Abstract
OBJECTIVES:
To examine 1-year functional outcomes after invasive mechanical ventilation for adults greater than or equal to 65 years with preexisting long-term care-needs.
DESIGN:
We used medical and long-term care administrative databases. The database included data on functional and cognitive impairments that were assessed with the national standardized care-needs certification system and were categorized into seven care-needs levels based on the total daily estimated care minutes. Primary outcome was mortality and care-needs at 1 year after invasive mechanical ventilation. Outcome was stratified by preexisting care-needs at the time of invasive mechanical ventilation: no care-needs, support level 1–2 and care-needs level 1 (estimated care time 25–49 min), care-needs level 2–3 (50–89 min), and care-needs level 4–5 (≥90 min).
SETTING:
A population-based cohort study in Tochigi Prefecture, one of 47 prefectures in Japan.
PATIENTS:
Among people greater than or equal to 65 years old registered between June 2014 and February 2018, patients who received invasive mechanical ventilation were identified.
INTERVENTIONS:
None.
MEASUREMENTS AND MAIN RESULTS:
Among 593,990 eligible people, 4,198 (0.7%) received invasive mechanical ventilation. The mean age was 81.2 years, and 55.5% were male. The 1-year mortality rates after invasive mechanical ventilation in patients with no care-needs, support level 1–2 and care-needs level 1, care-needs level 2–3, and care-needs level 4–5 at the time of invasive mechanical ventilation were 43.4%, 54.9%, 67.8%, and 74.1%, respectively. Similarly, those with worsened care-needs were 22.8%, 24.2%, 11.4%, and 1.9%, respectively.
CONCLUSIONS:
Among patients in preexisting care-needs levels 2–5 who received invasive mechanical ventilation, 76.0–79.2% died or had worsened care-needs within 1 year. These findings may aid shared decision-making among patients, their families, and heath care professionals on the appropriateness of starting invasive mechanical ventilation for people with poor functional and cognitive status at baseline.
Keywords: activities of daily living, invasive mechanical ventilation, long-term care, older people, shared decision-making
Invasive mechanical ventilation can be a life-saving treatment, but patients who undergo mechanical ventilation have both poor short- and long-term mortalities (1, 2). In older adults, especially those with preexisting long-term care-needs for functional and cognitive impairment, invasive mechanical ventilation may prolong their suffering without a clear benefit and increase an already substantial society burden (3–6). Therefore, it is important to discuss with patients and families if invasive mechanical ventilation would align with patient’s values and goals (e.g., if it has the potential to improve the quality of life) (7–9). However, there is limited evidence on the impact of invasive mechanical ventilation in older adults with poor functional and cognitive impairment at baseline (typical of frail elderly people or people with dementia).
Previous studies focused on the age (10, 11) or presence of dementia prior to the initiation of invasive mechanical ventilation (12–18). Given that the degree of functional and cognitive impairment varies greatly based on the age or presence of dementia, it is difficult to apply the evidence from these studies to patients in the real-world clinical setting. Furthermore, previous studies failed to assess functional and cognitive impairments prior to invasive mechanical ventilation, and there is limited evidence on the impact of invasive mechanical ventilation on change in functional and cognitive impairment. Understanding the current clinical practice patterns and societal burden of invasive mechanical ventilation is important to support shared decision-making between older adults with preexisting long-term care-needs and their families with respect to the appropriateness of this procedure.
Thus, this study aimed to investigate the incidence and 1-year outcomes of invasive mechanical ventilation in adults aged greater than or equal to 65 years with preexisting long-term care-needs, using data from a large administrative claims database of the Japanese National Health Insurance system and the Long-Term Care Insurance system. Patients’ functional and cognitive impairment were prospectively assessed with the national standardized care-needs certification system in the Long-Term Care Insurance system and were categorized based on the total daily estimated care minutes.
MATERIALS AND METHODS
Study Design and Data Source
This was a population-based cohort study approved by the Institutional Review Board of The Jichi Medical University (approval number 19–205; August 7, 2017; Development of Integrated Databases With Various Health and Medical Information). Given the deidentified nature of the data, the requirement for informed consent was waived. The procedures were followed in accordance with the ethical standards of the responsible committee on human experimentation and with the Helsinki Declaration of 1975.
Two administrative databases in Tochigi prefecture, one of 47 subdivisions of the country in Japan, were used. The first administrative database was from the National Health Insurance and Late Elders’ Health Insurance for medical care (19, 20). Since 1961, almost everyone in Japan has been publicly insured for medical care (19, 20). This database contains the following patient-level data for outpatient visits and hospitalization: date of birth; sex; diagnoses recorded with International Classification of Diseases, 10th Revision (ICD-10) codes; surgical and nonsurgical procedures; medications; and costs. The second administrative database was from the Long-Term Care Insurance system (21, 22). In 2000, the Japanese government implemented this public, mandatory long-term care insurance (21, 22). People greater than 65 years old were regarded as primary insured candidates, and people 40–64 years old who were diagnosed with one of the 16 predetermined diseases (including end-stage cancer, Alzheimer disease, and stroke) were regarded as secondary insured candidate. Of these candidates, people who satisfied the eligibility criteria can receive the Long-Term Care Insurance services, irrespective of income level and availability of informal care provided by the family (21, 22). Eligibility and care-needs levels are assessed by a national standardized care-needs certification system as explained later (23). This database contains the care-needs levels, long-term care services (facility service, home-based service, and community-based service), and their costs.
Residents in Tochigi prefecture who have National Health Insurance (for self-employed individuals, retired individuals, and their dependents) or Late Elders’ Health Insurance (for all people aged ≥75 yr) are registered in the database. Therefore, almost all residents greater than or equal to 65 years old in Tochigi are included in the database. We merged these medical care and long-term care administrative databases using a unique identifier for each individual.
Participants
People greater than or equal to 65 years old registered in the databases between June 2014 and February 2018 were identified. Of them, patients who received invasive mechanical ventilation during the study period were included. Invasive mechanical ventilation was identified based on the Japanese procedure codes J045 for invasive mechanical ventilation. This code includes invasive mechanical ventilations in the ICU, high-dependency care unit, and general ward but did not include those during general anesthesia, during cardiopulmonary resuscitation, or those in patients with home mechanical ventilation. Patients who received invasive mechanical ventilation after cardiopulmonary resuscitation (ICD-10 code I46) were excluded because the decision to start invasive mechanical ventilation in these patients was based on the cardiopulmonary resuscitation. For patients who received invasive mechanical ventilation multiple times during the study period, only the first episode was analyzed. All the eligible patients were followed up until death, 1 year from initiation of invasive mechanical ventilation, or dropout from any insurance for medical care.
Care-Needs Level
To receive the Long-Term Care Insurance services, the insured candidates or his/her caregivers need to contact the municipal government and obtain a national standardized care-needs certification (23). First, a trained local government official visits the home or hospital to evaluate nursing care-needs using a questionnaire on current physical and mental status (74 items). This questionnaire contained 20 items of physical function, 12 items of daily activity function, nine items of cognitive function, 15 items of behavioral disorders, six items of adjustment to social life, and 12 items of daily use of medical services (see more details in Supplemental Table S1, http://links.lww.com/minutes (see more details in Supplementary Table S2, http://links.lww.com/CCM/H299). The results are then entered into the computer to estimate time for the nine categories of care (grooming/bathing, eating, toileting, transferring, eating, assistance with instrumental activities of daily living, behavioral problems in dementia, rehabilitation, and medical services). Then, the candidates are initially assigned to one of seven care-needs levels based on the total daily estimated care minutes: support level 1, 25–31 minutes; support level 2, 32–49 minutes; care-needs level 1, 32–49 minutes; care-needs level 2, 50–69 minutes; care-needs level 3, 70–89 minutes; care-needs level 4, 90–109 minutes; and care-needs level 5, ≥110 minutes (see more details in Supplementary Table S2, http://links.lww.com/CCM/H299).
The Nursing Care Needs Certification Board, which involve physicians, nurses, and other experts in health and social services appointed by a mayor, determines the appropriateness of the initial assessment, considering the applicant’s primary care physician’s statement and the assessor’s note. The board’s decision is final, and the assigned care-needs levels determine service benefits covered by the Long-Term Care Insurance as shown in Supplementary Table S2 (http://links.lww.com/CCM/H299). Care-needs levels are reevaluated at 6–12-month intervals in principle. A previous study showed a good correlation between the care-needs levels and activities of daily living calculated by Barthel Index scores. That is, support level 1–2 and care-needs level 1 were comparable with Barthel Index scores of 85–95 (independent with minor assistance); care-needs level 2–3 was comparable with Barthel Index scores of 65–80 (partial dependence); and care-needs level 4–5 was comparable with Barthel Index scores of less than 40 (complete dependence) (24). Similarly, previous studies have shown a close association between the care need level and declining cognitive function (25, 26).
The primary interest in this study was the impact of preexisting care-needs at the time of invasive mechanical ventilation on functional outcomes. We categorized preexisting care-needs into four categories: no care-needs, support level 1–2 and care-needs level 1, care-needs level 2–3, and care-needs level 4–5.
Outcomes and Patient Characteristics
The primary outcome measure was care-needs at 1 year after invasive mechanical ventilation, which were categorized into no care-needs, support level 1–2 and care-needs level 1, care-needs level 2–3, care-needs level 4–5, and death. The secondary outcome measure was death during the first hospitalization and change in the care-needs levels at 1 year after the invasive mechanical ventilation. The change in the care-needs levels was categorized as improved, no change, worsened, and death.
Patient characteristics included age; sex; long-term care services and Charlson comorbidity index (27); main diagnosis; and treatments during hospitalization. Charlson comorbidity index was calculated by using ICD-10 codes if they appeared at least once in the diagnoses during the 6 months before the initiation of invasive mechanical ventilation (25).
Statistical Analysis
Overall and preexisting care-needs level-specific incidence of invasive mechanical ventilation per 100,000 population per year were calculated among the source population aged greater than or equal to 65 years. The age- and sex-specific incidence rates of invasive mechanical ventilation per 100,000 population per year were also calculated. Then, the characteristics and outcomes of the patients who received invasive mechanical ventilation, stratified by the preexisting care-needs levels, were investigated. For 1-year mortality after invasive mechanical ventilation, Kaplan-Meier curve was generated stratified by preexisting care-needs levels. For simple and clear shared decision-making discussions, the primary outcome was graphed using a matrix of 100 icons to represent an atrisk population. The primary outcome of care-needs levels at 1 year after invasive mechanical ventilation was considered as an ordinal 5-category scale (from best “No care-needs” to worst “death”) and was analyzed with a multivariable proportional odds model with the preexisting care-needs levels and the following variables (28): age, sex, Charlson comorbidity index, main diagnosis, and treatments during hospitalization. An adjusted odds ratio (aOR) greater than 1.0 indicated more unfavorable outcomes on the care-needs levels at 1 year after invasive mechanical ventilation, with no care-needs levels before invasive mechanical ventilation as reference. Death at 1-year from invasive mechanical ventilation and death during the first hospitalization were analyzed with multivariable logistic regression models. Sensitivity analyses were performed among patients who survived during the first hospitalization. All statistical analyses were performed using STATA/SE version 17.0 software (STATA, College Station, TX).
RESULTS
Among the 593,990 eligible people identified, 4,198 (0.7%) received invasive mechanical ventilation except after cardiopulmonary resuscitation. The characteristics of the 4,198 patients are shown in Table 1. The mean age was 80.2 years (sd, 7.4 yr), and 56.7% were male. The overall incidence of invasive mechanical ventilation per 100,000 population per year was 213 (95% CI, 206–219) (Fig. 1; and Supplementary Table S3, http://links.lww.com/CCM/H299). The incidence rates increased as the preexisting care-needs levels increased, from 139 among people with no careneeds to 1,054 among people with care-needs level 5. The age-specific incidence was the lowest among people 65–69 years old (97 per 100,000 population per year) and the highest among people 80–84 years old (362 per 100,000 population per year). The sex-specific incidence was higher in males than in females. In total, 58.0%, 14.5%, 14.8%, and 12.8% of patients had no care-needs, support level 1–2 and care-needs level 1, care-needs level 2–3, and care-needs level 4–5 at the time of invasive mechanical ventilation, respectively.
TABLE 1.
Patient Characteristics Stratified by Preexisting Care-Needs Before Invasive Mechanical Ventilation
| Preexisting Care-Needs Before Invasive Mechanical Ventilation |
|||||
|---|---|---|---|---|---|
| Characteristics | Overall, n = 4,198 | No Care-Needs, n = 2,434 | Support Level 1–2 and CNL 1, n = 607 | CNL 2–3, n = 621 | CNL 4–5, n = 536 |
| Age (yr), mean (SD) | 80.5 (7.4) | 78.2 (6.9) | 83.4 (6.5) | 84.2 (6.9) | 83.6 (7.3) |
| Age (yr), median (interquartile range) | 81.0 (75.0–86.0) | 78.5 (73.0–83.0) | 84.0 (79.0–88.0) | 85.0 (80.0–89.0) | 85.0 (79.0–89.0) |
| Male, n (%) | 2,379 (56.7) | 1,516 (62.3) | 294 (48.4) | 315 (50.7) | 254 (47.4) |
| Long-term care services, n (%) | |||||
| Institutional service | 190 (4.5) | 2 (0.1) | 7 (1.2) | 60 (9.7) | 121 (22.6) |
| Home-based service | 1,075 (25.6) | 17 (0.7) | 247 (40.7) | 472 (76.0) | 339 (63.2) |
| Community-based service | 188 (4.5) | 1 (0.0) | 43 (7.1) | 82 (13.2) | 62 (11.6) |
| Charlson comorbidity index | 3.0 (2.7) | 2.8 (2.7) | 3.5 (2.7) | 3.5 (2.7) | 3.2 (2.6) |
| Main diagnosis, n (%) | |||||
| Acute heart failure | 1,485 (35.4) | 844 (34.7) | 254 (41.8) | 222 (35.7) | 165 (30.8) |
| Pneumonia | 1,004 (23.9) | 513 (21.1) | 160 (26.4) | 176 (28.3) | 155 (28.9) |
| Acute myocardial infarction | 262 (6.2) | 176 (7.2) | 39 (6.4) | 27 (4.3) | 20 (3.7) |
| Valvular heart disease | 348 (8.3) | 232 (9.5) | 47 (7.7) | 45 (7.2) | 24 (4.5) |
| Aortic disease | 222 (5.3) | 173 (7.1) | 24 (4.0) | 20 (3.2) | 5 (0.9) |
| Acute exacerbation of chronic obstructive pulmonary disease | 249 (5.9) | 179 (7.4) | 32 (5.3) | 19 (3.1) | 19 (3.5) |
| Intracranial hemorrhage | 313 (7.5) | 178 (7.3) | 62 (10.2) | 43 (6.9) | 30 (5.6) |
| Treatments during hospitalization, n (%) | |||||
| ICU admission | 1,168 (27.8) | 881 (36.2) | 131 (21.6) | 115 (18.5) | 41 (7.6) |
| High-dependency care unit admission | 773 (18.4) | 466 (19.1) | 133 (21.9) | 99 (15.9) | 75 (14.0) |
| Renal replacement therapy | 397 (9.5) | 261 (10.7) | 59 (9.7) | 58 (9.3) | 19 (3.5) |
| General surgery | 1,085 (25.8) | 814 (33.4) | 110 (18.1) | 106 (17.1) | 55 (10.3) |
| Vasopressors | 2,008 (47.8) | 1,278 (52.5) | 255 (42.0) | 279 (44.9) | 196 (36.6) |
| Inotropes | 709 (16.9) | 514 (21.1) | 81 (13.3) | 79 (12.7) | 35 (6.5) |
| Transfusion | 1,278 (30.4) | 901 (37.0) | 135 (22.2) | 144 (23.2) | 98 (18.3) |
| Extracorporeal membrane oxygenation | 42 (1.0) | 33 (1.4) | 3 (0.5) | 4 (0.6) | 2 (0.4) |
CNL = care-needs level.
Figure 1.
Incidence of invasive mechanical ventilation (IMV). Data are shown as rates per 100,000 population per year stratified by preexisting care-needs levels (CNLs). SL = support level.
The most common primary diagnosis was acute heart failure (35.4%), followed by pneumonia (23.9%). Patients with higher preexisting care-needs levels were less likely to receive intensive care treatments including ICU admission, high-dependency care unit admission, renal replacement therapy, general surgery, vasopressors, inotropes, and transfusion.
The overall 1-year mortality rate after invasive mechanical ventilation was 52.6% (n = 2,208/4,198) (Table 2). The 1-year mortality rates after invasive mechanical ventilation were 43.4%, 54.9%, 67.8%, and 74.1% in patients with no care-needs, support level 1–2 and care-needs level 1, care-needs level 2–3, and care-needs level 4–5, respectively. Kaplan-Meier curves showed that more than half of deaths occurred immediately after the initiation of invasive mechanical ventilation, and the 1-year mortality after invasive mechanical ventilation significantly varied by preexisting care-needs levels (Fig. 2).
TABLE 2.
Outcomes After Invasive Mechanical Ventilation Stratified by Preexisting Care Need Before Invasive Mechanical Ventilation
| Preexisting Care-Needs Before IMV |
|||||
|---|---|---|---|---|---|
| Characteristics | Overall, n = 4,198 | No Care-Needs, n = 2,434 | SL 1–2 and CNL 1, n = 607 | CNL 2–3, n = 621 | CNL 4–5, n = 536 |
| Primary outcome | |||||
| Care-needs at 1 yr after IMV, n (%) | |||||
| No care-needs | 821 (19.6) | 821 (33.7) | 0 (0.0) | 0 (0.0) | 0 (0.0) |
| SL 1–2 | 381 (9.1) | 212 (8.7) | 149 (24.5) | 15 (2.4) | 5 (0.9) |
| CNL 2–3 | 372 (8.9) | 174 (7.1) | 58 (9.6) | 123 (19.8) | 17 (3.2) |
| CNL 4–5 | 416 (9.9) | 170 (7.0) | 67 (11.0) | 62 (10.0) | 117 (21.8) |
| Death | 2,208 (52.6) | 1,057 (43.4) | 333 (54.9) | 421 (67.8) | 397 (74.1) |
| Secondary outcomes, n (%) | |||||
| Death during first hospitalization | 1,703 (40.6) | 818 (33.6) | 262 (43.2) | 319 (51.4) | 304 (56.7) |
| Changes in care-needs, n (%) | |||||
| Improved | 51 (1.2) | 0 (0.0) | 8 (1.3) | 18 (2.9) | 25 (4.7) |
| No change | 1,155 (27.5) | 821 (33.7) | 119 (19.6) | 111 (17.9) | 104 (19.4) |
| Worsened | 784 (18.7) | 556 (22.8) | 147 (24.2) | 71 (11.4) | 10 (1.9) |
| Death | 2,208 (52.6) | 1,057 (43.4) | 333 (54.9) | 421 (67.8) | 397 (74.1) |
CNL = care-needs level, IMV = invasive mechanical ventilation, SL = support level.
Figure 2.
Kaplan-Meier curves for 1-yr mortality after invasive mechanical ventilation. Data are stratified by preexisting care-needs levels (CNLs). SL = support level.
Figure 3 shows the graphical illustration of the care-needs levels at 1 year after the invasive mechanical ventilation stratified by preexisting care-needs levels. A total of 22.8%, 24.2%, 11.4%, and 1.9% of patients with no care-needs, support level 1–2 and care-needs level 1, care-needs level 2–3, and careneeds level 4–5 had worsened care-needs levels after invasive mechanical ventilation, respectively. There were few patients whose care-needs levels improved after 1 year from the invasive mechanical ventilation (Table 2). In the multivariable proportional odds model, compared with patients with no care-needs levels before invasive mechanical ventilation, the care-needs levels at 1 year after invasive mechanical ventilation were unfavorable in patients with support level 1–2 and care-needs level 1 (aOR, 1.72; 95% CI, 1.44–2.06), care-needs level 2–3 (aOR, 2.71; 95% CI, 2.23–3.29), and care-needs level 4–5 (aOR, 3.57; 95% CI, 2.86–4.45) (Table 3). Death at 1-year from invasive mechanical ventilation and death during the first hospitalization also showed unfavorable trends with higher preexisting care-needs levels. Results of sensitivity analyses among patients who survived during the first hospitalization (n = 2,495) were similar with those in the main analyses (Supplemental Tables S4 and S5, http://links.lww.com/CCM/H299).
Figure 3.
Graphical illustration of the mortality and care-needs levels (CNLs) at 1 yr after invasive mechanical ventilation. This is generated using a matrix of 100 icons to represent an at-risk population stratified by preexisting CNLs. A, No care-needs. B, Support level (SL) 1–2 and CNL 1. C, CNL 2–3. D, CNL 4–5.
TABLE 3.
Analysis of the Associations Between Preexisting Care-Needs Before Invasive Mechanical Ventilation and the Outcomes
| Outcomes | Preexisting Care-Needs Before IMV |
|||
|---|---|---|---|---|
| No Care-Needs | Support Level 1–2 | CNL 1–3 | CNL 4–5 | |
| Care-needs at 1 yr from IMV, aOR (95% CI) | Reference | 1.72 (1.44–2.06) | 2.71 (2.23–3.29) | 3.57 (2.86–4.45) |
| Death at 1 yr from IMV, aOR (95% CI) | Reference | 1.13 (0.92–1.39) | 1.78 (1.44–2.19) | 2.20 (1.74–2.78) |
| Death during first hospitalization, aOR (95% CI) | Reference | 1.09 (0.89–1.35) | 1.32 (1.07–1.62) | 1.40 (1.13–1.74) |
aOR = adjusted odds ratio, CNL = care needs level, IMV = invasive mechanical ventilation.
Outcomes were adjusted with age, sex, Charlson comorbidity index, main diagnosis, and treatments during hospitalization.
DISCUSSION
This population-based cohort study found three key results. First, the incidence of invasive mechanical ventilation increased as preexisting care-needs levels increased and was the highest in preexisting care-needs level 5. Second, among patients with preexisting care-needs level 2–5 who received invasive mechanical ventilation, 76.0–79.2% died or had worsened care-needs levels within 1 year. Third, the independent associations between preexisting care-needs levels and the outcomes were observed after adjusting for potential confounders.
This study revealed that the incidence of invasive mechanical ventilation for older adults with pre-existing care-needs level 2–3 or care-needs level 4–5 was six to eight times higher than those with no care-needs. In addition, invasive mechanical ventilation for patients with pre-existing care-needs levels 2–3 and 4–5 accounted for 14.8% and 12.8% of all invasive mechanical ventilation for adults greater than or equal to 65 years old or older, respectively. In previous studies on patients greater than or equal to 65 years old who received invasive mechanical ventilation in the United States, Canada, and Spain, 9.3%, 8.6%, and 2.2%, respectively, had dementia (14, 17, 18). The incidence rates of invasive mechanical ventilation with and without dementia for individuals greater than or equal to 65 years old in Spain were 6.9 and 253.3 per 100,000 population per year, respectively (18). Therefore, the current study found that in Japan, invasive mechanical ventilation was performed aggressively even at the end of trajectory of further decline in functional status.
In this study, the 1-year mortality rates for patients requiring invasive mechanical ventilation with preexisting care-needs levels 2–3 and 4–5 were 67.8% and 74.1%, respectively, and the rate was almost 25–30% worse than those with no care-needs. In contrast, previous studies in the United States observed that among patients who received invasive mechanical ventilation, patients diagnosed with dementia either had better or comparable 1-year mortality to those who did not (12, 16). This paradoxical finding in the United States suggested that patient selection might play a role when deciding whether to use invasive mechanical ventilation by considering patient’s values and goals (12, 16). Based on these previous results, our findings may represent the fact that patient selection through shared decision-making or advanced care planning is not often applied in daily practice for invasive mechanical ventilation in Japan (29).
One study suggested that many older adults may refuse a high-burden intervention if they knew it would result in substantial disability (30). In another study, outcomes for patients who required invasive mechanical ventilation were significantly worse than expected by their families and physicians. The results of the present study can promote discussions about goals of care and reduce unwanted aggressive intervention in older adults with preexisting long-term care-needs that also have poor functional and cognitive impairment at baseline.
Our study has some limitations. First, it is possible that some older adults who are not independent of their activity of daily living do not receive long-term care services. Therefore, there may be a misclassification of care-needs levels at the time of and after invasive mechanical ventilation. However, we believe this may be unlikely because of the large benefit of public long-term care services. Second, we assumed that the source population was all older adults greater than or equal to 65 years old in Japan. Given that the study samples were exclusively from Tochigi prefecture, there is a possible threat of internal validity. Third, the structure of long-term care differs among countries. The care-needs levels in the Long-Term Care Insurance services in Japan are not a universal concept. The results of this study were obtained in Japan, and thus, the generalizability to other countries may be limited. However, the care-needs levels reflected the Barthel index and cognitive function (24–26) very well, enhancing the generalizability of these levels. Fourth, we were unable to assess resuscitation status, although all included patients in the outcome analysis received invasive mechanical ventilation, indicating a preference for at least some life-sustaining therapy. In addition, we were unable to assess the code status of patients who did not receive invasive mechanical ventilation. Therefore, we were unable to examine the extent to which the selection was determined by the will of patient and family decision through a do-not-intubate order. Fifth, we were unable to include the timing of care-needs assessment following invasive mechanical ventilation in our model. Care-needs levels are reevaluated at 6–12-month intervals in principle, but if the reassessment was performed after 1 year from the invasive mechanical ventilation event, misclassification of the outcome may have occurred.
Despite these limitations, to our best knowledge, this study is the first to report substantial differences in long-term prognosis and changes in functional and cognitive impairment after invasive mechanical ventilation, according to a functional and cognitive impairment at baseline. In addition, the strength of this study was that the preexisting care-needs levels were prospectively assessed by a national standardized care-needs certification system. A major weakness of previous studies was retrospective assessment of preadmission functional and cognitive impairment typically by proxy (31).
CONCLUSIONS
Among patients in care-needs level 2–5 who receive invasive mechanical ventilation, 76.0–79.2% died or had worsened care-needs levels within 1 year. These findings can promote discussion for shared decision-making with patients, their families, and heath care professionals on the appropriateness of starting invasive mechanical ventilation for people with poor functional and cognitive status at baseline.
Supplementary Material
KEY POINTS.
Question:
What are the 1-year functional outcomes after invasive mechanical ventilation for adults aged greater than or equal to 65 years with preexisting long-term care-needs?
Findings:
This population-based cohort study in a prefecture of Japan showed that among patients with partial and complete dependence on long-term care who receive invasive mechanical ventilation, approximately 76.0–79.2% died or had worsened care-needs levels within 1 year.
Meanings:
When considering to initiate invasive mechanical ventilation for older adults with poor functional and cognitive status at baseline, this evidence aids the shared decision-making with patients, their families, and heath care professionals.
Acknowledgments
Supported, in part, by The Ministry of Education, Culture, Sports, Science, and Technology (Grant Number 19K19394). The opinions, results, and conclusions reported in this article are independent from the funding sources.
Dr. Ouchi is supported by the National Institute on Aging (K76AG064434) and Cambia Health Foundation and received support for article research from the National Institutes of Health. Dr. Yasunaga’s institution received funding from the Ministry of Health, Labour, and Welfare, Japan. Drs. Yasunaga’s and Sasabuchi’s institutions received funding from the Ministry of Education, Culture, Sports, Science and Technology, Japan.
Footnotes
The remaining authors have disclosed that they do not have any potential conflicts of interest.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).
REFERENCES
- 1.Fernando SM, McIsaac DI, Rochwerg B, et al. : Frailty and invasive mechanical ventilation: Association with outcomes, extubation failure, and tracheostomy. Intensive Care Med 2019; 45:1742–1752 [DOI] [PubMed] [Google Scholar]
- 2.Unroe M, Kahn JM, Carson SS, et al. : One-year trajectories of care and resource utilization for recipients of prolonged mechanical ventilation: A cohort study. Ann Intern Med 2010; 153:167–175 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.A controlled trial to improve care for seriously ill hospitalized patients: The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). The SUPPORT principal investigators. JAMA 1995; 274:1591–1598 [PubMed] [Google Scholar]
- 4.Richardson SS, Sullivan G, Hill A, et al. : Use of aggressive medical treatments near the end of life: Differences between patients with and without dementia. Health Serv Res 2007; 42:183–200 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Boumendil A, Angus DC, Guitonneau AL, et al. : Variability of intensive care admission decisions for the very elderly. PLoS One 2012; 7:e34387 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Guidet B, Leblanc G, Simon T, et al. : Effect of systematic intensive care unit triage on long-term mortality among critically ill elderly patients in France: A randomized clinical trial. JAMA 2017; 318:1450–1459 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Heyland DK, Cook DJ, Rocker GM, et al. : Decision-making in the ICU: Perspectives of the substitute decision-maker. Intensive Care Med 2003; 29:75–82 [DOI] [PubMed] [Google Scholar]
- 8.Khandelwal N, Kross EK, Engelberg RA, et al. : Estimating the effect of palliative care interventions and advance care planning on ICU utilization: A systematic review. Crit Care Med 2015; 43:1102–1111 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.George NR, Kryworuchko J, Hunold KM, et al. : Shared decision making to support the provision of palliative and end-of-life care in the emergency department: A consensus statement and research agenda. Acad Emerg Med 2016; 23:1394–1402 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Ouchi K, Jambaulikar GD, Hohmann S, et al. : Prognosis after emergency department intubation to inform shared decision-making. J Am Geriatr Soc 2018; 66:1377–1381 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Bouza C, Martínez-Alés G, López-Cuadrado T: Recent trends of invasive mechanical ventilation in older adults: A nationwide population-based study. Age Ageing 2021; 50:1607–1615 [DOI] [PubMed] [Google Scholar]
- 12.Pisani MA, Redlich CA, McNicoll L, et al. : Short-term outcomes in older intensive care unit patients with dementia. Crit Care Med 2005; 33:1371–1376 [DOI] [PubMed] [Google Scholar]
- 13.Barnato AE, Albert SM, Angus DC, et al. : Disability among elderly survivors of mechanical ventilation. Am J Respir Crit Care Med 2011; 183:1037–1042 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Lagu T, Zilberberg MD, Tjia J, et al. : Use of mechanical ventilation by patients with and without dementia, 2001 through 2011. JAMA Intern Med 2014; 174:999–1001 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Teno JM, Gozalo P, Khandelwal N, et al. : Association of increasing use of mechanical ventilation among nursing home residents with advanced dementia and intensive care unit beds. JAMA Intern Med 2016; 176:1809–1816 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Lagu T, Zilberberg MD, Tjia J, et al. : Dementia and outcomes of mechanical ventilation. J Am Geriatr Soc 2016; 64:e63–e66 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Borjaille CZ, Hill AD, Pinto R, et al. : Rates of mechanical ventilation for patients with dementia in Ontario: A population-based cohort study. Anesth Analg 2019; 129:e122–e125 [DOI] [PubMed] [Google Scholar]
- 18.Bouza C, Martínez-Alés G, López-Cuadrado T: Effect of dementia on the incidence, short-term outcomes, and resource utilization of invasive mechanical ventilation in the elderly: A nationwide population-based study. Crit Care 2019; 23:291. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Ikegami N, Yoo BK, Hashimoto H, et al. : Japanese universal health coverage: Evolution, achievements, and challenges. Lancet 2011; 378:1106–1115 [DOI] [PubMed] [Google Scholar]
- 20.Yasunaga H: Real world data in Japan: Chapter I: NDB. Ann Clin Epidemiol 2019; 1:28–30 [Google Scholar]
- 21.Tamiya N, Noguchi H, Nishi A, et al. : Population ageing and wellbeing: Lessons from Japan’s long-term care insurance policy. Lancet 2011; 378:1183–1192 [DOI] [PubMed] [Google Scholar]
- 22.Iwagami M, Tamiya N: The long-term care insurance system in Japan: Past, present, and future. JMA J 2019; 2:67–69 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Tsutsui T, Muramatsu N: Care-needs certification in the long-term care insurance system of Japan. J Am Geriatr Soc 2005; 53:522–527 [DOI] [PubMed] [Google Scholar]
- 24.MatsudT, IwagamM, SuzukT, et al. l: Correlation between the Barthel index and care need levels in the Japanese long-term care insurance system. Geriatr Gerontol Int 2019; 19:1186–1187 [DOI] [PubMed] [Google Scholar]
- 25.Lin HR, Otsubo T, Imanaka Y: The effects of dementia and long-term care services on the deterioration of care-needs levels of the elderly in Japan. Med (Baltim) 2015; 94:e525. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Lin HR, Otsubo T, Imanaka Y: Survival analysis of increases in care needs associated with dementia and living alone among older long-term care service users in Japan. BMC Geriatr 2017; 17:182. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Quan H, Li B, Couris CM, et al. : Updating and validating the Charlson comorbidity index and score for risk adjustment in hospital discharge abstracts using data from 6 countries. Am J Epidemiol 2011; 173:676–682 [DOI] [PubMed] [Google Scholar]
- 28.French B, Shotwell MS: Regression models for ordinal outcomes. JAMA 2022; 328:772–773 [DOI] [PubMed] [Google Scholar]
- 29.Hammes BJ, Rooney BL, Gundrum JD: A comparative, retrospective, observational study of the prevalence, availability, and specificity of advance care plans in a county that implemented an advance care planning microsystem. J Am Geriatr Soc 2010; 58:1249–1255 [DOI] [PubMed] [Google Scholar]
- 30.Fried TR, Bradley EH, Towle VR, et al. : Understanding the treatment preferences of seriously ill patients. N Engl J Med 2002; 346:1061–1066 [DOI] [PubMed] [Google Scholar]
- 31.Hennessy D, Juzwishin K, Yergens D, et al. : Outcomes of elderly survivors of intensive care: A review of the literature. Chest 2005; 127:1764–1774 [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.