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Survival after ICU discharge is shaped more by chronic disease than admission severity
Alice Blet1, Anouk Walter-Petrich2, Ményssa Chérifa3
1AP-HP, Lariboisière - Saint-Louis Hospitals, Department of Anesthesia, Critical Care and Burn Center, Paris, France; Université Paris Cité, Inserm, Paris, France; INSERM U942 MASCOT, Inserm, Paris, France.
Insights
Pre-existing chronic conditions, measured by the Charlson Comorbidity Index (CCI), are key predictors of survival after intensive care unit (ICU) discharge. The CCI outperformed acute illness severity scores in predicting both short- and long-term mortality.
Area of Science:
- Critical Care Medicine
- Prognostic Biomarkers
- Health Outcomes Research
Background:
- High mortality rates persist during intensive care unit (ICU) stays and in the year following discharge.
- Factors influencing long-term post-ICU survival are not well understood.
- Pre-existing chronic conditions may significantly impact long-term outcomes.
Purpose of the Study:
- To investigate the association between pre-existing chronic conditions and post-ICU survival.
- To compare the prognostic value of chronic conditions with acute illness severity and admission diagnoses.
- To evaluate predictors of one-year mortality after ICU discharge.
Main Methods:
- Post-hoc analysis of the prospective, observational, multicenter FROG-ICU cohort (n=1400).
- Inclusion of ICU survivors with complete data on severity scores (SOFA, SAPS-II), comorbidities (CCI), and biomarkers.
- Assessment of one-year mortality associations using Cox models and time-dependent AUC for discriminatory performance.
Main Results:
- The Charlson Comorbidity Index (CCI) was the strongest predictor of mortality at 7 days (AUC 0.70) and 3 weeks (AUC 0.75).
- CCI maintained strong predictive value over one year, outperforming SAPS-II and SOFA scores.
- Biomarkers showed comparable short-term discrimination, but CCI excelled in predicting long-term outcomes across various admission diagnoses.
Conclusions:
- Pre-existing chronic conditions, assessed by CCI, are primary drivers of short- and long-term survival post-ICU discharge.
- The prognostic value of chronic conditions exceeds that of acute illness severity at ICU admission.
- CCI is a crucial tool for assessing long-term prognosis in ICU survivors.
Background:
Mortality is high both during intensive care unit (ICU) stay and in the year following discharge, yet factors influencing long-term survival remain poorly defined. We hypothesized that pre-existing chronic conditions may be more strongly associated with post-ICU survival than acute illness severity or admission diagnosis.
Methods:
This is a post-hoc analysis of the prospective, observational, multicenter FROG-ICU cohort, which included all consecutive patients admitted to 21 French ICUs and followed for one year after discharge. ICU survivors with complete data on admission severity scores (Sequential Organ Failure Assessment [SOFA], Simplified Acute Physiology Score II [SAPS-II]), comorbidities (Charlson Comorbidity Index [CCI]), and cardiovascular/renal biomarkers at discharge (n = 1400) were included. Associations with one-year mortality were assessed using Cox models. Discriminatory performance was evaluated with time-dependent area under the receiver operating characteristic curve (AUC).
Results:
Among 1548 ICU survivors, 1400 were analyzed (median age 61 years, 63 % male). Admission diagnoses included acute respiratory failure (19 %), septic shock (24 %), and neurologic conditions (16 %). The CCI was the strongest predictor of mortality at day 7 (AUC 0.70 [95 % Confidence Interval [CI], 0.64-0.77]), at 3 weeks (AUC 0.75 [0.69-0.78]), and remained high over one year, outperforming SAPS-II (0.63 [0.54-0.72]) and SOFA (0.61 [0.53-0.68]). Although cardiovascular (NT-proBNP, bio-ADM) and kidney (pNGAL) biomarkers had comparable short-term discriminatory value, CCI performed better for long-term outcomes across different admission diagnoses.
Conclusion:
In this analysis, pre-existing chronic conditions were primary drivers of short- and long-term survival after ICU discharge, exceeding prognostic value of acute illness severity at admission.
Clinical Trial Registration:
French and European Outcome Registry in Intensive Care Units (FROG-ICU) study: ClinicalTrials.govNCT01367093. Registered 3 June 2011.
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