What outcomes should be evaluated in critically ill patients?

Teixeira, Cassiano; Kern, Marcelo; Rosa, Regis Goulart

doi:10.5935/0103-507X.20210040

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REVIEW ARTICLE • Rev. bras. ter. intensiva 33 (2) • Apr-Jun 2021 • https://doi.org/10.5935/0103-507X.20210040 copy

What outcomes should be evaluated in critically ill patients?

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Randomized clinical trials in intensive care prioritize disease-focused outcomes rather than patient-centered outcomes. A paradigm shift considering the evaluation of measures after hospital discharge and measures focused on quality of life and common symptoms, such as pain and dyspnea, could better reflect the wishes of patients and their families. However, barriers related to the systematization of the interpretation of these outcomes, the heterogeneity of measurement instruments and the greater difficulty in performing the studies, to date, seem to hinder this change. In addition, the joint participation of patients, families, researchers, and clinicians in the definition of study outcomes is not yet a reality.

Keywords:
Patient outcome assessment; Critical illness; Critical care; Prognosis; Intensive care units

Domains	Examples
Important outcomes for the patient	Mortality at any time
	Quality of life
	Functional capacity after ICU discharge
	Cognitive capacity after ICU discharge
Clinical outcomes	Organ failure
	Adverse events (e.g., drug-induced skin reaction or hypotension during renal replacement therapy)
	Outcomes associated with medical care (e.g., hospital-acquired pneumonia, catheter-related infections) and delirium
	Clinical events (e.g., venous thromboembolism and myocardial infarction)
	Pain (in the ICU)
	Anxiety (in the ICU)
	Level of consciousness
	Return to spontaneous circulation
	Strength/muscle circumference
	Sleep duration
	NIHSS score for acute phase of CVA
	Clinical response to antibiotics
	Dyspnea (in the ICU)
	Tolerance to noninvasive ventilation
Biological, physiological, or radiological outcomes	BNP
	NGAL
	Total lung capacity
	X-ray severity score
Outcomes related to the decision of the caregiver	Duration of mechanical ventilation
	Length of ICU or hospital stay
	Exposure to antibiotics
	Reintubation
	Exposure to sedation (dose/time)
	Need for renal replacement therapy
	Need for ventilatory support (invasive or noninvasive)
	ICU readmission rate
	Tracheostomy rate
	Need for blood products
	Need for surgical procedure
Outcomes related to care performance	Quality of the care procedure
	Exposure to noise
	Exposure to light
Other outcomes	Family satisfaction
	ICU staff satisfaction
	Costs and charges
	Judgment of the patient on their readiness for discharge
	Team workload
	Compliance with service protocols
	Medico-legal conflict

Implementation challenges	Comment
Loss of follow-up	Long follow-up periods may result in large losses to follow-up (due to death or sequela).
Selection bias	More severe patients may become inaccessible over time due to death or severe sequelae, resulting in a population different from that representative of the post-ICU reality.
Memory bias	Long-term follow-up may favor the occurrence of memory bias regarding relevant outcomes, especially if the interval between follow-ups is long.
Confusion bias	Long-term outcomes can be determined by events subsequent to those studied.
Patient-centered outcomes
The limited inclusion of patients and relatives in the determination of relevant outcomes	There is a gap in the importance of outcomes between patients (and their families) and researchers/health professionals.
Lack of consensus on the health domains evaluated	The lack of consensus among researchers regarding a minimum set of health domains evaluated contributes to the lack of uniformity of publications and a delay in the evolution of knowledge on the subject
High heterogeneity of assessment instruments	The lack of uniformity of measurement instruments can make it difficult to summarize the evidence in meta-analyses, for example

Associação de Medicina Intensiva Brasileira - AMIB Rua Arminda, 93 - Vila Olímpia, CEP 04545-100 - São Paulo - SP - Brasil, Tel.: (11) 5089-2642 - São Paulo - SP - Brazil
E-mail: rbti.artigos@amib.com.br

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[1] Corresponding authore: Cassiano Teixeira Departamento de Clínica Médica / Ciências da Reabilitação Universidade Federal de Ciências da Saúde de Porto Alegre Rua Sarmento Leite, 245 Zip code: 90050-170 - Porto Alegre (RS), Brazil E-mail: cassiano.rush@gmail.com