evaluate postdischarge outcomes of hospital care for survivors of prolonged ventilatory assistance - survival rates, medical services utilized, and functional status. Potential associations among postdischarge survival and diagnosis, length of hospital stay, intensity of hospital care, and days of mechanical ventilation were evaluated.

the early 1960s, positive pressure mechanical ventilators have provided support lor patients with actual or impending respiratory failure. Mechanical ventilators are used routinely in acute care hospitals, usually in special care units. Although designed to be a temporary support measure, mechanical ventilation may be necessary t()r a prolonged period of time for some patients, and discontinuance of ventilator support may be difficult. Considerable human, technical, and financial resources are required to care for the ventilator-dependent individual. Reports from care providers raise important ethical, social, legal, and economic questions. From a cost-benefit perspective, the following conclusions can be drawn from the literature: (1) The costs of care for a critically ill patient in an intensive care unit are approximately four times greater than those of a non-LCl.I patient. 1.2 Care provided to patients undergoing a period of assisted ventilation is particularly expensive. The higher costs are due to a number of factors including length of stay and expenses for monitoring and respiratory therapy. ~l-fi (2) With the advent of prospective payment by diagnosis-related groups, costs of intensive care for Medicare patients far exceed payments." This loss to hospitals is, again, greater for patients requiring pro*FrOlll the Departments of Medicine, Medical Nursing, and Corporate Planning and Budgeting, Hush-Presbvterian-St. Luke's Medical Ce-nter, Chicago. Manuscript received December 15; revision accepted April 6. Rl'1J1i"t rrqursts: 1\ls. /<:lpl''-ll, 1725 \ll'st Harrison Street, l\/. .350, C"icll~O fj()(j12

1120

=

NRCU noninvasive respiratory care unit; MICU intensive care unit

=medical

METIIODS

The patient population used for this analysis of posthospital outcomes has been described in a previous report. fi Included in the Outcome for Elderly Survivors of Prolonged Ventilator Assistance (E/pem et 8/)

Table 1- Pro}iks of Patients Surviving to Discharge Patients Surviving to Discharge Group 1 Group 2 Group 3

70f14 (50%) 12 of 27 (41%) 12 of 42 (29%)

Average Age, yr

Median Duration of Hospital Stay, Days

70.1

20 (Range 12-56) 37 (Range 16-280) 27 (Range 13-53)

72.6 71.1

study sample were 95 Medicare patients who underwent a period of long-term ventilator dependence at Rush-Presbyterian-St. Luke's Medical Center during the period of July 1, 1983, through June 30, 1984. Thirty-one patients survived to discharge, including 20 men and 11 women aged 60 to 90 years. All subjects received three or more days of continuous ventilator treatment and spent no time in surgical intensive care, thus eliminating patients with an acute and easily reversible problem and those recovering from surgery. The length of hospital stay and total days spent on a mechanical ventilator were calculated for each patient. Patients were classified previously into groups to reRect the intensity of care required during hospitalization. Group I patients received all their ventilator care in a NRCU. This eight bed unit was designated to care for mechanically ventilated patients who were medically and hemodynamically stable, requiring primarily respiratory monitoring and care. On this unit one nurse typically cared for two to three patients at a time. Resident medical staff had responsibility for caring for NRCU patients plus those on the remainder of the 24-bed medical unit on which the NRCU was located. Group 2 patients were cared for in both a 14-bed MICU and in the NRCU. These patients had some period of hemodynamic instability in addition to respiratory failure. Transfer of patients between the MICU and NRCU was dependent on the patients' need for invasive monitoring and the extent of medical and nursing supervision required. Nurse:patient staffing ratios in the MICU were typically I: 1. The resident medical staff had responsibility for MICU patients only. Group 3 patients received all their ventilator management in the MICU prior to or following stays on a general medical unit. Group 4 patients were admitted directly to the MICU and died there while receiving mechanical ventilation. The hospital charts of patients who survived to discharge were reviewed to ascertain demographic data, next of kin, attending physician, diagnoses, discharge status, and discharge destination. Survivors were grouped into diagnostic categories that described the medical condition underlying the episode of respiratory failure. The categories and diagnoses included are listed as follows: nervous system - seizure disorder, cerebral vascular accident; respiratory system-pneumonia, chronic obstructive pulmonary disease; cardiovascular system - myocardial infarction, endocarditis, mitral stenosis, arrhythmias; neoplasm -lung cancer, renal cell cancer, Sezary syndrome, esophageal cancer; and other-gastrointestinal bleeding, hip fracture, diabetes mellitus, sepsis. As these categories reflect underlying diseases, a patient who, for example, was mechanically ventilated after suffering a myocardial infarction with resultant cerebral anoxia would be classified in the cardiovascular rather than nervous system category. The survivors and/or their relatives were contacted by one of the investigators. Information was obtained to determine whether the patient was living or deceased; date and cause of death where applicable; postdischarge use of institutional, community, and family resources; and subsequent hospitalizations. Survival after discharge was computed in months from the date of hospital discharge to either the date of death or the date of data collection. Subsequent hospital days were computed after dates of rehospitali-

Median Duration of Mechanical Ventilation, Days 5 (Range 3-17) 13 (Range 5-231)

5 (Range 3-11)

Median Survival Postdischarge, Mo 9.5 (Bange 2-42) 33

(Range 0.1-44) 13 (Range 1-35)

zation were verified by each admitting institution. All extended care facility stays were similarly verified. When patient or family members were not available, the attending physician or personnel from community agencies known to have been involved with the patient after discharge were contacted for data on survival and utilization of resources. All contacts were made in July or August 1987 to ensure at least three-year follow-up for all patients. Since the data sets frequently contained extreme scores, medians were computed to best describe central tendencies. RESULTS

Suroioal to Discharge Of the 95 patients ventilated for three or more days, 31 (33 percent) survived to be discharged from the hospital. Table 1 profiles these hospital survivors. Assignment to groups 1 to 3 reflects the intensity of care required during hospitalization. Survival to discharge was best for group 1 patients who were presumably hemodynamically stable, and therefore" did not spend any time in the MICU. The longer hospital stay and longer ventilator time in 1VouP 2 reflects a more protracted weaning course for these patients. The one patient who was still ventilatordependent at the time of discharge was in group 2. Despite the longer hospital stay, postdischarge survival was best for this group of patients. Postdischarge Suroival Postdischarge information was obtained for 30 of the 31 hospital survivors. One male patient for whom information was not available was excluded from subsequent analysis. Patient survival in the three years 100 90 80

70 60

50 40 30

20

\

•\ •

-.........................

\

...

\

10

0-+-------+------+------+-------4 40 10 20 30 o SURVIVAL AfTER DISCHARGE (MONTHS) FIGURE

1. Patient survival after discharge from the hospital. CHEST I 96 I 5 I NOVEMBER, 1989

1121

Table 2-Survival by Diagnostic Categories

Diagnostic Category

Numherof Hospital Survivors

Nervous system Respiratory system Cardiovascular system Neoplasm Other

2 of 10 (20%) 9 of 25 (36%) 10 of 32 (31%) 4 of 12 (33%) 6 of 16 (37%)

Median Survival After Discharge, Mo 1 33

35 4.5 27

after discharge is illustrated in Figure 1. Median survival was 13.5 months postdischarge. Fifteen of the original 95 patients (16 percent) were alive at 12 months. Thirteen patients (14 percent) survived two years and nine (9 percent) were alive three years after their episode of ventilator dependency. For reference, in 1980, the average remaining lifetime was 13.2 years for a 70-year-old Illinois resident and 10.4 for a 75year-old. Hospital survivors were grouped into diagnostic categories that described the underlying basis for their respiratory failure. As illustrated in Table 2, both short-term and long-term survival were poorest in patients with neurologic disorders. While survival to discharge was comparable across the other diagnostic categories, long-term survival for patients with malignancies was only 4.5 months compared to over 30 months for patients with respiratory or cardiovascular illnesses. For the nine individuals living at the time of data collection, four were in the cardiovascular group, two in the respiratory group, and three had other medical illnesses. Postdischarge survival was plotted against length of hospital stay and days of mechanical ventilation to check for potential associations among these variables. No consistent patterns were apparent. When hospital survivors were grouped by number of years survived postdischarge (Table 3), the patients alive more than three years after discharge had the shortest hospital stay. Postdischarge Use of Medical Resources

Twenty-six of the 30 subjects were rehospitalized.

Subsequent hospitalizations totaled 646 days. Readmission rates were not different for groups 1 to 3. When patients were stratified by length of survival, patients dying within 12 months accounted for 50 percent of the total hospital readmission days (Table 4). Nine patients spent time in an extended care facility after discharge. The length of stay in such facilities generally tended to be short (two to three weeks) with the exception of two patients. One patient who survived less than one year spent seven months in a nursing home. Another had been living in a nursing home for 30 months at the time of data collection. Overall, hospital survivors spent a total of 1,298 days in extended care institutions. Over half the patients studied received some type of home nursing support after discharge. Services provided included skilled nursing care as well as aide and homemaker services. The nine patients who were alive at the time of our three-year follow-up were contacted. Seven of these individuals described themselves as functionally independent and required no particular assistance from family or community resources. Of these seven, six lived with spouses or children and one lived in a senior citizens' apartment complex. The two remaining patients depended on close supervision and assistance for daily care. One patient had 24 h/day professional nursing help in the home and the other had resided in a nursing home for over 2 1/ 2 years at the time of data collection. . It was of interest to us that the patients and families we interviewed had considerable difficulty recalling the experience of ventilator dependency. Most interviewees claimed not to be able to recall the episode at all, or could do so only vaguely and imprecisely. This difficulty in recall has been reported by others. 12.13 DISCUSSION

This study was undertaken to provide an expanded data base for weighing costs and benefits of intensive respiratory care. Mechanical assistance to ventilation is widely available. The outcomes of this therapy are

Table 3-Follow-up of Survivors: Mortality Over Time Postdischarge Survival, Months Survived 0-12

No. of Patients

Age, yr

15

70.9

13-24

2

73

25-36

4

69

>36

9

72.4

(Still living)

1122

Median Duration of Hospital Stay, Days

Median Duration of Mechanical Ventilation, Days

36 (Range 12-280)

(Range 3-231)

30 (Range 17-43) 36 (Range 14-66) 20 (Range 13-35)

5 6 (Range 5-7) 16.5 (Range 5-50)

5 (Range 3-17)

Outcome for Elderly Survivors of Prolonged Ventilator Assistance (Elpern et al)

Table 4- Hospital Survioors: Postdischarge Utilization of Medical Re,ource, Postdiseharge Survival, Months Survived 0-12 13-24 25-36 >36 (Living)

(% of Total)

Extended Care Facility Days (% of Total)

Home Nursing Services (% of Group Using)

323 (50%) 31 (5%) 120 (18%) 172 (27%)

329 (25%) 21 (2%) 15 (1%) 933 (72%)

47%

Subsequent Hospital Days

less well established. Few would argue that respiratory intensive care must be discriminately applied, particularly considering the staggering costs involved. A key factor to consider in committing an individual to a mechanical ventilator is the reasonable prospect of substantial recovery for that patient. To date, the outcomes of ventilator assistance most frequently reported have been survival rates either for the period of ventilator dependency or to the point of discharge from the hospital. These short-term mortality calculations differ from study to study, due to dissimilarities in the study populations. Subjects in the present study were all Medicare recipients with nonsurgical illnesses who received at least three days of continuous mechanical ventilation. We were interested in this population because of the following: (1) the ranks of Medicare recipients continues to grow at a rapid pace; (2) analyses of patterns of use of mechanical ventilation demonstrate a trend toward treating more elderly patients and those with poorer premorbid health; 14 and (3) the financial burden to hospitals providing respiratory intensive care to these patients has been studied and is known to be significant. Our results underscore that the majority of elderly patients who undergo prolonged mechanical ventilation have a limited prognosis. Only one third of our patients survived to discharge, and one half of those who were discharged died in the first year afterward. These survival rates are lower than others have reported.3-5,9,l1,12 In contrast to previous studies, our inclusion criteria eliminated patients who were younger, were recovering from surgery, or were ventilated for less than three days-all factors that could have favorably influenced prognosis. As we previously reported, the total nonphysician costs of hospital care for the 95 patients from whom our sample was drawn were $3,656,137. 6 In averaging hospital costs over long-term survivorship, this represents a hospital investment of $243,742 per one-year survivor and $406,237 per three-year survivor. This estimate does not include the costs of the postdischarge care for surviving patients. In addition to a limited life expectancy, our findings

50% 75% 55%

raise questions about the quality of life for most hospital survivors. After successful weaning and eventual discharge, patients usually required continued supervision, as evidenced by the extensive readmissions and the frequent use of institutional and home nursing services. The "costs" of such ministrations, not only in terms of dollars, but stress on patients, their families and health care workers are factors to consider in analyzing outcomes of respiratory intensive care. From a cost-benefit perspective, it would be advantageous to be able to identify those patients with the best chances for long-term survival. S~rvival rates differed greatly by underlying disease categories. Although the numbers of patients in these categories were few; postdischarge survival for patients with neurologic and neoplastic disorders was quite limited. Our finding of a poor prognosis for cancer patients who survive an episode of mechanical ventilation is supported by a previously reported 7 percent survival for cancer patients followed up six months after a hospitalization for acute respiratory failure. IS Survival for patients with cardiovascular, respiratory, or other medical illnesses was more favorable, perhaps reflecting the more chronic nature of these illnesses. We were unable to identify any consistent associations of long-term survival with length of ventilator dependency or length of hospitalization. Our data did suggest that longer hospitalization and longer periods of ventilator commitment are often associated with limited survival, but these associations were not consistent. The survival rates for patients who were cared for in the MICU and NRCU suggest that even in instances where ventilator support is prolonged, long-term survival can be relatively favorable. The inability to discriminate 'short-term survivors from long-term survivors at the time of ventilation hinders the allocation of sometimes limited and always expensive special care resources to those patients with the best chance of significant recovery. As evidenced by the functional independence of seven of our nine three-year survivors, such recovery is achieved by a few who are not easily identifiable at the time of CHEST I 96 I 5 I NOVEMBER, 1989

1123

discharge. More investigation is needed in this important area. We support the recommendation that studies be performed to distinguish groups of patients for whom the utility of respiratory support is highly beneficial from those for whom it is only questionable. 16 In cases where survival is unlikely, less expensive care should be considered. In addition to determining predictors of survival, quality of life and costs of care for survivors must be better characterized. Ongoing assessments of quality of life for patients and their families, specification of goods and services required by patients as well as data on readmissions to health care institutions should be made. CONCLUSIONS

We draw the following conclusions from this study of long-term outcomes for elderly patients with nonsurgical illnesses who survived three or more days of continuous mechanical ventilation. Long-term survival after an episode of prolonged ventilator dependency is limited in terms of both number of survivors and length of survival. Length of hospitalization and length of ventilator assistance do not predict longterm survival. Survivors usually require continued medical and nursing care. The majority of patients who survive three or more years are able to function independently in the community. REFERENCES

1 Wagner D~ Wineland TD, Knaus WA. The hidden costs of treating severely ill patients: charges and resources consumption in an intensive care unit. Health Care Financing Rev 1983; 5:8186

1124

2 Parno lR, Terese D, Lemeshow S, Brown RB. Hospital charges and long-term survival of ICU versus non-l'Cl) patients. Crit Care Med 1982; 10:569-74 3 Davis H, Lefrak SS, Miller D, Malt S. Prolonged mechanically assisted ventilation. lAMA 1980; 243:43-45 4 Witek TJ, Schachter EN, Dean NL, Beck GJ. Mechanically assisted ventilation in a community hospital. Arch Intern Med 1985; 145:235-39 5 McLean RF, McIntosh ID, Kung GY, Leung DM~ Byrick RJ. Outcomes of respiratory intensive care for the elderly. Crit Care Med 1985; 13:625-29 fJ Douglass PS, Rosen RL, Butler p~ Bone RC. DRC payment for long-term ventilator patients. Chest 1987; 91:413-17 7 Butler P~ Bone RC, Field T. Technology under Medicare diagnosis-related groups prospective payment: implications for medical intensive care. Chest 1985; 87:229-34 8 Gracey on, Gillespie D, Nobrega F, Naessens 1M, Krishan I. Financial implications of prolonged ventilator care of Medicare patients under the prospective payment system. Chest 1987; 91:424-27 9 Spicher JD, White D I! Outcome and function following prolonged mechanical ventilation. Arch Intern Med 1987; 147:42125 10 Cox SC, Norwood SH, Duncan CA. Acute respiratory failure: mortality associated with underlying disease. Crit Care Med 1985; 13:1005-08 11 Schmidt CD, Elliott CG, Carmelli D, Jensen RL, et aI. Prolonged mechanical ventilation for respiratory failure: a costbenefit analysis. Crit Care Med 1983; 11:407-11 12 Byrick RJ, MindorffC, McKee L, Mudge B. Cost-effectiveness of intensive care for respiratory failure patients. Crit Care Med 1980; 8:332-36 13 Bergbom-Engberg I, Hajamar H. Patient experiences during respirator treatment. Crit Care Med 1989; 17:22-25 14 Swinburne AJ, Fedullo AJ, Shayne DS. Mechanical ventilation: Analysis of increasing use and patient survival. J Int Care Med 1988; 3:315-20 15 Snow RM, Miller WC, Rice DL, Ali MK. Respiratory failure in cancer patients. JAMA 1979; 241:2039-42 16 Purtilo RB. Ethical issues in the treatment of chronic ventilator dependent patients. Arch Phys Med Rehabill986; 67:718-21

Outcomefor ElderlySurvivorsof Prolonged VentilatorAssistance(Elpern et al)