SAN FRANCISCO — Non-drug medical needs commonly go unfulfilled in the early days after a stay in the intensive care unit (ICU), a study affirmed, although without proving the link to outcomes.
Fully 44% of acute respiratory failure patients had unfulfilled needs for durable medical equipment, home health services, or follow-up appointments, reported Somnath Bose, MD, MPH, of Beth Israel Deaconess Medical Center and Harvard Medical School in Boston.
“These point out areas which might need more careful introspection as we plan and optimize recovery for our patients,” Bose concluded during his presentation at the Society of Critical Care Medicine (SCCM) Critical Care Congress. “If there is one take-home message, that is the stark mismatch that exists even at tertiary care centers.”
However, there was a similar composite risk of readmission or death within 90 days of hospital discharge between patients with versus without unmet needs (risk ratio 0.89, 95% CI 0.51-1.57, P=0.690), the authors reported in their study, which was simultaneously published in Critical Care Medicine.
A larger cohort than the 195 patients studied might have shown an impact, Bose noted. Either way, he told MedPage Today, “if patients are not getting what they need, it’s a problem.”
Timothy Buchman, MD, PhD, of Emory University in Atlanta and a past-president of the SCCM, blamed design of the healthcare system: “You go out that door, I lose track of you, the system loses track of you, and frankly, you’re on your own. Are there unmet needs? Inevitably. That is structural in the system.”
As to the lack of association with outcomes, he said, “Absence of proof is not proof of absence.”
The small study was likely confounded by early readmissions to the hospital, he noted. “Common sense should suggest that if there’s a defined need and the need is not met, there will be an adverse consequence.”
While Bose’s analysis didn’t report on it, the unmet needs likely also had a health equity component, Buchman said. “If we are going to actually pursue health equity, we need to make sure that everybody’s needs are met to a degree of sufficiency. I may not be able to do everything, but we ought to have a minimum standard below which no patient should fall.”
The Addressing Post-Intensive Care Syndrome (APICS-01) study included 195 adults discharged home from the ICU after acute respiratory failure, who were recruited at six academic medical centers from January 2019 to August 2020. Among them, all but three (98.4%) had a medical need at discharge: 118 were prescribed durable medical equipment, 134 were prescribed home health services, and 189 needed at least one follow-up appointment according to discharge plans.
The median number of unmet needs was zero, so comparisons above and below the median were between those with no unmet needs and those who had unmet needs.
The patient cohort had a median age of 55, 53% were women, and 34% were people of color. Only 5.6% of the patients were uninsured. The median hospital length of stay was 14 days, and the median time to readmission was 12 days, “which is extremely, extremely early,” Bose said.
The biggest limitation to the study was the early readmission rate, which may have led to misclassification of exposure in a certain subset of patients, Bose noted. Also, the study couldn’t assess the quality of services provided, wasn’t powered to rule out smaller effects or residual confounding, and had unknown generalizability to care delivered outside of tertiary-level academic medical centers, such as at smaller community centers.
Furthermore, the study was completed as the COVID-19 pandemic was ramping up, such that 16.9% of the cohort was diagnosed with COVID. A second cohort of COVID patients is underway, Bose said. If anything, the unmet need “I anticipate would be higher,” he told MedPage Today, as the pandemic further disrupted organization of care delivery.
The study was supported by the Assistant Secretary of Defense for Health Affairs endorsed by the Department of Defense through the FY17 PRMRP Investigator-Initiated Research Award.
Bose disclosed his institution received funding from the Department of Defense.
Critical Care Medicine
Source Reference: Bose S, et al “Association between unmet nonmedication needs after hospital discharge and readmission or death among acute respiratory failure survivors: a multicenter prospective cohort study” Crit Care Med 2023; DOI: 10.1097/CCM.0000000000005709.