Medical and Economic Implications of Prolonged Mechanical Ventilation and Expedited Post–Acute Care

Abstract

This article describes the increasingly common phenomenon of prolonged mechanical ventilation in the context of the transition between the acute care hospital and post–acute care. Prolonged mechanical ventilation or chronic critical illness is associated with hospital mortality in the range of 20 to 40%, with median hospital length of stay ranging from 14 to 60 days. Fewer than 10% of patients are discharged home, and most hospital survivors require institutionalized post–acute care in the form of long-term acute care, skilled nursing facilities, or inpatient rehabilitation. Acute hospital readmission is common. Because of prolonged functional disabilities and multiple underlying comorbid conditions, overall 1 year mortality for prolonged mechanical ventilation patients ranges from 50 to 60%. Survivors experience significant functional limitations. The prolonged institutional care and poor long-term outcomes of these patients bring into question the cost-effectiveness of prolonged mechanical ventilation after acute illness, especially for patients with poor long-term prognoses. New measures to facilitate assessments of long-term prognosis and improve communication with surrogate decision makers may reduce the amount of ineffective care for some patients requiring prolonged mechanical ventilation.

Keywords

prolonged mechanical ventilation - prognosis - health care costs

• References

• 1 Nelson JE, Cox CE, Hope AA, Carson SS. Chronic critical illness. Am J Respir Crit Care Med 2010; 182 (4) 446-454
• 2 Hall WB, Willis LE, Medvedev S, Carson SS. The implications of long-term acute care hospital transfer practices for measures of in-hospital mortality and length of stay. Am J Respir Crit Care Med 2012; 185 (1) 53-57
• 3 Unroe M, Kahn JM, Carson SS , et al. One-year trajectories of care and resource utilization for recipients of prolonged mechanical ventilation: a cohort study. Ann Intern Med 2010; 153 (3) 167-175
• 4 MedPAC. Post–Acute Care: Healthcare Spending and the Medicare System. Washington, DC: MedPAC; 2009
• 5 Seneff MG, Wagner D, Thompson D, Honeycutt C, Silver MR. The impact of long-term acute-care facilities on the outcome and cost of care for patients undergoing prolonged mechanical ventilation. Crit Care Med 2000; 28 (2) 342-350
• 6 MedPAC. Report to Congress: Medicare Payment Policy. Washington, DC: MedPAC; 2010
• 7 Berenson A. Long-term care hospitals face little scrutiny. The New York Times. February 9, 2010
• 8 Kahn JM, Benson NM, Appleby D, Carson SS, Iwashyna TJ. Long-term acute care hospital utilization after critical illness. JAMA 2010; 303 (22) 2253-2259
• 9 Nelson JE, Cox CE, Hope AA, Carson SS. Chronic critical illness. Am J Respir Crit Care Med 2010; 182 (4) 446-454
• 10 Fletcher SN, Kennedy DD, Ghosh IR , et al. Persistent neuromuscular and neurophysiologic abnormalities in long-term survivors of prolonged critical illness. Crit Care Med 2003; 31 (4) 1012-1016
• 11 Nelson JE, Tandon N, Mercado AF, Camhi SL, Ely EW, Morrison RS. Brain dysfunction: another burden for the chronically critically ill. Arch Intern Med 2006; 166 (18) 1993-1999
• 12 Kalb TH, Lorin S. Infection in the chronically critically ill: unique risk profile in a newly defined population. Crit Care Clin 2002; 18 (3) 529-552
• 13 Angus DC, Linde-Zwirble WT, Lidicker J, Clermont G, Carcillo J, Pinsky MR. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med 2001; 29 (7) 1303-1310
• 14 Cox CE, Carson SS, Govert JA, Chelluri L, Sanders GD. An economic evaluation of prolonged mechanical ventilation. Crit Care Med 2007; 35 (8) 1918-1927
• 15 Halpern NA, Pastores SM, Greenstein RJ. Critical care medicine in the United States 1985-2000: an analysis of bed numbers, use, and costs. Crit Care Med 2004; 32 (6) 1254-1259
• 16 Oye RK, Bellamy PE. Patterns of resource consumption in medical intensive care. Chest 1991; 99 (3) 685-689
• 17 Services CfMaM. Overview of the prospective payment system. 2009. http://www.cms.hhs.gov/ProspMedicareFeeSvcPmtGen . Accessed November 12, 2009
• 18 International R. Post-acute care payment reform demonstration. 2009. http://www.pacdemo.rti.org/ . Accessed November 12, 2009
• 19 Cox CE, Carson SS, Holmes GM, Howard A, Carey TS. Increase in tracheostomy for prolonged mechanical ventilation in North Carolina, 1993-2002. Crit Care Med 2004; 32 (11) 2219-2226
• 20 Zilberberg MD, de Wit M, Pirone JR, Shorr AF. Growth in adult prolonged acute mechanical ventilation: implications for healthcare delivery. Crit Care Med 2008; 36 (5) 1451-1455
• 21 Cohen IL, Lambrinos J, Fein IA. Mechanical ventilation for the elderly patient in intensive care: incremental changes and benefits. JAMA 1993; 269 (8) 1025-1029
• 22 Hamel MB, Phillips RS, Davis RB , et al. Outcomes and cost-effectiveness of ventilator support and aggressive care for patients with acute respiratory failure due to pneumonia or acute respiratory distress syndrome. Am J Med 2000; 109 (8) 614-620
• 23 Covinsky KE, Goldman L, Cook EF , et al; SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment. The impact of serious illness on patients' families. JAMA 1994; 272 (23) 1839-1844
• 24 Neumann PJ, Rosen AB, Weinstein MC. Medicare and cost-effectiveness analysis. N Engl J Med 2005; 353 (14) 1516-1522
• 25 Luce JM. End-of-life decision making in the intensive care unit. Am J Respir Crit Care Med 2010; 182 (1) 6-11
• 26 Esserman L, Belkora J, Lenert L. Potentially ineffective care: a new outcome to assess the limits of critical care. JAMA 1995; 274 (19) 1544-1551
• 27 Piers RD, Azoulay E, Ricou B , et al; APPROPRICUS Study Group of the Ethics Section of the ESICM. Perceptions of appropriateness of care among European and Israeli intensive care unit nurses and physicians. JAMA 2011; 306 (24) 2694-2703
• 28 Cox CE, Martinu T, Sathy SJ , et al. Expectations and outcomes of prolonged mechanical ventilation. Crit Care Med 2009; 37 (11) 2888-2894 , quiz 2904
• 29 Carson SS, Kahn JM, Hough CL , et al. A multicenter mortality prediction model for patients receiving prolonged mechanical ventilation. Crit Care Med 2012; 40 (4) 1171-1176
• 30 Scheunemann LP, McDevitt M, Carson SS, Hanson LC. Randomized, controlled trials of interventions to improve communication in intensive care: a systematic review. Chest 2011; 139 (3) 543-554
• 31 Kandilov AMG, Dalton K, International R. Utilization and Payment Effects of Medicare Referrals to Long-Term Care Hospitals: Final Report for the Centers for Medicare and Medicaid Services. Research Triangle Park, NC: RTI International; 2011