Evaluation of a health and social care programme to improve outcomes following critical illness: a multicentre study

Abstract

Rationale: At present, clinicians aiming to support patients through the challenges after critical care have limited evidence to base interventions.

Objectives: Evaluate a multicentre integrated health and social care intervention for critical care survivors. A process evaluation assessed factors influencing the programme implementation.

Methods: This study evaluated the impact of the Intensive Care Syndrome: Promoting Independence and Return to Employment (InS:PIRE) programme. We compared patients who attended this programme with a usual care cohort from the same time period across nine hospital sites in Scotland. The primary outcome was health-related quality of life (HRQoL) measured via the EuroQol 5-dimension 5-level instrument, at 12 months post hospital discharge. Secondary outcome measures included self-efficacy, depression, anxiety and pain.

Results: 137 patients who received the InS:PIRE intervention completed outcome measures at 12 months. In the usual care cohort, 115 patients completed the measures. The two cohorts had similar baseline demographics. After adjustment, there was a significant absolute increase in HRQoL in the intervention cohort in relation to the usual care cohort (0.12, 95% CI 0.04 to 0.20, p=0.01). Patients in the InS:PIRE cohort also reported self-efficacy scores that were 7.7% higher (2.32 points higher, 95% CI 0.32 to 4.31, p=0.02), fewer symptoms of depression (OR 0.38, 95% CI 0.19 to 0.76, p=0.01) and similar symptoms of anxiety (OR 0.58, 95% CI 0.30 to 1.13, p=0.11). There was no significant difference in overall pain experience. Key facilitators for implementation were: integration with inpatient care, organisational engagement, flexibility to service inclusion; key barriers were: funding, staff availability and venue availability.

Conclusions: This multicentre evaluation of a health and social care programme designed for survivors of critical illness appears to show benefit at 12 months following hospital discharge.

Keywords: ARDS; critical care; pulmonary rehabilitation.

Figure 1

Recruitment flow chart. Patient flow and recruitment, intervention cohort and usual care cohort. InS:PIRE, Intensive Care Syndrome: Promoting Independence and Return to Employment.

Figure 2

Forest plot (adjusted unmatched). Effect of the intervention on measured outcomes representing the absolute difference in scores (linear models) or risk of screening positive for the condition (ORs), 1 year after intensive care compared with usual care. Point estimate values (circle, square, triangle) and 95% CI. InS:PIRE, Intensive care Syndrome: Promoting Independence and Return to Employment; EuroQol Health Utility Score, absolute difference, taken from EuroQol 5-Dimension 5-level (EQ-5D-5L) ‘crosswalk UK scores’, range - 0.594 to 1.0; EuroQol Visual Analogue Scale (EQ-VAS), absolute difference, range 0 to 100; Generalised Self Efficacy: absolute difference, range 10 to 40; HADS: Hospital Anxiety and Depression Scale with individual component scores for anxiety and depression, odds risk ratios of screening positive for anxiety or depression; Brief pain inventory (BPI), absolute difference in pain scores, all scores range from 0 to 10, average (single component score), worst pain (single component score), and summary score (composite / mean score from four pain scores: ‘average’, ‘worst’, ‘least’ and ‘pain right now’); Pain interference scores from BPI, absolute difference, scores range from 0 to 10, enjoyment in life (single component), work (single component), and summary pain interference (composite / mean score from seven interference components).

Figure 3

Propensity score matching panel. Demographic table (A): representative dataset of baseline characteristics after propensity score matching. ICU, intensive care unit; APACHE II, Acute Physiology and Chronic Health Evaluation II; SIMD, Scottish index of multiple deprivation; time to follow-up, months, from hospital discharge. Outcome measures table with splines (B): effects of intervention on all outcome measures alongside coefficient graph of effect size. Effect of intervention: absolute change in scores (linear models) and odds risk ratio of screening for the condition (anxiety or depression) 1 year after intensive care compared with usual care. Point estimate values (circle, square, triangle) and 95% CI. InS:PIRE, Intensive Care Syndrome: Promoting Independence and Return to Employment; EuroQol Health Utility Score, absolute change, taken from EuroQol 5-Dimension 5-level (EQ-5D-5L) ‘crosswalk UK scores’, range - 0.594 to 1.0; EuroQol Visual Analogue Scale (EQ-VAS), absolute change, range 0 to 100; Generalised Self-efficacy: absolute change, range 10 to 40; HADS: Hospital Anxiety and Depression Scale with individual component scores for anxiety and depression, odds risk ratios of screening positive for anxiety or depression; Brief pain inventory (BPI), absolute change in pain scores, all scores range from 0 to 10, average (single component score), worst pain (single component score), and summary score (composite/mean score from four pain scores: ‘average’, ‘worst’, ‘least’ and ‘pain right now’); pain interference scores from BPI, absolute change, scores range from 0 to 10, enjoyment in life (single component), work (single component), and summary pain interference (composite/mean score from seven interference components).

Figure 4

Key themes generated from the process evaluation, barriers and facilitators for intervention implementation.