ICU Outcomes

OVERVIEW

  • outcome measures are important for research and quality control
  • clinically meaningful outcomes measure how patients feel, function or survive, e.g. mortality, quality of life
  • surrogate outcomes is a substitute that would be expected to be beneficial based on epidemiological, physiological, therapeutic or other scientific grounds
  • unless validated surrogate outcomes should not be used to change clinical practice

ICU MORTALITY

Advantages

  • simple, single metric
  • concrete endpoint which is already available in hospital databases
  • death is an important endpoint
  • aggregation of a large number of diagnoses with a small number in each increases power to detect variation
  • variation over time may reflect institutional and organisational events or characteristics- budget cuts, bed pressure etc. and be able to detect true quality deficiencies
  • May be useful when combined as part of an overall quality program

Disadvantages

  • Definition of ICU is very hospital specific which can influence mortality (e.g. non-ICU stepdown areas in some hospitals)
  • can be ‘gamed’ e.g. transfers out to die in the ward or other units
  • Poor correlation between mortality and quality of care in some diagnoses; alternatives available e.g. diagnosis specific risk models such as EuroSCORE for CABG, APACHE SMR, trauma scores
  • Can mask problems in low volume diagnostic groups
  • Difficult to draw hospital comparisons and or allow league table construction
  • False conclusions can be drawn unless robust statistical methods used

HOSPITAL MORTALITY

  • Hospital mortality can often be 50% higher than ICU mortality, and is a reasonable surrogate (90%) for 90 days mortality

Advantages

  • gets over differences in definition of ICU and ICU discharge thresholds and avoids avoids many problems of censoring at ICU discharge.
  • Still a simple and robust endpoint
  • easy to obtain from exisiting hospital databases

Disadvantages

  • can confound intensive care outcomes with deficiencies in ward or other post ICU care
  • Does not address in any way functional outcomes, e.g discharge from hospital to a nursing home in a vegetative state is counted as a positive outcome

90 DAY MORTALITY

Advantages

  • simple robust endpoint
  •  addresses the issue of ongoing mortality after hospital discharge (though this difference is about 10% relative in recent large trials)
  • data may be available by linkage with external registries (e.g. Births, Deaths and Marriages)

Disadvantages

  • still an arbitrary time point
  • 90 days may still be insufficient to accurately measure the attributable mortality from an episode of critical illness
  • Problems with loss to follow up after ICU discharge
  • Ethical implications of contacting patients after discharge (especially for research studies)

1 YEAR FUNCTIONAL OUTCOME

Advantages

  • a ‘POEM’ (patient oriented endpoint that matters)
  • Takes into account disability and true long-term consequences of critical illness

Disadvantages

  • no ideal scoring tool available – existing tools all have problems; some measure particular functional domains well; problems with face validity
  • All functional outcome measures are time consuming to apply
  • Problems with loss to follow up
  • Follow up— time consuming, labour intensive, costly face to face vs. phone vs. mail
  • Depending on disease may reflect more the natural history of the disease rather than the ICU care per se

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health, a Clinical Adjunct Associate Professor at Monash University, and the Chair of the Australian and New Zealand Intensive Care Society (ANZICS) Education Committee. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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