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Abstract Background Research suggests an association between COVID-19 infection and certain financial hardships in the shorter term and among single-state and privately insured samples. Whether COVID-19 is associated with financial hardship in the longer-term or among socially vulnerable populations is unknown. Therefore, we examined whether COVID-19 was associated with a range of financial hardships 18 months after initial infection among a national cohort of Veterans enrolled in the Veterans Health Administration (VHA)—the largest national integrated health system in the US. We additionally explored the association between Veteran characteristics and financial hardship during the pandemic, irrespective of COVID-19. Methods We conducted a prospective, telephone-based survey. Out of 600 Veterans with COVID-19 from October 2020 through April 2021 who were invited to participate, 194 Veterans with COVID-19 and 194 matched comparators without a history of infection participated. Financial hardship outcomes included overall health-related financial strain, two behavioral financial hardships (e.g., taking less medication than prescribed due to cost), and seven material financial hardships (e.g., using up most or all savings). Weighted generalized estimating equations were used to estimate risk ratios (RR) and 95% confidence intervals (CI) of financial hardship by COVID-19 status, and to assess the relationship between infection and Veteran age, VHA copay status, and comorbidity score, irrespective of COVID-19 status. Results Among 388 respondents, 67% reported at least one type of financial hardship since March 2020, with 21% reporting behavioral hardships and 64% material hardships; 8% reported severe-to-extreme health-related financial strain. Compared with uninfected matched comparators, Veterans with a history of COVID-19 had greater risks of severe-to-extreme health-related financial strain (RR: 4.0, CI: 1.4–11.2), taking less medication due to cost (RR: 2.9, 95% CI: 1.0–8.6), and having a loved one take time off work to care for them (RR: 1.9, CI: 1.1–3.6). Irrespective of COVID-19 status, Veterans aged

Background: There is limited evidence to understand what impact, if any, recovery services might have for patients across the socioeconomic spectrum after critical illness. We analysed data from a multicentre critical care recovery programme to understand the impact of this programme across the socioeconomic spectrum. Methods: The setting for this pre-planned secondary analysis was a critical care rehabilitation programme—Intensive Care Syndrome: Promoting Independence and Return to Employment. Data were collected from five hospital sites running this programme. We utilised a Bayesian approach to analysis and explore any possible effect of the InS:PIRE intervention on Health-Related Quality of Life (HRQoL) across the socioeconomic gradient. A Bayesian quantile, non-linear mixed effects regression model, using a compound symmetry covariance structure, accounting for multiple timepoints was utilised. The Scottish Index of Multiple Deprivation (SIMD) was used to measure socioeconomic status and HRQoL was measured using the EQ-5D-5L. Results: In the initial baseline cohort of 182 patients, 55% of patients were male, the median age was 58 yr (inter-quartile range: 50–66 yr) and 129 (79%) patients had two or more comorbidities at ICU admission. Using the neutral prior, there was an overall probability of intervention benefit of 100% (β=0.71, 95% credible interval: 0.34–1.09) over 12 months to those in the SIMD≤3 cohort, and an 98.6% (β=−1.38, 95% credible interval: −2.62 to −0.16) probability of greater benefit (i.e. a steeper increase in improvement) at 12 months in the SIMD≤3 vs SIMD≥4 cohort in the EQ-visual analogue scale. Conclusions: Using multicentre data, this re-analysis suggests, but does not prove, that an integrated health and social care intervention is likely to improve outcomes across the socioeconomic gradient after critical illness, with a potentially greater benefit for those from deprived communities. Future research designed to prospectively analyse how critical care recovery programmes could potentially improve outcomes across the socioeconomic gradient is warranted.

Objective: Patients who survive critical illness endure complex physical and mental health conditions, referred to as post-intensive care syndrome (PICS). The University of Michigan's post-intensive cardiac care outpatient long-term outreach (PICCOLO) clinic is designed for patients recently admitted to the coronary care unit (CCU). The long-term goal of this clinic is to understand post-CCU patients' needs and design targeted interventions to reduce their morbidity and mortality post-discharge. As a first step toward this goal, we aimed to define the post-discharge needs of CCU survivors. Design, setting, particpants: We retrospectively reviewed case-mix data (including rates of depression, PTSD, disability, and cognitive abnormalities) and health outcomes for patients referred to the PICCOLO clinic from July 1, 2018, through June 30, 2021 at Michigan Medicine. Results: Of the 134 referred patients meeting inclusion criteria, 74 (55 %) patients were seen in the PICCOLO clinic within 30 days of discharge. Patients seen in the clinic frequently screened positive for depression (PHQ-2 score ≥3, 21.4 %) and cognitive impairment (MOCA

Abstract Background Understanding how SARS-CoV-2 infection impacts long-term patient outcomes requires identification of comparable persons with and without infection. We report the design and implementation of a matching strategy employed by the Department of Veterans Affairs’ (VA) COVID-19 Observational Research Collaboratory (CORC) to develop comparable cohorts of SARS-CoV-2 infected and uninfected persons for the purpose of inferring potential causative long-term adverse effects of SARS-CoV-2 infection in the Veteran population. Methods In a retrospective cohort study, we identified VA health care system patients who were and were not infected with SARS-CoV-2 on a rolling monthly basis. We generated matched cohorts within each month utilizing a combination of exact and time-varying propensity score matching based on electronic health record (EHR)-derived covariates that can be confounders or risk factors across a range of outcomes. Results From an initial pool of 126,689,864 person-months of observation, we generated final matched cohorts of 208,536 Veterans infected between March 2020-April 2021 and 3,014,091 uninfected Veterans. Matched cohorts were well-balanced on all 37 covariates used in matching after excluding patients for: no VA health care utilization; implausible age, weight, or height; living outside of the 50 states or Washington, D.C.; prior SARS-CoV-2 diagnosis per Medicare claims; or lack of a suitable match. Most Veterans in the matched cohort were male (88.3%), non-Hispanic (87.1%), white (67.2%), and living in urban areas (71.5%), with a mean age of 60.6, BMI of 31.3, Gagne comorbidity score of 1.4 and a mean of 2.3 CDC high-risk conditions. The most common diagnoses were hypertension (61.4%), diabetes (34.3%), major depression (32.2%), coronary heart disease (28.5%), PTSD (25.5%), anxiety (22.5%), and chronic kidney disease (22.5%). Conclusion This successful creation of matched SARS-CoV-2 infected and uninfected patient cohorts from the largest integrated health system in the United States will support cohort studies of outcomes derived from EHRs and sample selection for qualitative interviews and patient surveys. These studies will increase our understanding of the long-term outcomes of Veterans who were infected with SARS-CoV-2.

Background Survivors of in‐hospital cardiac arrest (IHCA) experience ongoing physical and cognitive impairments, often requiring support from a caregiver at home afterwards. Caregivers are important in the survivor's recovery, yet there is little research specifically focused on their experiences once the survivor is discharged home. In this study, we highlight how caregivers for veteran IHCA survivors described and experienced their caregiver role, the strategies they used to fulfill their role, and the additional needs they still have years after the IHCA event. Methods and Results Between March and July 2019, semistructured telephone interviews were conducted with 12 caregivers for veteran IHCA survivors. Interviews were transcribed, and content analysis was performed. Patterns within the data were further analyzed and grouped into themes. A predominant theme of “disruption” was identified across 3 different domains including the following: (1) disruption in caregiver's life, (2) disruption in caregiver–patient relationship, and (3) disruption in caregiver's well‐being. Disruption was associated with both positive and negative caregiver experiences. Strategies caregivers used and resources they felt would have helped them adjust to their caregiver role were also identified. Conclusions Caregivers for veteran IHCA survivors experienced a disruption in many facets of their lives. Caregivers felt the veterans' IHCA impacted various aspects of their lives, and they continued to need additional support in order to care for the IHCA survivor and themselves. Although some were able to procure coping strategies, such as counseling and engaging in stress‐relieving activities, most indicated additional help and resources were still needed.

Abstract Background Evidence-based practices (EBPs) for patients receiving invasive mechanical ventilation vary in the quality of their underlying evidence and ease of implementation. Research question How do researchers and clinicians prioritize EBPs to help guide clinical decision-making and focus implementation efforts to improve patient care using existing, validated measures? Study design and methods We developed a 4-step rapid method using existing criteria to prioritize EBPs associated with lower mortality and/or shorter duration of invasive mechanical ventilation for patients suffering from acute respiratory failure or acute respiratory distress syndrome. Using different types of data including surveys, we (1) identified relevant EBPs, (2) rated EBPs using the Guideline Implementability Appraisal (GLIA) tool, (3) surveyed practicing ICU clinicians from different hospital systems using a subset of GLIA criteria, and (4) developed metrics to assess EBP performance. In this paper, we describe steps 2 and 3. Results In step 2, we prioritized 11 EBPs from an initial list of 30, using surveys and ratings among a small group of clinician researchers. In step 3, 42 clinicians from 8 different hospital systems provided assessments of these 11 EBPs which inform the final step of metric development. Interpretation Our prioritization process allowed us to identify 11 EBPs out of a larger group that clinicians perceive is most likely to help optimize invasive mechanical ventilation and improve the outcomes of this vulnerable patient population. While this method was developed in critical care related to adults receiving invasive mechanical ventilation, it is adaptable to other health contexts.

Abstract Aim We sought to explore unmet needs in transitions of care for critical illness survivors that concern primary care physicians. Findings Semi-structured interviews with primary care physicians identified three categories of concerns about unmet transition needs after patients’ ICU stays: patients’ understanding of their ICU stay and potential complications, treatments or support needs not covered by insurance, and starting and maintaining needed rehabilitation and assistance across transitions of care. Conclusion Given current constraints of access to coordinated post-ICU care, efforts to identify and address the post-hospitalization needs of critical illness survivors may be improved through coordinated work across the health system.

Abstract Background Caregivers and family members of Intensive Care Unit (ICU) survivors can face emotional problems following patient discharge from hospital. We aimed to evaluate the impact of a multi-centre integrated health and social care intervention, on caregiver and family member outcomes. Methods This study evaluated the impact of the Intensive Care Syndrome: Promoting Independence and Return to Employment (InS:PIRE) programme across 9 sites in Scotland. InS:PIRE is an integrated health and social care intervention. We compared caregivers who attended this programme with a contemporary control group of ICU caregivers (usual care cohort), who did not attend. Results The primary outcome was anxiety measured via the Hospital Anxiety and Depression Scale at 12 months post-hospital discharge. Secondary outcome measures included depression, carer strain and clinical insomnia. A total of 170 caregivers had data available at 12 months for inclusion in this study; 81 caregivers attended the InS:PIRE intervention and completed outcome measures at 12 months post-hospital discharge. In the usual care cohort of caregivers, 89 completed measures. The two cohorts had similar baseline demographics. After adjustment, those caregivers who attended InS:PIRE demonstrated a significant improvement in symptoms of anxiety (OR: 0.42, 95% CI: 0.20–0.89, p = 0.02), carer strain (OR: 0.39; 95% CI: 0.16–0.98 p = 0.04) and clinical insomnia (OR: 0.40; 95% CI: 0.17–0.77 p

Objective: To assess whether survival rates for in-hospital cardiac arrest (IHCA) vary across hospitals depending on whether resuscitations are typically led by an attending physician, a physician trainee, or a nonphysician. Patients and Methods: In 2018, we conducted a survey of hospitals participating in the national Get with the Guidelines – Resuscitation registry for IHCA. Using responses from the question “Who typically leads codes at your institution?” we categorized hospitals on the basis of who typically leads their resuscitations: attending physician, physician trainee, or nonphysician. We then compared risk-adjusted hospital rates of return of spontaneous circulation, survival to discharge, and favorable neurological survival from 2015 to 2017 between these 3 hospital groups by using multivariable hierarchical regression. Results: Overall, 193 hospitals completed the study survey, representing a total of 44,477 IHCAs (mean age, 65.0±15.5 years; 40.8% were women). Most hospitals had resuscitations led by physicians, with 121 (62.7%) led by an attending physician, 58 (30.0%) by a physician trainee, and 14 (7.3%) by a nonphysician. The risk-standardized rates of survival to discharge were similar across hospitals, regardless of whether resuscitations were typically led by an attending physician, a physician trainee, or a nonphysician (25.6%±4.8%, 25.9%±4.7%, and 25.7%±3.6%, respectively; P=.88). Similarly, there were no differences between the 3 groups in risk-adjusted rates of return of spontaneous circulation (71.7%±6.3%, 73%±6.3%, and 73.4%±6.4%; P=.30) and favorable neurological survival (21.6%±7.1%, 22.7%±6.1%, and 20.9%±6.5%; P=.50). Conclusion: In hospitals in a national IHCA registry, IHCA resuscitations were usually led by physicians. However, there was no association between a hospital’s typical resuscitation team leader credentials and IHCA survival outcomes.

Abstract Background Survivors of severe COVID-19 are at risk of impaired health-related quality of life (HRQoL) and persistent physical and psychological disability after ICU and hospital discharge. The subsequent social burden is a major concern. We aimed to assess the short-term HRQoL, physical function and prevalence of post-traumatic stress symptoms of invasively mechanically ventilated COVID-19 patients treated in our ICU. Methods Prospective, observational cohort study in a follow-up clinic. Patients completed a 6-min walking test (6MWT) to assess their cardio-pulmonary function around 2 months (early follow-up) from hospital discharge, the EQ-5D-5L questionnaire for quality of life assessment around 2 months and at 6 months from hospital discharge and an anonymous web-based Impact of Event Scale-Revised (IES-R) questionnaire for Post-Traumatic Stress symptoms at 2 months. Results 47 patients attended our follow-up program, mean age 59 ± 10 years, median pre-morbid Clinical Frailty Scale (CFS) 2 [2–3]. The median distance walked in 6 min was 470 [406–516] m, 83 [67–99]% of the predicted value. Overall 1 out 3 patients and 4/18 (22%) among those with a good functional baseline prior to COVID-19 (CFS of 1 or 2) had lower (84%) than predicted 6MWT. EQ-5D-5L quality of life VAS was 80 [70–90] out of 100 at early follow-up with a slight improvement to 85 [77.5–90] at 6 months. Mobility, self-care and usual activities improved between the two timepoints, while pain/discomfort and depression/anxiety did not improve or got worse. The IES-R total score was greater than the threshold for concern of 1.6 in 27/41(66%) respondents. Conclusions Patients recovering from severe COVID-19 requiring invasive mechanical ventilation surviving hospital discharge present with early mild to moderate functional impairment, mildly reduced quality of life from hospital discharge with an overall improvement of mobility, self-care and the ability of performing usual activities, while a worsening of pain and depression/anxiety symptoms at 6 months and a large proportion of symptoms of post-traumatic distress soon after hospital discharge.

OBJECTIVES:. Primary care providers (PCPs) receive limited information about their patients’ ICU stays; we sought to understand what additional information PCPs desire to support patients’ recovery following critical illness. DESIGN:. Semistructured interviews with PCPs conducted between September 2020 and April 2021. SETTING:. Academic health system with central quaternary-care hospital and associated Veterans Affairs medical center. SUBJECTS:. Fourteen attending internal medicine or family medicine physicians working in seven clinics across Southeast Michigan (median, 10.5 yr in practice). MAIN OUTCOMES AND MEASURES:. We analyzed using a modified Rigorous and Accelerated Data Reduction (RADaR) technique to identify gaps in current discharge summaries for patients with ICU stays, impacts of these gaps, and desired ICU-specific information. We employed RADaR to efficiently consolidate data in Excel Microsoft (Redmond, WA) tables across multiple formats (lists, themes, etc.). RESULTS:. PCPs reported receiving limited ICU-specific information in hospital discharge summaries. PCPs often spent significant time reading inpatient records for additional information. Information desired included life-support interventions provided and duration (mechanical ventilation, dialysis, etc.), reasons for treatment decisions (code status changes, medication changes, etc.), and potential complications (delirium, dysphagia, postintensive care syndrome, etc.). Pervasive discharge gaps (ongoing needs, incidental findings, etc.) were described as worse among patients with ICU stays due to more complex illness and required interventions. Insufficient information was felt to lead to incomplete follow-up on critical issues, PCP frustration, and patient harm. PCPs stated that the COVID-19 pandemic exacerbated gaps due to decreased staffing, limited visitation policies, and reliance on telehealth follow-up visits. CONCLUSIONS AND RELEVANCE:. Our results identified key data elements sought by PCPs about patients’ ICU stays and suggest opportunities to improve care through developing tools/templates to provide PCPs with ICU-specific information for outpatient follow-up.

OBJECTIVES:. Spiritual and social support may be key facilitators for critical illness recovery and are identified as high priority for research. Understanding the prevalence of spiritual and social support needs in critical illness survivors may guide development of targeted interventions for support, which, in turn, may improve critical illness survivor quality of life. To characterize unmet spiritual and social support needs in critical illness survivors approximately 1 month after hospital discharge and examine the association of these needs with postintensive care syndrome (PICS)–related symptom burden. DESIGN:. Retrospective, cross-sectional study. SETTING:. University-affiliated hospital in Pittsburgh, PA. PATIENTS:. One hundred ninety-six consecutive adult critical illness survivors seen during an initial post-ICU clinic visit from June 2018 to March 2020. INTERVENTIONS:. None. MEASUREMENTS AND MAIN RESULTS:. Patient-reported clinical outcome measures assessing spiritual and social support needs and PICS-related symptoms were extracted from the electronic health record. Patients had a median age of 61 (interquartile range [IQR], 51–68.5), and majority were male (55.1%) with a moderate comorbidity burden (Charlson comorbidity index median score, 3; IQR, 2–5). Social support and spiritual needs were prevalent. Of the 196 patients, over 50% reported unpreparedness/fearful for the future, half of patients reported not feeling in control of their care, and over one-third reported needing more support than their family, friends, or insurance can provide. Nearly 13% of respondents reported feeling abandoned or punished by God/not supported by their church/faith. Many patients reported overlapping PICS-related symptom domains (physical, psychologic, and cognitive). Univariate and multivariate analyses revealed associations between reported PICS-related symptoms and the presence of spiritual and social needs. CONCLUSIONS:. Patients surviving critical illness experience significant social support and spiritual needs independent of commonly identified manifestations of PICS. These findings support the need for formal assessment and tailored interventions for social support and spiritual needs in critical illness survivors.

In the United States, approximately 292,000 adults (>18 years old) per year suffer an in-hospital cardiac arrest (IHCA). Survival rates have increased over the last decade and many survivors return to their communities. IHCA has been recognized as a unique disease entity because the arrest happens in a medical care setting and survivors often have more medical co-morbidities. Although more individuals are surviving IHCA, very little is known about their long-term recovery experiences. Semi-structured interviews with 19 IHCA survivors were conducted to better understand their recovery experiences and identify strategies of adaptation that they felt aided their recovery. Thematic analysis indicated that IHCA survivors experience ongoing challenges to recovery. Reconceptualization of independence was necessary for some participants to re-engage in social and physical activities and a few were able to engage in new activities. Our findings suggest that IHCA survivors often develop their own strategies for adaptation in order to continue participation in their social lives and that their recovery experiences are ongoing. Intervention programs and follow-up care should continuously ask survivors what is important to them and identify resources that will support their goals. Questions should include physical, cognitive, psychological and social goals that extend beyond those specifically related to IHCA since our findings indicate that the effects of IHCA are long-lasting and encompass all aspects of survivors’ lives.

Background We examined whether key sociodemographic and clinical risk factors for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection and mortality changed over time in a population-based cohort study. Methods and findings In a cohort of 9,127,673 persons enrolled in the United States Veterans Affairs (VA) healthcare system, we evaluated the independent associations of sociodemographic and clinical characteristics with SARS-CoV-2 infection (n = 216,046), SARS-CoV-2–related mortality (n = 10,230), and case fatality at monthly intervals between February 1, 2020 and March 31, 2021. VA enrollees had a mean age of 61 years (SD 17.7) and were predominantly male (90.9%) and White (64.5%), with 14.6% of Black race and 6.3% of Hispanic ethnicity. Black (versus White) race was strongly associated with SARS-CoV-2 infection (adjusted odds ratio [AOR] 5.10, [95% CI 4.65 to 5.59], p-value Conclusions In this study, we found that strongly positive associations of Black and AI/AN (versus White) race and urban (versus rural) residence with SARS-CoV-2 infection, mortality, and case fatality observed early in the pandemic were ameliorated or reversed by March 2021. George Ioannou and co-workers study the distribution of SARS-CoV-2 infections and outcomes among the United States population. Author summary Why was this study done? As the Coronavirus Disease 2019 (COVID-19) pandemic continues to evolve, some risk factors for infection with COVID-19 and death due to COVID-19 that were described early in the pandemic may be changing. Recognizing such changes is important in informing population-based approaches to prevent infection and reduce mortality. What did the researchers do and find? We investigated how the associations of key sociodemographic and clinical factors with COVID-19 infection, mortality, or case fatality changed between February 2020 and March 2021 among a cohort of approximately 9.1 million persons enrolled in the national US Veterans Affairs (VA) healthcare system, including 216,046 who tested positive and 10,230 who died of COVID-19 during the study period. Black (versus White) race was strongly associated with a 5-fold higher risk of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection, a 4-fold higher risk of mortality, and a 2.5-fold higher risk of case fatality in February to March 2020, but these associations attenuated over time and were no longer statistically significant by November 2020 for infection and mortality and were reversed for case fatality. American Indian/Alaska Native (AI/AN versus White) race was associated with SARS-CoV-2 infection early in the pandemic, but this association declined over time and reversed by March 2021. Urban (versus rural) residence was associated with 2-fold higher risk of infection, a 2.5-fold higher risk of mortality, and 2.2-fold higher risk of case fatality in February to April 2020, but these associations attenuated over time and reversed by September 2020. Throughout the observation period, high comorbidity burden, younger age, Hispanic ethnicity, and obesity were consistently associated with infection, while high comorbidity burden, older age, Hispanic ethnicity, and male sex were consistently associated with mortality. What do these findings mean? Early in the pandemic, there were strongly positive associations of Black and AI/AN (versus White) race and urban (versus rural) residence with SARS-CoV-2 infection, mortality, and case fatality, but these were ameliorated or even reversed by March 2021. Our results apply directly to VA enrollees who are predominantly male and have access to universal healthcare; they need to be confirmed in other populations.

Shortages of equipment, medication, and staff under coronavirus disease 2019 may force hospitals to make wrenching decisions. Although bioethical guidance is available, published procedures for decision-making processes to resolve the time-sensitive conflicts are rare. Failure to establish decision-making procedures before scarcities arise exposes clinicians to moral distress and potential legal liability, entrenches existing systemic biases, and leaves hospitals without processes to guarantee transparency and consistency in the application of ethical guidelines. Formal institutional processes can reduce the panic, inequity, and irresolution that arise from confronting ethical conflicts under duress. Drawing on expertise in critical care medicine, bioethics, and political science, we propose a decision-making protocol to ensure fairness in the resolution of conflict, timely decision-making, and accountability to improve system response.

Objectives: To describe the long-term outcomes of cardiac intensive care unit patients and their primary caregivers, and to explore the feasibility of implementing a complex intervention, designed to support problems associated with post-intensive care syndrome and post-intensive care syndrome–family, in the year following discharge from the cardiac intensive care unit. Design: A complex multidisciplinary rehabilitation programme, delivered as a quality improvement initiative, in a single centre in the West of Scotland. Outcomes were measured using surveys of health related quality of life, self efficacy, anxiety, depression, pain, caregiver strain, and insomnia. Participants: Patients and their caregivers were invited to participate 12 weeks after hospital discharge. Twenty-seven patients and 23 caregivers attended the programme. Results: Over 90% of patients had problems in at least one quality of life domain at baseline, 41% of patients had symptoms of anxiety and 22% had symptoms of depression. During the baseline visit, caregiver strain was present in 20% of caregivers, 57% had symptoms of anxiety, and 35% had symptoms of depression. Improvements in outcomes were seen in both patients and caregivers at 1-year follow-up. The programme was implemented, and iterative learning obtained about the content and the operationalization of the service, in order to understand feasibility. Conclusion: This small-scale quality improvement project has demonstrated that this complex multidisciplinary rehabilitation programme is feasible and has positive implications for patients following discharge from the cardiac intensive care unit, and their caregivers.

Abstract Background To study patient physiology throughout a period of acute hospitalization, we sought to create accessible, standardized nationwide data at the level of the individual patient-facility-day. This methodology paper summarizes the development, organization, and characteristics of the Veterans Affairs Patient Database 2014–2017 (VAPD 2014–2017). The VAPD 2014–2017 contains acute hospitalizations from all parts of the nationwide VA healthcare system with daily physiology including clinical data (labs, vitals, medications, risk scores, etc.), intensive care unit (ICU) indicators, facility, patient, and hospitalization characteristics. Methods The VA data structure and database organization represents a complex multi-hospital system. We define a single-site hospitalization as one or more consecutive stays with an acute treating specialty at a single facility. The VAPD 2014–2017 is structured at the patient-facility-day level, where every patient-day in a hospital is a row with separate identification variables for facility, patient, and hospitalization. The VAPD 2014–2017 includes daily laboratory, vital signs, and inpatient medication. Such data were validated and verified through lab value range and comparison with patient charts. Sepsis, risk scores, and organ dysfunction definitions were standardized and calculated. Results We identified 565,242 single-site hospitalizations (SSHs) in 2014; 558,060 SSHs in 2015; 553,961 SSHs in 2016; and 550,236 SSHs in 2017 at 141 VA hospitals. The average length of stay was four days for all study years. In-hospital mortality decreased from 2014 to 2017 (1.7 to 1.4%), 30-day readmission rates increased from 15.3% in 2014 to 15.6% in 2017; 30-day mortality also decreased from 4.4% in 2014 to 4.1% in 2017. From 2014 to 2017, there were 107,512 (4.8%) of SSHs that met the Center for Disease Control and Prevention’s Electronic Health Record-based retrospective definition of sepsis. Conclusion The VAPD 2014–2017 represents a large, standardized collection of granular data from a heterogeneous nationwide healthcare system. It is also a direct resource for studying the evolution of inpatient physiology during both acute and critical illness.

Objectives:. To understand the unmet needs of caregivers of ICU survivors, how they accessed support post ICU, and the key components of beneficial ICU recovery support systems as identified from a caregiver perspective. Design:. International, qualitative study. Subjects:. We conducted 20 semistructured interviews with a diverse group of caregivers in the United States, the United Kingdom, and Australia, 11 of whom had interacted with an ICU recovery program. Setting:. Seven hospitals in the United States, United Kingdom, and Australia. Interventions:. None. Measurements and Main Results:. Content analysis was used to explore prevalent themes related to unmet needs, as well as perceived strategies to improve ICU outcomes. Post-ICU care was perceived to be generally inadequate. Desired caregiver support fell into two main categories: practical support and emotional support. Successful care delivery initiatives included structured programs, such as post discharge telephone calls, home health programs, post-ICU clinics, and peer support groups, and standing information resources, such as written educational materials and online resources. Conclusions:. This qualitative, multicenter, international study of caregivers of critical illness survivors identified consistently unmet needs, means by which caregivers accessed support post ICU, and several care mechanisms identified by caregivers as supporting optimal ICU recovery.

Objectives:. Many clinicians have implemented follow-up and aftercare to support patients following ICU. Some of this care is supported and facilitated by peer volunteers. There is limited contemporary work that has explicitly explored volunteer roles within ICU recovery services or the experience of volunteers undertaking these roles. We sought to explore the experience of survivors of critical illness, as volunteers, involved in ICU recovery services and understand their motivation for undertaking these roles. Design:. Qualitative exploration using in-depth semistructured interviews. The study design used an inductive content analysis process. We also documented the roles that were adopted by volunteers in each site involved in the study. Setting:. Patients and caregivers were sampled from seven sites across three continents. Patients and Subjects:. Patients and caregivers who had adopted peer-volunteering roles were undertaken. Interventions:. None. Measurements and Main Results:. Twelve patient and caregiver peer volunteers were interviewed. Four key themes were identified. These themes related to the experience of volunteers within ICU recovery services and their motivation for undertaking these roles: 1) self-belief and acceptance, 2) developing peer support, 3) social roles and a sense of purpose, and 4) giving back. Overwhelmingly, participants were positive about the role of the volunteer in the critical care setting. Conclusions:. Peer volunteers undertake a variety of roles in ICU recovery services and during recovery more generally. These roles appear to be of direct benefit to those in these roles. Future research is needed to develop these roles and fully understand the potential impact on the service, including the impact on other patients.

Abstract Background Many randomized controlled trials (RCTs) employ mortality at a given time as a primary outcome. There are at least three common ways to measure 90-day mortality: first, all-location mortality, that is, all-cause mortality within 90 days of randomization at any location. Second, ARDSnet mortality is death in a healthcare facility of greater intensity than the patient was in prior to the hospitalization during which they were randomized. Finally, in-hospital mortality is death prior to discharge from the primary hospitalization of randomization. Data comparing the impact of these different measurements on sample size are lacking. We evaluated the extent to which event rates vary by mortality definition. Methods This was a retrospective cohort study of 30,691 patients hospitalized at Veterans Affairs (VA) hospitals for sepsis during 2009. 12,727 (41.5%) received care in an ICU setting. For each patient, we measured event rates for three different 90-day mortality outcomes: all-location mortality, ARDSnet mortality, and in-hospital mortality. We also calculated sample sizes necessary to power an example RCT given those event rates. Results At 90 days, all-location mortality was 26.4% (95% CI 25.9–26.9%), ARDSnet mortality was 19.2% (95% CI 18.8–19.7%), and in-hospital mortality was 13.4% (95% CI 13.0–13.8%) (p < 0.01 all comparisons). These respective event rates result in different required sample sizes to achieve a 20% relative reduction in mortality with 80% power and a 5% false positive rate. Such a trial of VA sepsis patients would require 2080 patients for all-location mortality, 3080 for ARDSnet mortality, and 4796 for in-hospital mortality. Among sepsis patients mechanically ventilated in an ICU, 2438 experienced all-location mortality (46.2% [95% CI 44.8–47.5%]), 2181 experienced ARDSnet mortality (41.3% [95% CI 40.0–42.6%]), and 1894 experienced in-hospital mortality (36.0% [95% CI 34.7–37.3%]). Conclusions Event rates vary substantially in sepsis patients based on the chosen 90-day mortality definition. This could have important implications for RCT design trade-offs.

Abstract In this review, we seek to highlight how critical illness and critical care affect longer-term outcomes, to underline the contribution of ICU delirium to cognitive dysfunction several months after ICU discharge, to give new insights into ICU acquired weakness, to emphasize the importance of value-based healthcare, and to delineate the elements of family-centered care. This consensus of 29 also provides a perspective and a research agenda about post-ICU recovery.

Abstract Background Connected individuals (or nodes) in a network are more likely to be similar than two randomly selected nodes due to homophily and/or network influence. Distinguishing between these two influences is an important goal in network analysis, and generalized estimating equation (GEE) analyses of longitudinal dyadic network data are an attractive approach. It is not known to what extent such regressions can accurately extract underlying data generating processes. Therefore our primary objective is to determine to what extent, and under what conditions, does the GEE-approach recreate the actual dynamics in an agent-based model. Methods We generated simulated cohorts with pre-specified network characteristics and attachments in both static and dynamic networks, and we varied the presence of homophily and network influence. We then used statistical regression and examined the GEE model performance in each cohort to determine whether the model was able to detect the presence of homophily and network influence. Results In cohorts with both static and dynamic networks, we find that the GEE models have excellent sensitivity and reasonable specificity for determining the presence or absence of network influence, but little ability to distinguish whether or not homophily is present. Conclusions The GEE models are a valuable tool to examine for the presence of network influence in longitudinal data, but are quite limited with respect to homophily.