Health Expectations and Quality of Life After Acute Respiratory Failure: A Multicenter Prospective Cohort Study.

BACKGROUND: Patients often have high expectations for recovery after critical illness, but the impact of these expectations on subsequent quality of life (QoL) after serious illnesses has not been evaluated empirically. RESEARCH QUESTION: Among adult survivors of acute respiratory failure (ARF), are met vs unmet expectations for health associated with self-reported QoL 6 months after discharge? STUDY DESIGN AND METHODS: This was a prospective longitudinal cohort study enrolling consecutive adult patients with ARF managed in ICUs at five academic medical centers. At hospital discharge, we evaluated participants' expected health 6 months in the future via a visual analog scale (VAS; range, 0-100), with higher scores representing better expected health. At 6-month follow-up, perceived health was assessed using the EQ-5D VAS, and QoL was assessed using the World Health Organization Quality of Life Brief Version (WHOQOL-BREF) instrument. Participants' health expectations were categorized as having been met when perceived health at 6 months was no more than eight points lower than their expectation at study enrollment. The primary analysis compared WHOQOL-BREF domain scores (range, 0-100) at 6 months after discharge in patients with met vs unmet health expectations using the nonparametric Mann-Whitney U test. Secondary analysis modeled WHOQOL-BREF domain scores using multivariate regression, and sensitivity analyses assessed QoL using EQ-5D-5L index values. RESULTS: In the primary analysis, QoL was significantly better among participants with met vs unmet health expectations across all domains of the WHOQOL-BREF: physical health (estimated difference in scores: median, 19 [interquartile range (IQR), 12-15]; P < .001), psychological health (median, 12 [IQR, 6-18]; P < .001), social relationships (median, 6 [IQR, 0-13]; P = .02), and environmental health (median, 12 [IQR, 6-13]; P < .001). In multivariate regression, the difference between expected and perceived health remained associated significantly with the physical health domain score. INTERPRETATION: Fulfillment of health expectations is associated with better QoL after ARF, suggesting a mechanism underpinning successful ICU recovery programs that incorporate normalization and expectation management.

Fulfillment of Patient Expectations after Acute Respiratory Failure: A Multicenter Prospective Cohort Study.

Rationale: Discussion of patient expectations for recovery is a component of intensive care unit (ICU) follow-up clinics. However, few studies have formally evaluated recovery-related expectations of ICU survivors. Objectives: To estimate the prevalence of unmet expectations for recovery 6 months after hospital discharge among adult survivors of acute respiratory failure (ARF). Methods: This was a prospective, longitudinal, cohort study of survivors of ARF discharged to home from five U.S. medical centers. Expectations for functional recovery were assessed by asking which activities and instrumental activities of daily living (I/ADLs) survivors expected to perform independently at 6 months. Survivors' expectations for overall health status were assessed using a visual analogue scale ranging from 0 to 100. At 6-month follow-up, participants reported which I/ADLs they could perform independently and rated their overall health status using a 100-point visual analogue scale. We defined a participant's functional expectations as being met if they reported independently performing I/ADLs as expected at hospital discharge. Health expectations were considered to be met when self-rated health status at 6 months was no more than 8 points lower than expected at enrollment. Results: Among 180 enrollees, 169 (94%) were alive, and 160 of these (95%) participated in 6-month follow-up. Functional expectations were met for 71% of participating survivors, and overall health expectations were met for 50%. Expectations for functional independence were high, ranging from 87% (housekeeping) to 99% (using a telephone). General health expectations were variable (median, 85; interquartile range [IQR], 75-95). At 6-month follow-up, self-rated, overall health ranged from 2 to 100 (median, 80; IQR, 60-85). In exploratory analyses, participants with met versus unmet expectations differed most in formal education (functional expectations standardized difference = 0.88; health expectations standardized difference = 0.41). Conclusions: Expectations of survivors of ARF about independent functioning were high and generally met, but half had unmet general health expectations 6 months after discharge. It is difficult to predict whose health expectations will be unmet, but possessing less formal education may be a risk factor. Clinical trial registered with www.clinicaltrials.gov (NCT03797313).

Evaluation of Telehealth Visit Attendance After Implementation of a Patient Navigator Program.

Importance: The dramatic rise in use of telehealth accelerated by COVID-19 created new telehealth-specific challenges as patients and clinicians adapted to technical aspects of video visits. Objective: To evaluate a telehealth patient navigator pilot program to assist patients in overcoming barriers to video visit access. Design, Setting, and Participants: This quality improvement study investigated visit attendance outcomes among those who received navigator outreach (intervention group) compared with those who did not (comparator group) at 2 US academic primary care clinics during a 12-week study period from April to July 2021. Eligible participants had a scheduled video visit without previous successful telehealth visits. Interventions: The navigator contacted patients with next-day scheduled video appointments by phone to offer technical assistance and answer questions on accessing the appointment. Main Outcomes and Measures: The primary outcome was appointment attendance following the intervention. Return on investment (ROI) accounting for increased clinic adherence and costs of implementation was examined as a secondary outcome. Results: A total 4066 patients had video appointments scheduled (2553 [62.8%] women; median [IQR] age: intervention, 55 years [38-66 years] vs comparator, 52 years [36-66 years]; P = .02). Patients who received the navigator intervention had significantly increased odds of attending their appointments (odds ratio, 2.0; 95% CI, 1.6-2.6) when compared with the comparator group, with an absolute increase of 9% in appointment attendance for the navigator group (949 of 1035 patients [91.6%] vs 2511 of 3031 patients [82.8%]). The program's ROI was $11 387 over the 12-week period. Conclusions and Relevance: In this quality improvement study, we found that a telehealth navigator program was associated with significant improvement in video visit adherence with a net financial gain. Our findings have relevance for efforts to reduce barriers to telehealth-based health care and increase equity.

Physician Self-assessment of Shared Decision-making in Simulated Intensive Care Unit Family Meetings.

Importance: Professional guidelines have identified key communication skills for shared decision-making for critically ill patients, but it is unclear how intensivists interpret and implement them. Objective: To compare the self-evaluations of intensivists reviewing transcripts of their own simulated intensive care unit family meetings with the evaluations of trained expert colleagues. Design, Setting, and Participants: A posttrial web-based survey of intensivists was conducted between January and March 2019. Intensivists reviewed transcripts of simulated intensive care unit family meetings in which they participated in a previous trial from October 2016 to November 2017. In the follow-up survey, participants identified if and how they performed key elements of shared decision-making for an intensive care unit patient at high risk of death. Transcript texts that intensivists self-identified as examples of key communication skills recommended by their professional society's policy on shared decision-making were categorized. Main Outcomes and Measures: Comparison of the evaluations of 2 blinded nonparticipant intensivist colleagues with the self-reported responses of the intensivists. Results: Of 116 eligible intensivists, 76 (66%) completed the follow-up survey (mean [SD] respondent age was 43.1 [8.1] years; 72% were male). Sixty-one of 76 intensivists reported conveying prognosis; however, blinded colleagues who reviewed the deidentified transcripts were less likely to report that prognosis had been conveyed than intensivists reviewing their own transcripts (42 of 61; odds ratio, 0.10; 95% CI, 0.01-0.44; P < .001). When reviewing their own transcript, intensivists reported presenting many choices, with the most common choice being code status. They also provided a variety of recommendations, with the most common being to continue the current treatment plan. Thirty-three participants (43%) reported that they offered care focused on comfort, but blinded colleagues rated only 1 (4%) as explaining this option in a clear manner. Conclusions and Relevance: In this study, guidelines for shared decision-making and end of life care were interpreted by intensivists in disparate ways. In the absence of training or personalized feedback, self-assessment of communication skills may not be interpreted consistently.

Effect of Intensivist Communication in a Simulated Setting on Interpretation of Prognosis Among Family Members of Patients at High Risk of Intensive Care Unit Admission: A Randomized Trial.

Importance: Discordance about prognosis between a patient's health care decision-making surrogate and the treating intensivist is common in the intensive care unit (ICU). Empowering families, friends, and caregivers of patients who are critically ill to make informed decisions about care is important, but it is unclear how best to communicate prognostic information to surrogates when a patient is expected to die. Objective: To determine whether family members, who are often health care decision-making surrogates, interpret intensivists as being more optimistic when questions about prognosis in the ICU are answered indirectly. Design, Setting, and Participants: This web-based randomized trial was conducted between September 27, 2019, and October 17, 2019, among a national sample of adult children, spouses, partners, or siblings of people with chronic obstructive pulmonary disease who were receiving long-term oxygen therapy. Participants were shown video vignettes depicting an intensivist answering a standardized question about the prognosis of a patient at high risk of death on day 3 of ICU admission. Participants were excluded if they had worked as a physician, nurse, or advanced health care practitioner. Data were analyzed from October 18, 2019, to November 12, 2019. Interventions: Participants were randomized to view 1 of 4 intensivist communication styles in response to the question "What do you think is most likely to happen?": (1) a direct response (control), (2) an indirect response comparing the patient's condition with that of other patients, (3) an indirect response describing the patient's deteriorating physiological condition, or (4) redirection to a discussion of the patient's values and goals. Main Outcomes and Measures: Participant responses to 2 questions: (1) "If you had to guess, what do you think the doctor thinks is the chance that your loved one will survive this hospitalization?" and (2) "What do you think are the chances that your loved one will survive this hospitalization?" answered using a 0% to 100% probability scale. Results: Among 302 participants (median [interquartile range] age, 49 [38-59] years; 204 [68%] women) included in the trial, 165 (55%) were adult children of the individual with chronic obstructive pulmonary disease; 77 participants were randomized to view a direct response, 77 participants were randomized to view an indirect response referencing other patients, 68 participants were randomized to view an indirect response referencing physiological condition, and 80 participants were randomized to view a redirection response. Compared with participants who viewed a direct response, participants who viewed an indirect response referencing other patients (ß = 10 [95% CI, 1-19]; P = .03), physiological condition (ß = 10 [95% CI, 0-19]; P = .04), or redirection to a discussion of the patient's values and goals (ß = 19 [95% CI, 10-28]; P < .001) perceived the intensivist to have a significantly more optimistic prognostic estimate. Conclusions and Relevance: These findings suggest that family members interpret indirect or redirection responses to questions about prognosis in the ICU setting as more optimistic than direct responses. Trial Registration: ClinicalTrials.gov Identifier: NCT04239209.