PATIENT-CENTERED OUTCOMES PROGNOSTICATION IN INTENSIVE CARE UNIT PATIENTS (PCOPS)

Transcription

1 PATIENT-CENTERED OUTCOMES PROGNOSTICATION IN INTENSIVE CARE UNIT PATIENTS (PCOPS) Isabella Ciuffetelli SUMR 2014 Mentors: Scott Halpern, MD, PhD, MBE Elizabeth Cooney, MPH

2 AGENDA I. Overview II. Significance III. Aims of the PCOPS Study IV. Study Design V. My Role VI. Qualitative Data Analysis a) Methods b) Preliminary Findings VII. Lessons Learned

3 I. OVERVIEW When patients are admitted to the intensive care unit (ICU), they and their families are concerned about the patient s short and long-term prognosis. A prognosis is provided to achieve appropriate expectations and help make decisions for immediate clinical care. Expected effectiveness of ICU interventions. Patient s previously expressed wishes. Understanding of likely outcomes Wish to pursue aggressive therapies Mortality Functional Morbidity Patient s quality of life Caregiving needs

4 II. SIGNIFICANCE Currently, the literature includes several markers of severity of illness (APACHE, MPM) that are primarily used for benchmarking in research rather than for routine clinical practice and decision-making. Not considered to be accurate enough for individual decision-making. They predict mortality, length of stay or nursing workload, which may not be the most important outcomes of interest.

5 II. SIGNIFICANCE Families want to know if patients will survive with significant functional impairment, increased caregiver requirements or an inability to return to their original place of residence. Over the past 20 years, as a result of improvements in survival of ICU syndromes, research in critical care has evolved with an increased focus on these outcome measures. BUT research in prognostication has not kept pace with this shift in ICU survivorship.

6 II. SIGNIFICANCE The ability of ICU clinicians to predict functional outcomes is unknown.

7 III. AIMS Measure clinician s ability to predict 6-month functional outcomes in patients admitted in the ICU who require some degree of life support. Compare agreement on prognosis of long-term functional outcomes between ICU attending physician and bedside nurse involved in the care of the same ICU patient. Identify which pieces of information clinicians consider most important when explaining how they came to conclude their predicted 6-month functional outcomes.

8 IV. STUDY DESIGN Prospective cohort study evaluating 6-month functional outcomes of patients from 5 different ICUs in the Penn Med System. I. Informed Consent & Baseline Data: Patient demographics Premorbid functional status ICU and hospital data II. Prognostic Assessments: Mortality In-hospital 6 months Functional Outcomes Return to place of residence Return to work/primary pastime Toileting Ambulation Cognition Quality of life III. Follow-Up: Mortality Perceived functional outcomes ICU Admission ICU 3-6 days 6 months after Discharge ICU Admission

9 V. MY ROLE Called patients to obtain 6-month follow up data on patients perceived cognitive and functional outcomes. Qualitative data analysis. Identifying which pieces of information clinicians consider most important when explaining how they came to conclude their predicted 6-month functional outcomes.

10 Methods Evaluated clinicians responses on the information they deemed the most important in devising their prognosis. Created standardized variables to capture specific concepts in the clinician s answers. Generated free-lists for each of the clinician s responses using the standardized variables.

11 Example Our study would like to understand how you arrived at your judgments as they relate to survival and function 6 months from now. Using single words or phrases, please list all of the factors you considered to come to these conclusions. wheelchair bound, chronic use of alcohol and sedataive hypnotics, acute PNA and severe sepsis baseline physical functional status behavioral acute clinical conditions

12 Meta themes, variables and associated key words Originally identified 27 different variables, which were ultimately lumped together in 23 unique variables and 7 different meta-themes.

13 Meta themes, variables and associated key words Variable( Explanation( Key(Words( Code( B. HOSPITAL(TRAJECTORY,(CLINICAL(CONDITION(AND(FORSEEABLE(COMPLICATIONS(IN(CARE( Practitioner*mentions* labs*and*imaging*results,*severity*of* acuteclinical* 4.(Acute(Conditions( patient s*current*clinical* illness,*acute*injury,*vital*signs*are* conditions.* stable,*icu*syndromes,*multi=organ* failure,*fever,*intubated,*on* 5.(Diagnosis( 6.(Hospital(Course( 7.(Current( Functional(Status(( 8.(Anticipated( Potential( Complications(! Practitioner*mentions*the* primary*reason*for*the* patient s*admission.* Practitioner*refers*to*the* patient s*improvement*or* deterioration*during*the* hospital*stay.* Practitioner*mentions*the* patient s*current*functional* status*and*abilities*to* perform*adls.* Practitioner*mentions* complications*that*may*arise* in*the*future*given*the* patient s*current*condition* vasopressors,*current*mental*status( underlying*disease,*primary* diagnosis,*underlying*diagnosis,* pathophysiology,*non*terminal* illness,*current*illness* length*of*stay,*trajectory,* complications,*deconditioning,* resilient,*wean*on*ventilator* ability*to*toilet,*immobility,*current* functional*status,*claudication,* strength,*mobility* at*risk*for,*foreseeable*complications* for,*will*need* rehab/dialysis/tracheostomy* diagnosis* trajectory* funcstatus* apcomplications*

14 Meta themes, variables and associated key words Variable( Explanation( Key(Words( Code( C. PAST(MEDICAL(HISTORY(AND(HEALTHCARE(UTILIZATION( Practitioner*mentions*past* COPD,*chronic*critical*illness,* medhistory* 9.(Medical(History( medial*history*or*specific* malnutrition,*amputations,*arthritis,* and(cogmorbidities( premorbid*conditions.* chronic*heart*failure,*peripheral* vascular*disease,*chronic*kidney* disease,*dialysis*dependency,* previous*transplant,*past*medical* 10.(Cancer( Practitioner*mentions*that* the*patient*has*cancer.* history,*obesity,*premorbid*obesity* cancer,*metastatic*cancer,*aml,* malignancy,*lymphoma* cancer* 11.(Readmissions(! Practitioner*mentions*that* the*patient*has*been* previously*admitted*to*the* hospital.* Previous*hospital*admissions* readmissions*

15 Meta themes, variables and associated key words Variable( Explanation( Key(Words( Code( D. SOCIAL,(BEHAVIORAL,(PSYCHOLOGIC(AND(DEMOGRAPHIC(FACTORS( 12.(Social(Support( 13.(Behavioral( Factors( 14.(Psychological( Factors( 15.(Age(! Practitioner*mentions* patient s*social*support* mechanisms.* Practitioner*mentions* patient s*lifestyle*and* behaviors.* Practitioner*mentions* psychological*factors* affecting*the*patient.* Practitioner*mentions*the* patient s*age.* social*challenges,*support*system,* family,*friends! substance*abuse,*active/inactive* lifestyle,*diet,*compliance*with* treatment,*smoking,*engaged*with* medical*care,*motivation,*self=care! depression,*anxiety* young,*advanced*age,*elderly* social* behavioral* psychology* age*

16 Meta themes, variables and associated key words Variable( Explanation( Key(Words( Code( E. THERAPIES,(TREATMENTS(AND(MEDICAL(PROCEDURES( 16.(Procedures( 17.(Definitive( Treatment( 18.(Medication(! Practitioner*mentions* specific*surgical*procedures.! Practitioner*mentions* undergoing*medical* treatments*necessary*for*the* patient s*acute*recovery*or* survival.* Practitioner*mentions*the* medications*the*patient*is* currently*on.* invasive*procedure,*embolization,* surgery,*debridement,*hip* replacement,*recent*transplant* experimental*medical*trial,*antibiotic* therapy,*need*for*transplant,*bone* marrow*pending,*chemotherapy* current*medications,*iv*drips,*hiv/bp* medications* procedure* treatment* medications*

17 Meta themes, variables and associated key words Variable( Explanation( Key(Words( Code( F. CLINICIAN S(EXPERIENCES(AND(INTERACTIONS(WITH(PATIENT(&(OTHER(CLINICIANS( Practitioner*mentions*his* other*patients *outcomes,*personal* experience* 19.(Clinician s( previous*experiences*with* experience,*expertise,*research*data,* previous(experience( 20.(Clinician s( interactions(with( the(patient( 21.(Interdisciplinary( interactions( between(clinicians(! similar*patients.* Practitioner*mentions*his* previous*and*current* interactions*with*the*patient.* Practitioner*mentions*other* doctor s*or*the*nurse s*input.* knowledge*of*literature* practitioner*had*conversation*with* patients,*knew*patient*from*before,* family s*statements* MD*input,*mention*of*rounds* interactions* doctorinput* *

18 Meta themes, variables and associated key words Variable( Explanation( Key(Words( Code( G. PREFERENCE(FOR(PALLIATIVE(VS.(AGGRESSIVE(CARE( Practitioner*mentions*that* deny*aggressive*treatment,* palliative* 22.(Palliative( patient*or*family*are*not* considering*palliation* approach( inclined*to*continue* aggressive*treatment.* Practitioner*mentions*that* committed*to*aggressive*care* agressivecare* 23.(Aggressive(Care( patient*or*family*are*inclined* to*continue*aggressive* treatment.*!

19 Findings: Frequency of Variables by Type of Clinician MD RN Rank Variable Variable 1 acuteclinical 24.5% acuteclinical 22.1% 2 medhistory 12.1% trajectory 12.3% 3 trajectory 10.5% medhistory 11.6% 4 diagnosis 6.4% behavioral 5.9% 5 age 5.8% age 5.2% 6 basefunc1on 5.6% experience 4.3% 7 cancer 5.6% basephyfunc1on 4.3% 8 basephyfunc1on 4.3% procedure 4.3% 9 procedure 3.9% social 4.1% 10 treatment 3.9% cancer 4.1% 11 apcomplica1ons 3.2% diagnosis 3.8% 12 experience 2.8% funcstatus 3.5% 13 basecogfunc1on 2.2% basefunc1on 3.5% 14 social 2.2% apcomplica1ons 2.2% 15 behavioral 2.1% interac1ons 1.7% 16 pallia1ve 1.1% treatment 1.7% 17 readmissions 1.1% basecogfunc1on 1.6% 18 funcstatus 0.7% readmissions 1.4% 19 interac1ons 0.7% medica1ons 0.7% 20 psychology 0.6% psychology 0.7% 21 agressivecare 0.2% doctorinput 0.4% 22 doctorinput 0.2% pallia1ve 0.4% 23 medica1ons 0.2% agressivecare 0.0%

20 Findings: Frequency of Meta themes by Type of Clinicians DOCTORS NURSES Trajectory, current condition and foreseeable complications 45.2% 43.8% acuteclinical trajectory diagnosis apcomplications funcstatus Past medical history and healthcare utilization 54.1% 23.1% 14.0% 7.0% 1.7% 18.9% 50.5% 28.1% 8.6% 5.0% 7.9% 17.1% medhistory cancer readmissions Prior function 64.36% 29.70% 5.94% 12.1% 67.80% 23.73% 8.47% 9.4% basefunction basephyfunction basecogfunction Social, behavioral, psychologic and demographic factors 46.2% 35.4% 18.5% 10.7% 36.9% 46.2% 16.9% 15.9% age social behavioral psychology Therapies, treatments and medical procedures 54.4% 21.1% 19.3% 5.3% 8.0% 32.7% 25.5% 37.3% 4.5% 6.8% procedure treatment medications Clinician's experiences and interactions 48.8% 48.8% 2.3% 3.7% 63.8% 25.5% 10.6% 6.5% experience interactions doctorinput Preference for palliative or aggressive care 75.0% 20.0% 5.0% 1.31% 66.7% 26.7% 6.7% 0.43% palliative agressivecare 85.71% % 14.29% 0.00%

21 Next Steps Identify what meta-themes and variables are associated with higher accuracy in clinicians prognosis of survival and functional outcomes.

22 VII. LESSONS LEARNED Limitations of tools for prognostication of functional outcomes. Exposure to intensive care medicine. Team dynamics in clinical research. Exposure to issues in advance-care planning and decision making for the end-of-life care. Telephone interviewing skills, data collection and qualitative data analysis methods.

23 VII. AKNOWLEDGEMENTS Dr. Scott Halpern Beth Cooney Mike Detsky The FIELDS Team Joanne Levy Safa Browne and the LDI Team