Quality of life before intensive care using EQ-5D: patient versus proxy responses.

OBJECTIVE: To compare patients' retrospectively reported baseline quality of life before intensive care hospitalization with population norms and proxy reports. DESIGN: Prospective cohort study. SETTING: Thirteen ICUs at four teaching hospitals in Baltimore, MD. PATIENTS: One hundred forty acute lung injury survivors and their designated proxies. INTERVENTIONS: Around the time of hospital discharge, both patients and proxies were asked to retrospectively estimate patients' baseline quality of life before hospital admission using the EQ-5D quality-of-life instrument. MEASUREMENTS AND MAIN RESULTS: Mean patient-rated EQ-5D visual analog scale scores and utility scores were significantly lower than population norms but were significantly higher than proxy ratings. However, the magnitude of difference in average utility scores between patients and either population norms or proxies was not clinically important. For the five individual EQ-5D domains, κ statistics revealed slight to fair agreement between patients and proxies. Bland-Altman plots demonstrated that for both the visual analog scale and utility scores, proxies underestimated scores when patients reported high ratings and overestimated scores for low patient ratings. CONCLUSIONS: Patients retrospectively reported worse baseline health status before acute lung injury than population norms and better status than proxy reports; however, the magnitude of these differences in health status may not be clinically important. Proxies had only slight to fair agreement with patients in all five EQ-5D domains, attenuating patients' more extreme ratings toward moderate scores. Caution is required when interpreting proxy retrospective reports of baseline health status for survivors of acute lung injury.

The functional comorbidity index had high inter-rater reliability in patients with acute lung injury.

BACKGROUND: The Functional Comorbidity Index (FCI) was recently developed to predict physical function in acute lung injury patients using comorbidity data. Our objectives were to determine: (1) the inter-rater reliability of the FCI collected using in-patient discharge summaries (primary objective); and (2) the accuracy and predictive validity of the FCI collected using hospital discharge summaries and admission records versus complete chart review (secondary objectives). METHODS: For reliability, we evaluated the FCI's intraclass correlation coefficient (ICC) among trained research staff performing data collection for 421 acute lung injury patients enrolled in a prospective cohort study. For validity and accuracy, we compared the detection of FCI comorbidities across three types of inpatient medical records, and the association of the respective FCI scores obtained with patients' SF-36 physical function subscale (PFS) scores at 1-year follow-up. RESULTS: Inter-rater reliability was near-perfect (ICC 0.91; 95% CI 0.89-0.94). Hospital admission records and discharge summaries (vs. complete chart review) significantly underestimated the total FCI score. However, using multivariable linear regression, FCI scores collected using each of the three types of inpatient medical records had similar associations with PFS, suggesting similar predictive value. CONCLUSIONS: Data collection using in-patient discharge summaries represents a reliable and valid method for collecting FCI comorbidity information.

Baseline quality of life before intensive care: a comparison of patient versus proxy responses.

OBJECTIVE: To compare acute lung injury patients' self-reported, retrospective baseline quality of life before their intensive care hospitalization with population norms and retrospective proxy estimates. DESIGN: Prospective cohort study using the Short Form 36 quality-of-life survey. SETTING: Thirteen intensive care units at four teaching hospitals in Baltimore, Maryland. PATIENTS: One hundred thirty-six acute lung injury survivors and their designated proxies. INTERVENTIONS: Both patients and proxies were asked to estimate patient baseline quality of life before hospital admission using the Short Form 36 survey. MEASUREMENTS AND MAIN RESULTS: Compared with population norms, quality-of-life scores were lower in acute lung injury patients across all eight domains, but the difference was significantly greater than the minimum clinically important difference in only two of eight domains (Physical Role and General Health). The mean paired difference between patient and proxy responses revealed no clinically important difference. However, kappa statistics demonstrated only fair to moderate agreement for all domains. Bland-Altman analysis revealed that, for all domains, proxies tended to overestimate quality of life when patient scores were low and underestimate the quality of life when patient scores were high. CONCLUSION: Retrospective assessment of quality of life before hospitalization revealed that acute lung injury patients' scores were consistently lower than population norms, but the magnitude of this difference may not be clinically important. Proxy assessments had only fair to moderate agreement with patient assessments. Across all eight Short Form 36 quality-of-life domains, proxy responses represented an attenuation of patient quality-of-life estimates.

Depression in general intensive care unit survivors: a systematic review.

PURPOSE: To critically review data on the prevalence of depressive symptoms in general intensive care unit (ICU) survivors, risk factors for these symptoms, and their impact on health-related quality of life (HRQOL). METHODS: We conducted a systematic review using Medline, EMBASE, Cochrane Library, CINAHL, PsycINFO, and a hand-search of 13 journals. RESULTS: Fourteen studies were eligible. The median point prevalence of "clinically significant" depressive symptoms was 28% (total n = 1,213). Neither sex nor age were consistent risk factors for post-ICU depression, and severity of illness at ICU admission was consistently not a risk factor. Early post-ICU depressive symptoms were a strong risk factor for subsequent depressive symptoms. Post-ICU depressive symptoms were associated with substantially lower HRQOL. CONCLUSIONS: Depressive symptoms are common in general ICU survivors and negatively impact HRQOL. Future studies should address how factors related to individual patients, critical illness and post-ICU recovery are associated with depression in ICU survivors.

Posttraumatic stress disorder in general intensive care unit survivors: a systematic review.

OBJECTIVE: Our objective was to summarize and critically review data on the prevalence of posttraumatic stress disorder (PTSD) in general intensive care unit (ICU) survivors, risk factors for post-ICU PTSD and the impact of post-ICU PTSD on health-related quality of life (HRQOL). METHODS: We conducted a systematic literature review using Medline, EMBASE, Cochrane Library, CINAHL, PsycINFO and a hand-search of 13 journals. RESULTS: Fifteen studies were eligible. The median point prevalence of questionnaire-ascertained "clinically significant" PTSD symptoms was 22% (n=1,104), and the median point prevalence of clinician-diagnosed PTSD was 19% (n=93). Consistent predictors of post-ICU PTSD included prior psychopathology, greater ICU benzodiazepine administration and post-ICU memories of in-ICU frightening and/or psychotic experiences. Female sex and younger age were less consistent predictors, and severity of critical illness was consistently not a predictor. Post-ICU PTSD was associated with substantially lower HRQOL. CONCLUSIONS: The prevalence of PTSD in ICU survivors is high and negatively impacts survivors' HRQOL. Future studies should comprehensively address how patient-specific factors (e.g., pre-ICU psychopathology), ICU management factors (e.g., administration of sedatives) and ICU clinical factors (e.g., in-ICU delirium) relate to one another and to post-ICU PTSD. Clinicians caring for the growing population of ICU survivors should be aware of PTSD risk factors and monitor patients' needs for early intervention.