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One-Year Trajectories of Care and Resource Utilization for Recipients of Prolonged Mechanical Ventilation: A Cohort Study

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Unroe, Mark, Kahn, Jeremy M., Carson, Shannon S., Govert, Joseph A., Martinu, Tereza, Sathy, Shailaja J., Clay, Alison S., Chia, Jessica, Gray, Alice, Tulsky, James A., Cox, Christopher E.·2010·Annals of Internal Medicine

DOI 10.7326/0003-4819-153-3-201008030-00007PMC PMC2941154

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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.

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Authors: Unroe, M., Kahn, J. M., Carson, S. S., Govert, J. A., Martinu, T., Sathy, S. J., Clay, A. S., Chia, J., Gray, A., Tulsky, J. A., & Cox, C. E.
Affiliations: University of North Carolina at Chapel Hill (US)
Corresponding author: Unroe, Mark
Venue: Annals of Internal Medicine
Publisher: American College of Physicians
Published: 2010-08-03
Volume: 153
Issue: 3
Pages: 167-175
ISSN: 0003-4819 (ISSN-L)
1539-3704
DOI: 10.7326/0003-4819-153-3-201008030-00007
PMC: PMC2941154
OpenAlex: W2171302398
Cited by: 427
References: 51
Citations by year: 2026: 14 · 2025: 11 · 2024: 17 · 2023: 27 · 2022: 18 · 2021: 24 · 2020: 26 · 2019: 32 · 2018: 30 · 2017: 29 · 2016: 43 · 2015: 37 · 2014: 33 · 2013: 27 · 2012: 31
FWCI: 22.67
Type: journal article
Language: en
Open access: green
www.ncbi.nlm.nih.gov
Licence: www.acpjournals.org/journal/aim/text-and-data-mining (tdm)
Locations: Annals of Internal Medicine (publishedVersion)
PubMed (publishedVersion)
PubMed Central (acceptedVersion)
Funders: National Heart, Lung, and Blood Institute (K23HL082650, K23HL081048, K23HL067068)
Topics: Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Respiratory Support and Mechanisms
Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative Care and End-of-Life Issues
Health Sciences › Medicine › Critical Care and Intensive Care Medicine › Nosocomial Infections in ICU
Keywords: prolonged mechanical ventilation, post-acute care, hospital readmission, resource utilization (health care), health care costs, functional outcome, tracheostomy, home health care, intensive care unit survivors, Medicare claims data, prognostic factors, surrogate decision-making, end-of-life care
MeSH terms: Adult, Aged, Aged, 80 and over, Female, Health Resources, Humans, Intensive Care Units, Length of Stay, Male, Middle Aged, North Carolina, Patient Discharge, Patient Transfer, Prospective Studies, Quality of Life, Respiration, Artificial, Survival Analysis, Critical Illness, Health Care Costs, Outcome Assessment, Health Care, Young Adult

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One-Year Trajectories of Care and Resource Utilization for Recipients of Prolonged Mechanical Ventilation: A Cohort Study

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