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2017年06月19日 研究点评, 进展交流 暂无评论

What Happens to Patients After They Leave the ICU

Aaron B. Holley, MD

June 08, 2017

Joblessness and Lost Earnings After ARDS in a 1-Year National Multicenter Study

Kamdar BB, Huang M, Dinglas VD, et al; National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome Network

Am J Respir Crit Care Med. 2017 Apr 27. [Epub ahead of print]

Background 背景

When designing a study in the intensive care unit (ICU) and choosing an outcome of interest, "hard" data points are popular. Think ventilator and ICU days or survival to hospital discharge. None of these are open to interpretation, and all three can be tracked. They're also appealing to ICU physicians who don't see their patients after they leave the unit. We're in the business of survival and recovery. Extubations and ward transfers make us feel like we're doing our job.

当设计ICU相关研究并选择预后指标时,“硬性”数据指标非常普遍。试想采用机械通气时间,ICU住院日或住院存活率作为预后指标。上述指标的解读不存在疑问,且很容易进行追踪。另外,对于那些不再随访ICU存活患者的ICU医生而言,这些指标也具有吸引力。我们关心的是生存率及康复。如果患者能够顺利拔除气管插管并转出ICU,则我们会感到完成了自己的使命。

But what happens to our patients after they leave the ICU? A new study published online in the American Journal of Critical Care Medicine (AJRCCM) tracked outcomes at 6 and 12 months post ICU admission for acute respiratory distress syndrome (ARDS).[1] The measures of interest were employment and return to work, along with lost earnings and healthcare coverage. The report was part of the ARDS network (ARDSNet) long-term outcome study (ALTOS) and included data from four different ARDSNet clinical trials. For those unfamiliar, the ARDSNet has published several seminal papers on ARDS management.[2,3,4]

但是,患者离开ICU后究竟发生了什么?美国呼吸与重症医学杂志在线发表的一项研究追踪了因ARDS入住ICU的患者6个月及12个月的预后。预后指标包括就业与返回工作岗位的情况,以及收入减少和医疗保险。这项报告是ARDSnet长期预后研究(ALTOS)的一部分,包括了4项不同的ARDSNet临床试验的数据。ARDSNet发表了数项有关ARDS治疗的重要论文。

The Study 研究简介

Not surprisingly, the socioeconomic burden from ARDS is high. The major findings from the study are as follows:

不出所料,ARDS造成了极大的社会经济负担。研究的主要发现如下:

  • Among those previously employed (n=386), 49% and 44% were unemployed at 6 and 12 months, respectively. 在既往就业人群中(n = 386),6个月和12个月随访时分别有49%和44%失业。
  • Among those who did return to work after 12 months, 111 (43%) never returned to previous levels (in hours per week), 69 (27%) reported reduced effectiveness, and 62 (24%) ultimately lost their jobs. 在12个月后返回工作岗位的患者中,111名(43%)未能恢复既往工作水平(根据每周工作时间),69名(27%)报告工作效率降低,62名(24%)最终失去工作。
  • Among survivors who were left unemployed or disabled, there was a shift from private insurance (40% to 30%) to Medicaid/Medicare (33% to 49%). 在未就业或残疾患者中,呈现私人医疗保险(40% to 30%)向Medicaid/Medicare (33% to 49%0的转变。

As a whole, the population was reasonably young. The mean age was 45 (±13) years, and only 14 (4%) were over age 65 years.

总体而言,患者人群较为年轻。平均年龄45 (±13) 岁,65岁以上患者仅有14 名(4%)。

Viewpoint 观点

Why is this study important, and what are the takeaways? First, it's part of the growing literature on post ICU ARDS outcomes published by the ARDSNet[5]and others.[6,7,8] Intensivists need to pay close attention because our day-to-day experiences offer little insight into longer-term, patient-centered outcomes. Information on the post-ICU experience might drive our clinical decision-making and family counseling sessions in new directions. Ignoring it can lead to damaging biases. As a hypothetical example, if neuromuscular blockade improves survival but leads to permanent disabilities and post-ICU posttraumatic stress disorder, we may be less likely to use it.

这项研究为何重要?其主要发现是什么?首先,这是ARDSnet及其他研究者发表的有关ARDS患者转出ICU后长期预后的诸多研究中的一项。ICU医生需要对此加以关注,因为我们每天的工作很少能够了解长期的以患者为中心的预后情况。有关ICU后的预后信息有助于我们在临床决策以及与家属讨论时采取新的视角。无视这些情况可能导致偏倚。例如,如果神经肌肉阻滞剂能够改善生存率但却导致永久的残疾和ICU创伤后应激障碍,那么我们就可能较少使用。

Second, at 12 months, most ARDS survivors suffer lingering effects from their illness. It's notable that very few of the patients studied were at retirement age (assuming 65 years old is a reasonable estimate), yet the majority was working less or not at all. The insurance burden shifted from private to public. In short, ARDS is an expensive disease with economic effects on the patient and society.

其次,在12个月随访时,多数ARDS存活者依然受到疾病的不同程度的影响。需要指出的是,研究人群极少在退休年龄(假设65岁是合理的年龄界限),然而,多数患者工作减少或根本不能工作。医疗保险负担从私人医疗保险转向公共保险。简言之,ARDS医疗费用昂贵,对患者及社会都能够造成经济负担。

Lastly, socioeconomic data are critical for measuring the impact of disease. The data quantify the true burden to the patient, which helps hospital systems and policy makers to prioritize the use of limited resources. Data should drive decision-making at the individual physician level as well. We need more data, so the AJRCCM paper[1] is a welcome addition to the literature. In summary, the ARDSNet continues to do important work.

最后,社会经济数据对于评价疾病影响非常关键。数据量化了疾病对患者的真正负担,有助于医疗系统及政策制定者优化有限资源的合理使用。数据还能够在医生水平促进决策。我们需要更多的数据,因此,这项研究是现有数据的有益补充。总之,ARDSNet仍然在继续重要的研究工作。

Abstract

References

1. Acute Respiratory Distress Syndrome Network, Brower RG, Matthay MA, et al. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000;342:1301-1308. Abstract

 

2. Yoshida T, Torsani V, Gomes S, et al. Spontaneous effort causes occult pendelluft during mechanical ventilation. Am J Respir Crit Care Med. 2013;188:1420-1427. Abstract

 

3. Cressoni M, Cadringher P, Chiurazzi C, et al. Lung inhomogeneity in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med. 2014;189:149-158. Abstract

 

4. Loring SH, Topulos GP, Hubmayr RD. Transpulmonary pressure: the importance of precise definitions and limiting assumptions. Am J Respir Crit Care Med. 2016;194:1452-1457. Abstract

 

5. Akoumianaki E, Maggiore SM, Valenza F, et al; PLUG Working Group (Acute Respiratory Failure Section of the European Society of Intensive Care Medicine). The application of esophageal pressure measurement in patients with respiratory failure. Am J Respir Crit Care Med. 2014;189:520-531. Abstract

 

6. Yoshida T, Fujino Y, Amato MB, Kavanagh BP. Fifty years of research in ARDS. Spontaneous breathing during mechanical ventilation. Risks, mechanisms, and management. Am J Respir Crit Care Med. 2017;195:985-992. Abstract

 

7. Gonzalez M, Arroliga AC, Frutos-Vivar F, et al. Airway pressure release ventilation versus assist-control ventilation: a comparative propensity score and international cohort study. Intensive Care Med. 2010;36:817-827. Abstract

 

8. Herridge MS, Tansey CM, Matté A, et al; Canadian Critical Care Trials Group. Functional disability 5 years after acute respiratory distress syndrome. N Engl J Med. 2011;364:1293-1304. Abstract

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