The epidemiology and costs of chronic critical illness☆
Section snippets
Demographics
We reviewed specific studies of CCI patients to define the clinical characteristics of these patients. We then analyzed a representative dataset of U.S. hospital discharges to estimate the nationwide burden of this disease category. Two of the more helpful cohort studies are by Spicher and White, published in 1987 [7], and by Gracey et al [8], published in 1992. Both studies describe cohorts of patients requiring prolonged mechanical ventilation in large tertiary care hospitals. Spicher and
Risk factors
Investigations into risk factors for CCI have predominantly focused on predictors of prolonged mechanical ventilation. Several studies have examined risk factors for prolonged mechanical ventilation after coronary artery bypass surgery. One study found that risk factors associated with preoperative medical instability, especially cardiac or respiratory insufficiency, were strong predictors of mechanical ventilation for >4 days. The Society of Thoracic Surgeons-predicted mortality estimate was
Survival
As with most outcomes studies, case mix is a key determinant for survival assessments of CCI patients. The ideal study would be a prospective study enrolling consecutive patients from multiple different acute ICU settings using a single definition of CCI. This ideal study has not been performed, so we must instead make judgments based upon multiple single institution studies or administrative datasets. Another important issue when discussing survival in the context of CCI is what length of
Predictors of survival
As is apparent from the previous section, CCI is associated with a high mortality. It would be advantageous to be able predict early within their hospital course which patients are more likely to survive. This would help patients and families understand the implications and expected outcomes of their disease, it would allow for rational resource allocation, and it would assist in the assessment of new therapies and interventions. Investigations into outcome prediction for this patient
Functional status and quality of life
Formal assessments of functional status of CCI patients beyond hospital discharge are limited. Three studies assessed functional status after 1 year by telephone interview. In the two acute hospital cohorts summarized in Table 1, Spicher and White [7] reported that 3% of patients had no functional deficits, 24.7% had mild deficits, 32.7% were housebound, and 39.6% were institutionalized at follow-up. Gracey et al [8], on the other hand, found that 54% of survivors were functioning fully and
Resource utilization and costs
The extreme costs associated with the management of CCI patients were instrumental in drawing attention to them as a unique patient group. In a study by Douglas Wagner in 1989 [2], resource utilization based upon the Therapeutic Intervention Scoring System was estimated for 3884 patients from 12 hospitals that made up one of the original APACHE databases. The 227 patients from that group who were ventilated for 7 or more days consumed 37% of total ICU resources, and 21% of the total resources
Pediatric patients with CCI
Pediatric populations of ICU patients differ from adult populations in terms of underlying diagnoses and survival, but costs are similar [42]. The same is true for pediatric populations of CCI patients. Schreiner et al [43] followed 101 infants who required mechanical ventilation for more than 28 days in a pediatric ICU between 1967 and 1984. Thirty-six children had severe bronchopulmonary dysplasia, 50 had congenital anomalies, and 15 had neuromuscular disorders. The mean duration of
Summary
CCI patients are patients who have suffered acute illness or injury and require life support or care in an ICU setting for periods of weeks or months. These patients account for between 5% and 10% of ICU admissions, and they appear to be increasing in number. Over half of the patients are over age 65. Patients with underlying premorbid conditions who suffer complications of acute illness are at highest risk for becoming CCI. These patients have poor short-term and long-term survival, although
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This work was supported by grant No. 1K23CA86968-01 from the NCI.