Post-ICU Rehab Program Misses Mark for Improving Quality of Life

A from-home rehabilitation program for intensive care unit (ICU) survivors who had been on mechanical ventilation did not improve health-related quality of life after discharge overall, but secondary outcomes suggested benefit after longer follow-up and with shorter ventilation times, a randomized trial showed.

Mean EuroQoL 5-dimension 5-level questionnaire (EQ-5D-5L) utility scores were similar at 8 weeks between the intervention and standard care (0.69 vs 0.67 on a scale that ranges from -0.285 at worst to 1 at best, P=0.05), a neutral finding for the primary endpoint, reported Brenda O’Neill, PhD, of Ulster University in Derry, Northern Ireland, at the American Thoracic Society annual meeting in Orlando.

But at 6 months, the quality of life endpoint measure significantly favored the intervention (0.71 vs 0.67, P=0.003) in the findings published simultaneously in JAMA. The intervention improved four of the six secondary outcomes, including leg strength and exercise capacity, fatigue, anxiety, and acceptability of the intervention and any adverse events.

Clinically important benefits for people mechanically ventilated for no more than 7 days were seen in an a priori subgroup analysis, with a mean EQ-5D-5L utility score of 0.74 with the intervention versus 0.66 in the standard care group (adjusted mean difference 0.10, 95% CI 0.03-0.16; minimum clinically important difference was 0.08).

For such a complex intervention, a generic outcome measure like the EQ-5D-5L might not adequately capture impact, noted an accompanying editorial by Michelle Kho, PT, PhD, of McMaster University in Hamilton, Ontario, and colleagues.

“However, when the findings are considered as a pattern across outcomes, rather than through the EQ-5D-5L end point alone, the overall interpretation becomes more favorable,” they wrote. “Across outcomes, this consistency suggests that the intervention achieved its intended therapeutic targets.”

Importantly, Kho and colleagues called the intervention “potentially scalable and customizable across healthcare systems in high- and middle-income countries.”

The pragmatic trial included 429 adults (mean age 55.4, 57.1% male) who had been discharged from an ICU admission at 52 U.K. hospitals within the prior 12 weeks and who had required at least 48 hours of mechanical ventilation. Mean APACHE II score was 18.4, and patients stayed in the hospital an average of 35 days with about 11 days of mechanical ventilation.

Participants were randomized to usual care or the multicomponent rehabilitation intervention that O’Neill called a “very low-key intervention,” as the therapists joined the patients from a laptop and patients joined remotely either on their own device at home or by telephone.

The 6-week intervention included a “box of ingredients” that, depending on patient needs, could include management of symptoms like breathlessness, fatigue, trouble swallowing, pain, and altered sleep; psychological support to address delirium, acceptance, and mindfulness; group-based peer support; and weekly individualized one-on-one exercise appointments along with group exercise sessions and on-demand recorded exercise.

“But there are core ingredients that need to be delivered, and importantly they were patient centered,” O’Neill said. “So people drove the intervention but still received a very standardized program.”

While she called adherence “really good” overall, the 89% of patients with at least partial adherence to the intervention showed a significant quality of life benefit. Age didn’t predict impact.