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

Mark Unroe, MD; Jeremy M. Kahn, MD, MSc; Shannon S. Carson, MD; Joseph A. Govert, MD; Tereza Martinu, MD; Shailaja J. Sathy, MD; Alison S. Clay, MD; Jessica Chia, MD; Alice Gray, MD; James A. Tulsky, MD; and Christopher E. Cox, MD, MPH
[+] Article, Author, and Disclosure Information

From Duke University, Durham, and University of North Carolina, Chapel Hill, North Carolina, and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania.

Grant Support: By the National Institutes of Health (grants K23 HL081048, K23 HL082650, and K23 HL067068).

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M09-2795.

Reproducible Research Statement:Study protocol and data set: Available from Dr. Cox (e-mail, christopher.cox@duke.edu). Statistical code: Not available.

Requests for Single Reprints: Christopher E. Cox, MD, MPH, Duke University Medical Center, Division of Pulmonary and Critical Care Medicine, Box 102043, Durham, NC 27710; e-mail, christopher.cox@duke.edu.

Current Author Addresses: Drs. Unroe, Govert, Martinu, Chia, Gray, and Cox: Division of Pulmonary and Critical Care Medicine, Box 2629, Duke University, Durham, NC 27710.

Dr. Kahn: University of Pennsylvania Medical Center, Blockley Hall, Room 723, 423 Guardian Drive, Philadelphia, PA 19104-6160.

Dr. Carson: Division of Pulmonary and Critical Care Medicine, University of North Carolina, 4134 Bioinformatics Building, Chapel Hill, NC 27599.

Dr. Sathy: Division of Pulmonary and Critical Care Medicine, University of Washington, Harborview Medical Center, 325 Ninth Avenue, Seattle, WA 98104.

Dr. Clay: Department of Surgery, Duke University, Box 2945 Durham, NC 27710.

Dr. Tulsky: Center for Palliative Care, Hock Plaza, Suite 1105, 2424 Erwin Road, Durham, NC 27705.

Author Contributions: Conception and design: S.S. Carson, J.A. Govert, T. Martinu, A.S. Clay, J. Chia, J.A. Tulsky, C.E. Cox.

Analysis and interpretation of the data: M. Unroe, J.M. Kahn, S.S. Carson, J.A. Govert, J.A. Tulsky, C.E. Cox.

Drafting of the article: M. Unroe, S.S. Carson, J.A. Govert, A.S. Clay, J.A. Tulsky, C.E. Cox.

Critical revision of the article for important intellectual content: M. Unroe, J.M. Kahn, S.S. Carson, J.A. Govert, S.J. Sathy, J. Chia, A. Gray, J.A. Tulsky, C.E. Cox.

Final approval of the article: M. Unroe, J.M. Kahn, S.S. Carson, J.A. Govert, T. Martinu, A.S. Clay, J. Chia, A. Gray, J.A. Tulsky, C.E. Cox.

Provision of study materials or patients: T. Martinu.

Statistical expertise: C.E. Cox.

Obtaining of funding: J.A. Tulsky, C.E. Cox.

Administrative, technical, or logistic support: A.S. Clay, C.E. Cox.

Collection and assembly of data: J.M. Kahn, T. Martinu, S.J. Sathy, A.S. Clay, J. Chia, A. Gray, C.E. Cox.

Ann Intern Med. 2010;153(3):167-175. doi:10.7326/0003-4819-153-3-201008030-00007
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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.

Primary Funding Source: None.


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Figure 2.
Patient trajectories at 1 year, by health outcome.

Each bar shows patients at 3- and 12-mo intervals, grouped by survival and number of functional limitations in basic activities of daily living. The arrows indicate 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 at fair outcome (n = 18), or worsened to a poor outcome (n = 4) or died (n = 7). Percentages in both 3- and 12-mo outcomes categories are calculated by including 36 (29%) patients (not shown) who were dead at 3 mo.

* These 23 (18%) patients improved or remained in the good-outcome grouping between 3 and 12 mo.

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Figure 1.
Trajectories of care for patients in the prolonged mechanical ventilation cohort over the first year after discharge.

Arrows between care locations indicate both the direction of patient transitions and the total number of patients transferred between locations over 1 year. Solid lines represent initial transitions between the hospital and other locations. Dashed lines represent subsequent hospital readmissions and discharges involving postdischarge care locations. Dotted lines represent transitions among postdischarge care locations, including home. Each box summarizes the total numbers of both readmissions and patients admitted, as well as how many patients remained or died in each location of care at 1 year.

* 7 transitions to inpatient hospice and death not shown (3 from the acute hospitalization and 1 each from home, long-term acute care facility, skilled nursing facility, and hospital readmission).

† 1 transition from skilled nursing facility to skilled nursing facility not shown.

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Summary for Patients

What Happens to People Who Need a Breathing Machine for More Than a Few Days?

The summary below is from the full report titled “One-Year Trajectories of Care and Resource Utilization for Recipients of Prolonged Mechanical Ventilation. A Cohort Study.” It is in the 3 August 2010 issue of Annals of Internal Medicine (volume 153, pages 167-175). The authors are M. Unroe, J.M. Kahn, S.S. Carson, J.A. Govert, T. Martinu, S.J. Sathy, A.S. Clay, J. Chia, A. Gray, J.A. Tulsky, and C.E. Cox.


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