Association Between Unmet Nonmedication Needs After Hospital Discharge and Readmission or Death Among Acute Respiratory Failure Survivors: A Multicenter Prospective Cohort Study*

Abstract

To characterize early unmet nonmedication discharge needs (UDNs), classified as durable medical equipment (DME), home health services (HHS), and follow-up medical appointments (FUAs) and explore their association with 90-day readmission and mortality among survivors of acute respiratory failure (ARF) who were discharged home. DESIGN:Prospective multicenter cohort study. SETTING: Six academic medical centers across United States.PARTICIPANTS: Adult survivors of ARF who required an ICU stay and were discharged home from hospital. INTERVENTIONS:None. Exposure of interest was the proportion of UDN for the following categories: DME, HHS, and FUA ascertained within 7-28 days after hospital discharge. MEASUREMENTS AND MAIN RESULTS:Two hundred eligible patients were recruited between January 2019 and August 2020. One-hundred ninety-five patients were included in the analytic cohort: 118 were prescribed DME, 134 were prescribed HHS, and 189 needed at least one FUA according to discharge plans. 98.4% (192/195) had at least one identified nonmedication need at hospital discharge. Median (interquartile range) proportion of unmet needs across three categories were 0 (0-15%) for DME, 0 (0-50%) for HHS, and 0 (0-25%) for FUA, and overall was 0 (0-20%). Fifty-six patients (29%) had 90-day death or readmission. After adjusting for prespecified covariates, having greater than the median level of unmet needs was not associated with an increased risk of readmission or death within 90 days of discharge (risk ratio, 0.89; 0.51-1.57; p = 0.690). Age, hospital length of stay, Acute Physiology and Chronic Health Evaluation II severity of illness score, and Multidimensional Scale Perceived Social Support score were associated with UDN. CONCLUSIONS: UDN were common among survivors of ARF but not significantly associated a composite outcome of 90-day readmission or death. Our results highlight the substantial magnitude of UDN and identifies areas especially vulnerable to lapses in healthcare coordination.KEY WORDS: acute respiratory failure; critical care; discharge planning; health services research; long-term outcomes; post-intensive care syndrome S urvivorship following acute respiratory failure (ARF) continues to improve despite an overall increase in disease severity and prevalence (1-4).

Meeting the Needs of ICU Survivors: A Gap Requiring Systems Thinking and Shared Vision*

“…The analysis by Bose et al (1) is a stark reminder of the significant nonmedication needs for ICU survivors and current limitations of our current care models to meet patient needs after hospital discharge. Failure to effectively support ICU survivors exacts a significant cost on our patients and society.…”

“…Interventions focused on care transitions and the outpatient setting therefore appear to be an essential next step. Bose et al (1) highlight the volume of outpatient needs typically present post-ICU stay, which was striking given the growing number of ICU survivors. This highlights the need to identify barriers to high quality post-ICU care and to implement targeted corrective actions.…”

“…In a recent single-center study by Bloom et al (11), a multifaceted ICU recovery program extended the median time to hospital readmission by 2 weeks, but did not significantly decrease the 30-day hospital readmission rate. An important limitation of the study by Bose et al (1) was that although 90% of patients in the intervention arm received at least one inpatient intervention (e.g., an inpatient visit by a transition program nurse practitioner), only 13% of patients received any outpatient intervention (e.g. a case management screen).…”

“…As we learn more about post-ICU recovery, we have come to recognize the wide gulf between merely surviving and thriving. One might argue that the latter state is what we really envision when we think of successful treatment (1). Mortality is also an endpoint that despite its apparent simplicity is laden with complex and unanswered questions (2).…”

“…I n this issue of Critical Care Medicine, Bose et al (1) describe the frequency of unmet nonmedication healthcare needs (i.e., durable medical equipment, home health services, outpatient follow-up appointments) after hospital discharge for a cohort of patients admitted with acute respiratory failure. The vast majority of patients (98%) had at least one non medication need, with a median of 5 needs per patient.…”