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Risk Factors for 1-Year Mortality and Hospital Utilization Patterns in Critical Care Survivors

A Retrospective, Observational, Population-Based Data Linkage Study*

Szakmany, Tamas, MD, PhD, EDIC, DESA, FRCA, FFICM1; Walters, Angharad M., MSc2; Pugh, Richard, FRCA, FFICM3; Battle, Ceri, PhD4; Berridge, Damon M., PhD2; Lyons, Ronan A., MD2

doi: 10.1097/CCM.0000000000003424
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Objectives: Clear understanding of the long-term consequences of critical care survivorship is essential. We investigated the care process and individual factors associated with long-term mortality among ICU survivors and explored hospital use in this group.

Design: Population-based data linkage study using the Secure Anonymised Information Linkage databank.

Setting: All ICUs between 2006 and 2013 in Wales, United Kingdom.

Patients: We identified 40,631 patients discharged alive from Welsh adult ICUs.

Interventions: None.

Measurements and Main results: Primary outcome was 365-day survival. The secondary outcomes were 30- and 90-day survival and hospital utilization in the 365 days following ICU discharge. Kaplan-Meier curves were plotted to compare survival rates. Cox proportional hazards regression models were used to determine risk factors of mortality. Seven-thousand eight-hundred eighty-three patients (19.4%) died during the 1-year follow-up period. In the multivariable Cox regression analysis, advanced age and comorbidities were significant determinants of long-term mortality. Expedited discharge due to ICU bed shortage was associated with higher risk. The rate of hospitalization in the year prior to the critical care admission was 28 hospitalized days/1,000 d; post critical care was 88 hospitalized days/1,000 d for those who were still alive; and 57 hospitalized days/1,000 d and 412 hospitalized days/1,000 d for those who died by the end of the study, respectively.

Conclusions: One in five ICU survivors die within 1 year, with advanced age and comorbidity being significant predictors of outcome, leading to high resource use. Care process factors indicating high system stress were associated with increased risk. More detailed understanding is needed on the effects of the potentially modifiable factors to optimize service delivery and improve long-term outcomes of the critically ill.

1Division of Population Medicine, Department of Anaesthesia, Intensive Care and Pain Medicine, Cardiff University, Heath Park Campus, Cardiff, United Kingdom.

2Health Data Research UK, Swansea University Medical School, Data Science Building, Swansea, United Kingdom.

3Department of Anaesthetic, Glan Clywdd Hospital, Betsi Cadwaladar University Health Board, Bodelwyddan, Rhyl, United Kingdom.

4Morriston Hospital, Abertawe Bro Morgannwg University Health Board, Heol Maes Eglwys, Swansea, United Kingdom.

*See also p. 121.

Drs. Szakmany and Walters contributed equally to the article.

Dr. Szakmany conceived and supervised the study, performed data interpretation, and developed the article. Dr. Walters extracted data, performed data analysis, and developed the article. Dr. Pugh conceived the study, performed data interpretation, and provided input on article development. Dr. Battle provided input on data interpretation, helped write the article, and provided critical input on its revisions. Dr. Berridge performed data analysis and provided critical input on article revisions. Dr. Lyons supervised the study, provided input on data interpretation, helped write the article, and provided critical input on its revisions.

A data visualization tool associated with this article can be viewed here: https://lippincott.shinyapps.io/WelshStudy2/.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).

Supported, in part, by a grant from the Critical Illness Implementation Group, Welsh Assembly Government.

Presented, in part, at the 46th Critical Care Congress, Honolulu, HI, January 21–25, 2017.

Drs. Szakmany’s and Pugh’s institution received funding from the Critical Illness Implementation Group, Welsh Assembly Government. Dr. Szakmany’s institution also received funding from a Medical research Council Developmental Pathway Funding Scheme Grant, a patent pending on biomarker panels for sepsis, Fiona Elizabeth Agnew Trust (Fiona Elizabeth Agnew Trust – Understanding, Research and Education about Sepsis Awards Award), Welsh Intensive Care Society Research Grant, and the Society of Critical Care Medicine (travel). He received funding from Couton Mutton Diagnostics Ltd, and disclosed that he is one of the Clinical Leads of the All Wales Critical Care and Trauma Network, which oversees the strategic development of critical care services in Wales. Dr. Walters’ institution received funding from the Farr Institute Centre for Improvement of Population Health through E-records Research, which is supported by a 10- funder consortium: Arthritis Research UK, the British Heart Foundation, Cancer Research UK, the Economic and Social Research Council, the Engineering and Physical Sciences Research Council, the Medical Research Council, the National Institute of Health Research, the National Institute for Social Care and Health Research (Welsh Assembly Government), the Chief Scientist Office (Scottish Government Health Directorates), and the Wellcome Trust (MRC Grant No: MR/K006525/1). Dr. Pugh’s institution also received funding from Clinical Research Time Award, Health and Social Services Group, Welsh Government. Dr. Lyons’ institution received funding from National Health Service Wales, Medical Research Council, Economic and Social Research Council, Engineering and Physical Sciences Research Council, British Heart Foundation, Wellcome Trust, National Institute of Health Research, Welsh Government, and he received support for article research from Wellcome Trust/Charity Open Access Fund and Research Councils UK. The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: szakmanyt1@cardiff.ac.uk

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