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(Chest. 2003;124:1039-1045.)
© 2003 American College of Chest Physicians

Risk Assessment for Inpatient Survival in the Long-term Acute Care Setting After Prolonged Critical Illness*

Jane E. Dematte D’Amico, MD, FCCP; Helen K. Donnelly, RN; Gökhan M. Mutlu, MD, FCCP; Joseph Feinglass, PhD; Borko D. Jovanovic, PhD and Ikeadi Maurice Ndukwu, MD, MPH, FCCP

* From the Department of Medicine, Division of Pulmonary and Critical Care (Drs. Dematte D’Amico and Mutlu, and Ms. Donnelly) and Department of Preventive Medicine (Drs. Feinglass and Jovanovic), Northwestern University Feinberg School of Medicine, Chicago, IL; and The Medical Group of Michigan City, PC (Dr. Ndukwu), Michigan City, IN.

Correspondence to: Jane E. Dematte D’Amico, MD, FCCP, Department of Medicine, Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, 303 E. Chicago Ave, Tarry 14-707, Chicago IL 60611; e-mail: j-dematte{at}northwestern.edu


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Objective: The past decade has witnessed growth in the long-term acute care (LTAC) hospital industry. There are no reliable risk assessment models that can adjust outcomes across such facilities with different criteria for admitting patients. Variation in reported outcomes makes it difficult to determine whether a patient, or group of patients, may benefit from such care. This study sought to determine the extent to which survival in the LTAC setting is associated with age, race, residual organ system failures (OSFs), or APACHE (acute physiology and chronic health evaluation) III scores at the time of admission to LTAC.

Design: Retrospective medical record review.

Setting: Four freestanding facilities of a LTAC hospital.

Patients: A sample of 300 hospital admissions weighted to represent the study hospital population.

Measurements: Inpatient survival modeled as a function of age, APACHE III score calculated within 72 h prior to LTAC admission, and residual OSFs present on admission to LTAC.

Results: Logistic regression analysis shows age and OSF were most predictive of inpatient survival (receiver operating characteristic curve area = 0.81). APACHE III score was not predictive of survival in the multivariate model.

Conclusions: Survival in LTAC is primarily associated with age and OSFs, which should be used to adjust for patient populations among LTAC settings when comparing outcomes. Our model identifies a group of patients with the poorest likelihood of survival in the LTAC setting, and may be used to facilitate dialogue with patients and family in cases where continued aggressive care is least effective.

Key Words: acute physiology and chronic health evaluation • long-term acute care • multiple organ failure • risk assessment


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
Studies evaluating the impact of long-term acute care (LTAC) hospitals on patient outcome have focused on patients requiring mechanical ventilation. In this context, LTAC hospitals have been compared with other types of weaning units.1 2 3 4 5 6 7 8 9 10 11 12 13 Survival until discharge in these settings ranged between 48% and 93%, and long-term survival ranged from as low as 23% at 1 year to as high as 53% at 4 years.1 2 3 4 5 6 7 8 9 10 11 12 13 The variability in reported success may be explained by differences among hospital admission criteria, case mix, and referral patterns. The primary aim of our study was to determine if survival of a cohort of patients admitted to an LTAC hospital could be predicted by age, race, number of residual organ system failures (OSFs) at the time of admission to the LTAC hospital, or APACHE (acute physiology and chronic health evaluation) III score at the time of admission to the LTAC.

A number of models exist that predict survival in the ICU setting. One such early model was developed using cumulative OSFs over 7 days.12 The most well-known prognostic systems are those of APACHE medical systems, APACHE II and APACHE III scores, which describe a method for assessing group death rates among ICU admissions using first-day risk assessment.14 15 While of limited value for individual management decisions, they are useful for risk stratification, research, quality assurance, and utilization review.16 APACHE III is a proprietary tool. Other scoring systems include the Sequential Organ Failure Assessment,17 Therapeutic Intervention Scoring System,18 Mortality Prediction Model,19 and the Simplified Acute Physiology Score II.20 21 Most prognostic scoring systems, similar to APACHE, use the worst values in the first 24 h after ICU admission and thus do not account for the impact of response to therapy on prognosis. Serial reprognostication using modified APACHE III formulas was hoped to yield a dynamic risk of death with more reliable estimates of individual risk.16 The probability of survival decreased when the acute physiology score (APS) component of the modified APACHE III score increased over the first several days; it also increased, to a lesser degree, when the APS failed to improve.

Caution must be used when applying a model to a population other than that in which it was developed. APACHE III, when applied to a group of ICUs in the United Kingdom, overestimated death and had poor calibration and uniformity of fit.22 No predictive or descriptive models, to the best of our knowledge, have been developed in patients surviving the acute phase of critical illness requiring LTAC. Our objective was to determine the extent to which survival in these patients is associated with age, race, residual OSFs, or APACHE III score on admission to LTAC.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
Setting
The study included patients who were admitted from a diversity of area hospitals to one of four freestanding facilities of an LTAC hospital. These facilities are geographically independent and draw patients from different communities, primarily from within Chicago and neighboring areas. Each facility has a fully equipped ICU. Telemetry monitoring is available on the medical floors at each facility, and some of the facilities have a designated step-down unit. Services critical to successful rehabilitation of the long-term, acutely ill patient were available at all four facilities on a full-time basis. These services include respiratory, physical and occupational, and speech and swallowing therapy. A clinical psychologist evaluates most patients on LTAC admission by consultation. Basic radiology and laboratory services are available 24 h a day.

Attending staff physicians are board certified in their specialties. Pulmonary consultation is required for all patients receiving mechanical ventilation. All facilities had consultation services available in most medical and surgical subspecialties. Hemodialysis is conducted on site. Physicians provide in-house nighttime coverage for all patients.

Study Design
The study was a retrospective medical record review conducted on a sample of patients admitted directly from an acute care facility to any one of the four facilities between January 1, 1999, and June 30, 1999, and already discharged at the time of chart review. The number of medical records reviewed at each facility was proportional to the average daily census at that facility for the first 6 months of 1999. Charts were consecutively reviewed beginning with the first LTAC admission for each month until the predetermined number of charts for the month was met, and review then began with the following month. Patients were excluded if they were not admitted from an acute care facility, or had not yet been discharged from the LTAC. As there was an overselection of patients who died, analyses were also performed with weighting to reflect the incidence of mortality for a representative population of unselected patients from the same LTAC hospital. Because differences were very slight, only unweighted results are reported below.

Measurements
Data were collected using a predesigned form that included patient demographics, APACHE III, basic laboratory data, vital signs, utilization of mechanical ventilation or hemodialysis, LTAC admission medications, major acute care diagnoses, major comorbidities, route of feeding, presence of urinary or IV catheters, resuscitation status at acute care and at LTAC, date of discharge, and discharge disposition. Follow-up organ system function was assessed at day 28 after admission to the LTAC facility in those who remained at the LTAC. After all data abstraction was complete, three of the authors reviewed all data sheets and assigned, by consensus, OSFs. Based on the predetermined objective criteria set to define each OSF, there was no disagreement among the three authors regarding the presence or absence of an OSF. The APACHE III scores were calculated by the LTAC area case managers who screened patients for transfer. Scores were calculated from data obtained from the acute care hospital chart 24 to 72 h prior to transfer to the LTAC; these are hereafter referred to as LTAC admission APACHE III scores. There is no prescreening for rehabilitation or weaning potential at this LTAC.

Criteria for OSFs
Criteria for OSFs were modified to reflect subacute or chronic organ failure (Table 1 ) and to ensure consistency and objectivity as three of the authors (J.E.D.D., H.K.D., G.M.M.) performed chart abstraction. An OSF score was calculated for each subject by assigning one point for each OSF in an unweighted fashion. The score of one was assigned for the CNS only if the patients were unresponsive.


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  		Table 1. Criteria, Prevalence, and Outcome of OSFs

 
Statistical Analysis
The relative risk of mortality associated with each OSF category, APACHE III score, age, and African-American ethnicity were assessed using {chi}2 statistics. Multiple logistic regression with forced entry was used to determine the effect of age, OSF score, and LTAC admission APACHE III on the logs odds of inpatient survival. The area under the receiver operating characteristic curve was computed to measure model discrimination. The Hosmer-Lemeshow test was used to measure model calibration. Kaplan-Meier survival analysis was used to compare inpatient survival probabilities, as well as day-28 survival probabilities, among subjects in different OSF categories. A paired Student t test was used to compare the change in OSF score between LTAC admission and day 28. Statistical analyses were performed using Statview version 5.0 (SAS Institute; Cary, NC).

The project was reviewed and approved by the Institutional Review Board of Northwestern University. Informed consent was waived in accordance with the Department of Health and Human Services regulations for the protection of human research subjects 45 CFR 46.116(d).


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
A total of 300 records were reviewed, of which 285 were eligible for analysis; exclusions from analysis were due primarily to inadequate information regarding organ system function. The primary diagnosis at the acute care hospital was available in 87% of patients, and complete data regarding comorbidities were available in 69% of patients. These data are summarized, along with demographic data, in Table 2 . Comorbidities that occurred in at least 5% of patients are shown. On LTAC admission, urinary catheters were present in 75% of patients, feeding tubes in 64%, and central venous catheters in 45%.


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  		Table 2. Patient Characteristics

 
The number of patients with each OSF and the associated percent mortality with the OSF are shown in Table 1 . Survival is compared among subjects in different OSF categories in Figure 1 . One patient with six OSFs and nine patients with five OSFs are grouped together with patients with four OSFs, resulting in five OSF categories. The relative risks of mortality in those with OSFs, compared to those with no OSFs, were 3.3 with one OSF (confidence interval [CI], 1.4 to 7.8; p < .001), 11.9 with two OSFs (CI, 4.8 to 29.6; p < .001), 31.3 with three OSFs (CI, 9.1 to 107.3; p < .001), and 58.2 with four or more OSFs (CI, 12.0 to 281.6; p < .001). No patient with more than two OSFs returned home at LTAC discharge (Fig 1) . Logistic regression indicated significant predictors of mortality were age group (age < 60 years, age 60 to 74 years, age > 74 years), OSF score, and APACHE III score. The impact of age on survival for each OSF category is shown in Figure 2 . African-American ethnicity was not a significant predictor of mortality, and hence was not included in multivariate analysis. When taken together, age group and OSF score remained significant predictors of survival, but not APACHE III score. Results of the multivariate logistic regression for inpatient survival are shown in Table 3 . The area under the receiver operating characteristic curve for the prediction equation was 0.81 (p < 0.001) indicating good model discrimination. The Hosmer-Lemeshow test p value was 0.39, indicating good model calibration.



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  		Figure 1. Survival and mortality by OSF category. Inset depicts discharge destination of survivors. Patients readmitted to acute care were excluded from analysis, as ultimate disposition was unknown. Numbers in parentheses along the x-axis show number of subjects in each category.

 


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  		Figure 2. The impact of age on the probability of survival for each OSF category. *This data point represents only four observations in this group.

 

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  		Table 3. Multivariate Logistic Regression Analysis of Inpatient Survival*

 
A Kaplan-Meier survival analysis comparing inpatient survival probabilities among those in different OSF categories (none, single, or multiple) is shown in Figure 3 (log-rank test, p < 0.0001). Most patients with no OSFs were removed from analysis due to discharge from the LTAC facility, whereas patients with four or more OSFs were removed from analysis primarily due to death. No effort was made to determine the long-term survival of those discharged alive. A Kaplan-Meier survival analysis comparing survival at 28 days after LTAC admission in the same groups yielded similar results, with a log-rank test p value < 0.0001.



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  		Figure 3. Kaplan-Meier analysis comparing survival among subjects with no, single, or multiple OSFs. Inset of the first 100 days enlarges the densest area of the curve. Most patients with no OSFs were censored (discharged alive). Most with four or more OSFs were removed at death; log-rank p < 0.0001.

 
Of those patients who remained at the LTAC at day 28 (n = 159), OSF score increased in those who ultimately died (p = 0.05) and decreased by half in those who were subsequently discharged home (p = 0.04). There was a nonsignificant trend toward improvement in those who were discharged to nursing homes (p = 0.07), and no change in those who were eventually transferred to acute care.


   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
Our data show that outcome in the LTAC setting can be predicted from age and number of residual OSFs present at admission to the LTAC hospital. Our OSF score is a simple assessment that requires few laboratory values and appears to be a good discriminator of survivors and decedents.

Long-term care hospitals were originally founded to care for patients with chronic illness in need of extended care. They have evolved over the past 2 decades to fill a need created by the Health Care Finance Administration implementation of a prospective payment system to acute care hospitals. This system of reimbursement made it financially difficult for acute care hospitals to continue to deliver care to increasing numbers of patients surviving catastrophic critical illness with multiple complex medical problems requiring prolonged hospitalization.23 24 25 Hence, long-term hospitals have developed to assume the post-ICU care of these patients, and have become known as long-term acute care hospitals. Because of the typically long length of stay of their patients, LTAC hospitals have been exempt from a prospective payment system, and reimbursement is based on the Tax Equity and Fiscal Responsibility Act cost-basis reimbursement.26 The LTAC hospital is, by design, intended to deliver care to high-acuity, medically complex patients more efficiently in part by concentrating patients with similar needs in one geographic location.1 24 27 Over the 6-year period from 1990 to 1996, the number of LTAC hospitals increased 106%, from 90 to 185 hospitals.28

It is important to differentiate groups of patients being cared for in the LTAC setting. Some patients are transferred with the goal of continued recovery from catastrophic illness with a return to previous level of independence and home discharge. Others are transferred, despite a very low potential for continued recovery, primarily to unburden the acute care hospital ICUs. In these cases, potential for recovery may be uncertain at the time of transfer. Alternatively, the health-care team, patients, and or families may have unrealistic goals and expectations leading to a continued desire for aggressive medical care. An emerging literature describing the experiences of patients undergoing critical care brings us recognition of the pain and suffering associated with its administration.29 30 The number of patients in our facilities who were receiving mechanical ventilation and required instrumentation suggest that their care was similarly burdened. Families of these patients may also suffer serious consequences related to loss of income and devastation of savings. While this has been attributed to costs related to disability and home care,31 in our experience, families of patients in the LTAC setting suffer similar consequences. Appropriate decisions at an earlier stage of hospitalization may help to ease this burden on patients and families. In our study, survival was < 10% for those with more than two OSFs at LTAC admission, with none returning home. Furthermore, none of these patients had improvement in OSFs after 28 days in the LTAC facility. It seems plausible that many had the dying process prolonged by aggressive medical interventions in what may be termed ineffective care.32 By identifying such patients, a dialogue may ensue with patients and families to explore other options for care focusing on the quality of death. Such options may include withdrawal of life support, greater focus on palliation of symptoms, and or hospice care. While the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments33 demonstrated that prognostic information provided to physicians did not alter outcomes related to resuscitation orders or aggressiveness of care in the acute hospital setting, it is plausible that such information provided at a later stage of illness may have a greater impact on physicians and families.

Our study differs from previous outcome studies conducted in the LTAC setting, as it was not limited to ventilator-dependent patients. During calendar year 2000, only 39% of patients admitted to the four facilities of the LTAC hospital contributing patients to this study were ventilator dependent.

We are cognizant of concerns regarding publication of results showing dismal outcome of patients receiving prolonged mechanical ventilation in the LTAC setting.34 We concur with the view of Carson et al,3 that lack of selection criteria at some LTAC hospitals results in a variable patient population. This may not imply that patients not meeting selection criteria are inappropriate for transfer but rather that patients with established OSFs in the ICU setting, showing no trend toward improvement, have a poor prognosis regardless of whether they remain in the acute setting or are transferred to an LTAC setting. This is suggested by data on serial measurement of APACHE III APS scores over the first 7 days of ICU care.16 Mortality was not only higher in those with escalating APS scores, but also in those with stable scores that were not decreasing. The simple prediction score presented here, once validated prospectively, may be useful to control for differences in patient populations when comparing outcomes in different LTAC settings.

There are limitations to our study. While it was conducted at only one LTAC hospital, this hospital has four facilities that draw patients from a large geographic area. Nevertheless, our findings need to be validated in a broader population encompassing patients from other LTAC settings. Another limitation is that mortality after discharge was not pursued. Another study3 of ventilator-dependent patients from a similar LTAC setting showed that mortality 1 year after discharge from an LTAC is high. Our review was retrospective, as such the findings regarding predictability of death based on OSFs must be confirmed prospectively. In addition, we did not test for interobserver variability in chart abstraction, and medical record reviews were not blinded to outcome. This may have led to some bias in recording OSFs despite our attempt to define them objectively. Despite these limitations, data from this study may be important to health-care providers in understanding the role of LTAC hospitals in caring for patients surviving critical illness. Furthermore, it might be important for patients and family members in developing realistic expectations regarding outcomes. This, in turn, may impact decisions made regarding future medical interventions.


   Acknowledgements
 
The authors thank Dr. Jacob I. Sznajder and Dr. Kevin Weiss for their critical review of the manuscript.


   Footnotes
 
Abbreviations: APACHE = acute physiology and chronic health evaluation; APS = acute physiology score; CI = confidence interval; LTAC = long-term acute care; OSF = organ system failure

Northwestern Medical Faculty Foundation has a contract with the long-term acute care facility known as Kindred (previously Vencor) to provide services as the medical director of the special care unit at Lake Shore. The facilities from which patients were identified for this study were Kindred facilities. Dr. Dematte D’Amico provides this service for Northwestern Medical Faculty Foundation. The per hour stipend received for this service does not directly benefit her.

Received for publication September 4, 2002. Accepted for publication February 14, 2003.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

  1. Bagley, PH, Cooney, E (1997) A community-based regional ventilator weaning unit: development and outcomes. Chest 111,1024-1029[ISI][Medline]
  2. Bach, PB, Carson, SS, Leff, A Outcomes and resource utilization for patients with prolonged critical illness managed by university-based or community-based subspecialists. Am J Respir Crit Care Med 1998;158(5 pt 1),1410-1415
  3. Carson, SS, Bach, PB, Brzozowski, L, et al Outcomes after long-term acute care: an analysis of 133 mechanically ventilated patients. Am J Respir Crit Care Med 1999;159,1568-1573[Abstract/Free Full Text]
  4. Dasgupta, A, Rice, R, Mascha, E, et al Four-year experience with a unit for long-term ventilation (respiratory special care unit) at the Cleveland Clinic Foundation. Chest 1999;116,447-455[CrossRef][ISI][Medline]
  5. Gluck, EH Predicting eventual success or failure to wean in patients receiving long-term mechanical ventilation. Chest 1996;110,1018-1024[Medline]
  6. Gracey, DR, Viggiano, RW, Naessens, JM, et al Outcomes of patients admitted to a chronic ventilator-dependent unit in an acute-care hospital. Mayo Clin Proc 1992;67,131-136[ISI][Medline]
  7. Gracey, DR, Naessens, JM, Viggiano, RW, et al Outcome of patients cared for in a ventilator-dependent unit in a general hospital. Chest 1995;107,494-499[Medline]
  8. Gracey, DR, Hardy, DC, Naessens, JM, et al The Mayo Ventilator-Dependent Rehabilitation Unit: a 5-year experience. Mayo Clin Proc 1997;72,13-19[ISI][Medline]
  9. Indihar, FJ A 10-year report of patients in a prolonged respiratory care unit. Minn Med 1991;74,23-27[ISI][Medline]
  10. Latriano, B, McCauley, P, Astiz, ME, et al Non-ICU care of hemodynamically stable mechanically ventilated patients. Chest 1996;109,1591-1596[ISI][Medline]
  11. Nava, S, Rubini, F, Zanotti, E, et al Survival and prediction of successful ventilator weaning in COPD patients requiring mechanical ventilation for more than 21 days. Eur Respir J 1994;7,1645-1652[Abstract]
  12. Knaus, WA, Draper, EA, Wagner, DP, et al Prognosis in acute organ-system failure. Ann Surg 1985;202,685-693[ISI][Medline]
  13. Scheinhorn, DJ, Chao, DC, Stearn-Hassenpflug, M, et al Post-ICU mechanical ventilation: treatment of 1,123 patients at a regional weaning center. Chest 1997;111,1654-1659[ISI][Medline]
  14. Knaus, WA, Draper, EA, Wagner, DP, et al APACHE II: a severity of disease classification system. Crit Care Med 1985;13,818-829[ISI][Medline]
  15. Knaus, WA, Wagner, DP, Draper, EA, et al The APACHE III prognostic system: risk prediction of hospital mortality for critically ill hospitalized adults. Chest 1991;100,1619-1636[ISI][Medline]
  16. Wagner, DP, Knaus, WA, Harrell, FE, et al Daily prognostic estimates for critically ill adults in intensive care units: results from a prospective, multicenter, inception cohort analysis. Crit Care Med 1994;22,1359-1372[ISI][Medline]
  17. Vincent, JL, Moreno, R, Takala, J, et al The SOFA (sepsis-related organ failure assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med 1996;22,707-710[ISI][Medline]
  18. Cullen, DJ, Civetta, JM, Briggs, BA, et al Therapeutic intervention scoring system: a method for quantitative comparison of patient care. Crit Care Med 1974;2,57-60[Medline]
  19. Lemeshow, S, Teres, D, Pastides, H, et al A method for predicting survival and mortality of ICU patients using objectively derived weights. Crit Care Med 1985;13,519-525[ISI][Medline]
  20. Le Gall, JR, Loirat, P, Alperovitch, A, et al A simplified acute physiology score for ICU patients. Crit Care Med 1984;12,975-977[ISI][Medline]
  21. Le Gall, JR, Lemeshow, S, Saulnier, F A new simplified acute physiology score (SAPS II) based on a European/North American multicenter study. JAMA 1993;270,2957-2963[Abstract]
  22. Pappachan, JV, Millar, B, Bennett, ED, et al Comparison of outcome from intensive care admission after adjustment for case mix by the APACHE III prognostic system. Chest 1999;115,802-810[Medline]
  23. Bone, RC Long-term ventilator care: a Chicago problem and a national problem. Chest 1987;92,536-539[Medline]
  24. Elpern, EH, Silver, MR, Rosen, RL, et al The noninvasive respiratory care unit: patterns of use and financial implications. Chest 1991;99,205-208[Medline]
  25. Gracey, DR, Nobrega, FT, Naessens, JM, et al Financial implications of prolonged ventilator care under DRGs 474 and 475. Chest 1989;96,193-194[Medline]
  26. Hotes, LS, Kalman, E The evolution of care for the chronically critically ill patient. Clin Chest Med 2001;22,1-11[CrossRef][ISI][Medline]
  27. Scheinhorn, DJ, Artinian, BM, Catlin, JL Weaning from prolonged mechanical ventilation: the experience at a regional weaning center. Chest 1994;105,534-539[Medline]
  28. Liu, K, Gage, B, Harvell, J, et al Medicare’s post-acute care benefit: background, trends, and issues to be faced. January 1999 US Department of Health and Human Services Available at: http://aspe.os.dhhs.gov/daltcp/reports/mpacb.htm; accessed August 18, 2003
  29. Desbiens, NA, Mueller-Rizner, N, Connors, AF, Jr, et al The symptom burden of seriously ill hospitalized patients. J Pain Symptom Manage 1999;17,248-255[CrossRef][ISI][Medline]
  30. Nelson, JE, Meier, DE, Oei, EJ, et al Self-reported symptom experience of critically ill cancer patients receiving intensive care. Crit Care Med 2001;29,449-450[CrossRef][ISI][Medline]
  31. Covinsky, KE, Goldman, L, Cook, EF, et al The impact of serious illness on patients’ families. SUPPORT Investigators: Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment. JAMA 1994;272,1839-1844[Abstract]
  32. Cher, DJ, Lenert, LA Method of Medicare reimbursement and the rate of potentially ineffective care of critically ill patients. JAMA 1997;278,1001-1007[Abstract]
  33. The SUPPORT Principal Investigators.. 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). JAMA 1996;274,1591-1598
  34. Scheinhorn, DJ Outcomes after acute care: analysis of 133 mechanically ventilated patients. Am J Respir Crit Care Med 1999;160(5 pt 1),1788-1789



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