| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
(Stroke. 2000;31:2346.)
© 2000 American Heart Association, Inc.
Original Contributions |
Cost and Outcome of Mechanical Ventilation for Life-Threatening Stroke
From the Department of Neurology (S.A.M., D.C., G.L.B., B.B-A., L.L., S.K., R.L.S.) and the Gertrude H. Sergievsky Center (R.L.S.), Columbia University College of Physicians and Surgeons, and the Divisions of Epidemiology (R.L.S.) and Socio-Medical Science (B.B-A.), Columbia University School of Public Health, New York, NY.
 |
Abstract |
|---|
 Top Abstract IntroductionSubjects and MethodsResultsDiscussionReferences |
|---|
Background and Purpose—Hospital mortality rates of 50% to 90% have been reported for stroke patients treated with mechanical ventilation. These data have raised serious questions about the cost-effectiveness of this intervention. We sought to determine how often stroke patients are mechanically ventilated, identify predictors of 30-day survival among ventilated patients, and evaluate the cost-effectiveness of this intervention.
Methods—We identified mechanically ventilated patients in a population-based multiethnic cohort of 510 incidence stroke patients who were hospitalized between July 1993 and June 1996. Factors affecting 30-day survival were identified in a multiple logistic regression analysis. We calculated the cost per patient discharged alive, life-year saved, and quality-adjusted life-year saved using a zero-cost, zero-life assumption.
Results—Ten percent of patients (n=52) were mechanically ventilated. Thirty-day mortality was 65% overall and did not differ significantly by stroke subtype. Glasgow Coma Scale score on the day of intubation (P<0.01) and subsequent neurological deterioration (P=0.02) were identified as predictors of 30-day mortality. The cost (1996 US dollars) of hospitalization per patient discharged alive was $89 400; the cost per year of life saved was $37 600; and the cost per quality-adjusted life-year saved was $174 200. Functional status of most survivors was poor; at 6 months, half were severely disabled and completely dependent. In a worst-case scenario of quality of life preferences, mechanical ventilation resulted in a net deficit of meaningful survival.
Conclusions—Two thirds of mechanically ventilated stroke patients die during their hospitalization, and most survivors are severely disabled. Survival is particularly unlikely if patients are deeply comatose or clinically deteriorate after intubation. In our multiethnic urban population, mechanical ventilation for stroke was relatively cost-effective for extending life but not for preserving quality of life.
Key Words: cerebrovascular disorders • cost-benefit analysis • critical care • quality of life • stroke outcome • ventilators, mechanical
|
Introduction |
|---|
|
TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
|---|
The risks and benefits of intensive care and mechanical ventilation (MV) for life-threatening stroke have come under increasing scrutiny in recent years. Endotracheal intubation is often performed as a potentially life-saving intervention in stroke patients with depressed level of consciousness, airway compromise, or respiratory failure. However, the prognosis of stroke patients treated with MV is poor, with reported mortality rates of 49% to 93%,1 2 3 4 5 6 7 8 9 10 and most survivors are severely disabled. Because care provided in intensive care units (ICUs) is expensive, these data have raised serious questions about the cost-effectiveness and cost-utility of MV for stroke. Although the cost-effectiveness of ICU care for the very elderly,11 those with cancer,12 and those with AIDS13 has been analyzed in recent years, whether MV prolongs meaningful survival in stroke patients at a reasonable cost is unknown.
When the prognosis is poor, deciding whether to intubate stroke patients can be a difficult decision, because withholding MV almost always leads to death within the next 24 to 48 hours,5 whereas intubation can lead to survival with severe neurological deficits. Although some patients may be willing to forgo life support when faced with neurological futility,14 definitive prognostic criteria on which to base decisions to withhold or withdraw care are lacking. Of equal importance, if the decision has been made to provide life support, identification of patients with a poor prognosis may help physicians and families to decide whether to implement heroic interventions to improve neurological outcome, such as decompressive craniectomy,15 intra-arterial thrombolysis,16 or moderate hypothermia.17
We conducted this study to (1) determine how frequently stroke patients are mechanically ventilated, (2) identify predictors of 30-day mortality, and (3) evaluate the cost-effectiveness of MV for stroke in terms of patients discharged alive, years of life saved, and quality-adjusted life-years (QALYs) saved. To our knowledge, this is the first study to analyze MV in a population-based cohort of stroke patients and the first to specifically evaluate the cost-effectiveness of this intervention.
|
Subjects and Methods |
|---|
|
TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
|---|
Study Population
The study population consists of 510 incidence stroke patients who were hospitalized and prospectively enrolled in the population-based Northern Manhattan Stroke Study (NOMASS) between July 1, 1993, and June 30, 1996. There is a rich ethnic distribution within this community, which consists of approximately 250 000 individuals who reside in a geographic area bounded by 5 zip codes.
Patients were enrolled if they met the following criteria: (1) hospitalized for first stroke between July 1, 1993, and June 30, 1996; (2) aged >39 years at onset of stroke; and (3) resided in Northern Manhattan in a household with a telephone. The methods of case detection in NOMASS have been described previously.18 The study was approved by the Institutional Review Boards at Columbia-Presbyterian Medical Center and other primary hospitals, and all participants or their surrogates provided written informed consent.
Clinical Management and Analysis
Patients enrolled in NOMASS who were hospitalized at
Columbia-Presbyterian Medical Center and treated with MV were
prospectively identified and included in the present
analysis; we did not include patients treated with MV at other
hospitals. During the study period, thrombolytic
therapy and hemicraniectomy were not used for patients with cerebral
infarction; intracerebral hemorrhage (ICH)
patients were offered surgical evacuation or ventricular
drainage when indicated; aneurysmal subarachnoid
hemorrhage (SAH) patients were treated with early surgical
clipping or coil embolization, nimodipine, and hypertensive
hypervolemic therapy, but angioplasty was not used to treat medically
refractory vasospasm.
Data were collected through review of medical records and neurological examination by the study physicians. Admission CT scans were evaluated for the presence of ICH, SAH, or infarction. Indications for MV were categorized as follows: elective, for airway protection; emergent, for acute neurological deterioration; pneumonia; seizure; pulmonary edema; and pulmonary embolism. Neurological status was evaluated on a daily basis, after temporary discontinuation of sedative or analgesic agents. We recorded National Institutes of Health Stroke Scale score19 on admission, Glasgow Coma Scale (GCS)20 scores daily, and Barthel Index (BI)21 scores before the stroke and 14 days after the stroke. Neurological deterioration was defined as a 2-point decrease in the GCS or worsened neurological deficit (eg, hemiparesis or aphasia), and neurological improvement was defined as a 2-point increase in the GCS or improved neurological deficit; both were categorized as occurring before MV, after MV, or before and after MV. For all patients discharged alive, patients and caregivers were interviewed by telephone or in person 6, 12, and 24 months after the stroke to assess poststroke survival, functional status (BI), and disposition. A final follow-up assessment of all survivors was performed in July 1999. A complete list of other data recorded is available from the authors by request.
Cost-Effectiveness Analysis
To evaluate the cost-effectiveness of MV for stroke in our study
population, we made the assumption that all patients would have died on
the day of their stroke had they not been intubated (zero-cost,
zero-life assumption). Although this model does not take into account
the incremental cost of hospital care were the patients not intubated,
it is the common standard for evaluating the cost-effectiveness of ICU
care for acute, life-threatening diseases.11 12 13 To
simplify our analysis, we also assigned patients who died in
the hospital within 30 days a poststroke survival of zero.
To evaluate the cost-effectiveness of MV for stroke from the
perspective of the hospital, we divided the cost of hospitalization for
the entire study cohort (excluding physician fees) by the number of
patients discharged alive. To evaluate the cost-effectiveness of MV for
stroke from the perspective of the healthcare system, we divided the
cost of hospitalization plus the estimated costs of posthospital care
(ie, rehabilitation and skilled nursing facility [SNF]
expenses) by estimated survival, expressed in both life-years and
QALYs. We did not include indirect economic costs related to work loss
or reduced productivity. Both survival and costs were continuously
discounted at an annual rate of 3%,22 with a range of 0%
to 5% tested in a sensitivity analysis. All costs and cost
estimates (Table 1
) were adjusted to 1996
US dollars with the use of the medical care component of the consumer
price index for all urban consumers23 and were rounded to
the nearest $100. For the purposes of comparison, we performed an Ovid
MEDLINE search combining the search terms "cost-benefit
analysis" and "quality-adjusted life-years" with
"cerebrovascular disorders," "ventilators, mechanical," and
"intensive care" to identify pertinent studies published since 1990
reporting life-years or QALY saved. When more than one analysis
of a particular intervention was identified, we selected the study
finding the lowest degree of cost-effectiveness or cost-utility for
comparison.
|
Estimation of Costs
Financial data from the hospital accounting system were obtained
to calculate the cost of hospitalization for each patient. We
multiplied line-item charges from each patient’s hospital bill,
beginning on the calendar day of intubation, by specific charge-to-cost
ratios that were calculated annually for 18 different hospital
departments. Charges were converted to costs on the basis of these
ratios. Since physicians bill patients separately, there was no way to
reliably determine these costs through the accounting system.
Therefore, cost of hospitalization does not include physician fees.
Posthospital follow-up data were used to estimate the cost of inpatient
and outpatient rehabilitation and SNF care for each patient (Table 1
). The costs of additional hospitalization for recurrent stroke
or other medical problems were not included. We assumed that all
patients discharged home from the hospital or an acute rehabilitation
facility (ARF) underwent outpatient rehabilitation and would
remain at home until death. We also assumed that all patients residing
in a SNF at the time of last follow-up would remain there until death.
Patients lost to follow-up after discharge to an ARF were assumed to
have subsequently resided at home in the baseline analysis and
in a SNF in the high-cost sensitivity analysis. Rehabilitation
costs were estimated from a recent examination of stroke-related costs
for Medicare patients nationwide suffering a stroke in
1993.24 25 The annual costs for SNF care were estimated on
the basis of a study of long-term care insurers in the United States in
1993.25 26 To estimate the cost of SNF care for patients
who were initially discharged to an ARF, we assumed that the duration
of hospitalization and rehabilitation was 3 months.
Estimation of Survival
The date of death was recorded for each patient who died
during the follow-up period (range, 3 to 6 years). Duration of survival
for those who remained alive or were lost to follow-up at the end of
this period was calculated with the use of 1996 age-, sex-, and
race-specific estimates of life expectancy provided by the National
Center for Health Statistics.27 We assumed a mortality
rate for each patient 2.67 times that of the age-adjusted mortality
rate for the US population in the baseline analysis, with a
range of 1.25 to 4 times tested in the sensitivity
analysis.25 28 29 We did not adjust mortality
rates on the basis of degree of disability.30
Value/Preference Assumptions
To adjust the life-years accumulated by each hospital survivor
for quality of life, we assessed functional status within a series of
time epochs (0 to 3, 4 to 12, 13 to 24, and 25 to 36 months after
stroke) and assigned a utility value for each epoch or fraction
thereof. To satisfy the QALY concept, utility values must be based on
patient preferences, anchored on perfect health (1.0) and death (0.0),
and measured in an interval scale.22 The utility values we
used (Table 1) were adapted from a published cost-effectiveness
analysis of tissue plasminogen
activator for acute stroke, which assigned utility values
(with ranges) to the modified Rankin Scale (mRS).25 These
utilities were derived from a patient preference survey for stroke
outcomes, in which a state of perfect health was assigned 100 (scaled
value 1.00), minor disability 51 (0.56), moderate disability 40 (0.44),
death 9.8 (0.00), and severe disability 8 (-0.02).31
Because we did not use the mRS in our follow-up assessments, we
converted BI scores to mRS categories according to published criteria
as follows: BI 95 to 100=mRS 0 to 2; BI 70 to 90=mRS 3; BI 40 to 65=mRS
4; BI 0 to 35=mRS 5.32 We used the 14-day evaluation to
estimate functional status during the 0- to 3-month epoch, the 6-month
evaluation to estimate the 4- to 12-month epoch, the 1-year evaluation
to estimate the 13- to 24-month epoch, and the 2-year evaluation to
estimate the 25- to 36-month epoch. Patients followed for at least 6
months were assumed to have a stable future level of disability if they
were subsequently lost to follow-up or survived beyond 2
years.29 Because functional capacity was uniformly poor at
14 days, patients with no assessment of functional capacity after the
14-day assessment were assigned a default mRS of 4 (BI 40 to 65), with
a range of mRS 0 to 2 and mRS 5 tested in the sensitivity
analysis.
Sensitivity Analysis
In the baseline analysis we calculated the following
primary outcome measures: (1) the cost of hospitalization per patient
discharged alive, (2) the number of life-years saved per patient, (3)
the cost of hospital plus posthospital care per life-year saved, (4)
the number of QALYs saved per patient, and (5) the cost of hospital
plus posthospital care per QALY saved. We then performed a series of
1-way sensitivity analyses to evaluate the effect of varying
different assumptions on these primary outcome measures, while holding
the other variables fixed according to baseline assumptions (Table 1). Finally, to test the outside plausible range of our results,
we adjusted all assumptions in the model to test a best-case and
worst-case scenario.
Statistical Analysis
Continuous variables were compared with 2-tailed tests for
normally distributed data and with the Mann-Whitney U test
for nonnormally distributed data. Proportions were compared with the
2 test or Fisher’s exact test. For evaluation
of prognostic factors, we chose 30-day mortality as the primary end
point rather than the duration of poststroke survival because all but
one in-hospital death occurred within 30 days and because the
functional outcome of most patients surviving beyond this period was
extremely poor. Demographic, CT, and clinical variables that were
significantly associated with 30-day mortality in a
univariate analysis were entered into a multiple
logistic regression model to identify independent predictors of 30-day
mortality. Survival curves were obtained by the Kaplan-Meier method.
Significance was judged at the P<0.05 level.
|
Results |
|---|
|
TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
|---|
Of 510 hospitalized incidence stroke patients, 52 (10%) were treated with MV. MV was performed in 5% of patients (20/392) with cerebral infarction, 26% of patients with ICH (24/92), and 47% of patients (8/17) with SAH (P<0.0001).
Patient Characteristics
Mean age of the 52 study patients was 65 years (range, 34 to 94
years); there were 28 women (54%) and 24 men (46%). Thirty-one were
Hispanic (60%), 14 black (27%), and 7 white (13%). The mean
admission National Institutes of Health Stroke Scale score was 17.3
(range, 0 to 30), and mean GCS score was 9.6 (range, 3 to 15). The
median interval from stroke onset to intubation was 6.5 hours (range,
30 minutes to 12 days); 65% (n=34) were intubated within 24 hours of
onset. Indications for MV included elective intubation for airway
protection in 52% (n=27), emergent intubation for acute neurological
deterioration in 23% (n=12), pneumonia in 12% (n=6), seizures in 6%
(n=3), and pulmonary edema or embolism in 6% (n=3); in 1
patient the indication was unknown.
Neurological deterioration occurred in 63% of patients (n=33). Deterioration occurred before intubation in 8 patients (15%), after intubation in 21 (40%), and before and after intubation in 4 (8%). Neurological improvement occurred after intubation in 13 patients (25%); 5 of these subjects had previously experienced deterioration.
Survival and Outcome
Overall mortality at 30 days was 65% (34/52); 30-day mortality
was 50% (10/20) in patients with cerebral infarction, 71%
(17/24) in ICH patients, and 88% (7/8) in SAH patients
(P=0.13). All but 1 in-hospital death occurred within 30
days of stroke onset. The mean (±SD) duration of MV was 7.7±10.5 days
(range, 1 to 52), mean ICU length of stay was 5.9±4.4 days
(range, 1 to 22), and mean hospital length of stay was 18.4±17.4 days
(range, 1 to 62). Among those who died in the hospital, the mean
interval between stroke onset and death was 8.9±9.9 days; the
immediate cause of death was neurological in 77% (n=26, including 12
who died of brain death) and due to a medical complication in 23%
(n=9). Twenty-five patients (48%) had a do-not-resuscitate order
written during their hospitalization, and do-not-resuscitate status was
associated with higher 30-day mortality (84% [21/25] versus 48%
[13/27]; P=0.007). MV was actively withdrawn from 4 of the
35 patients who died in the hospital (12%). Of the 17 patients who
were discharged alive, 59% (n=10) were discharged to a SNF, 29% (n=5)
to an ARF, and 12% (n=2) to home.
Functional capacity 6 months and 1 and 2 years after stroke was
generally poor (Table 2). At 6 months, of
16 patients (31%) who were still alive, half were severely disabled
and completely dependent (BI=35). At 1 year, among 14 known survivors
(27%), only 2 (4%) were moderately independent (BI=70).
|
Factors Influencing 30-Day Survival
In a univariate analysis, 30-day survival was
significantly influenced by 3 variables (Table 3): day of intubation GCS score,
neurological deterioration after intubation, and neurological
improvement after intubation. In a multiple logistic regression model,
neurological deterioration after intubation (coded yes=1, no=0; odds
ratio, 22.9; 95% CI, 2.4 to 215.3; P=0.006) and day of
intubation GCS score (odds ratio, 0.71 per 1-point increase in GCS
score; 95% CI, 0.53 to 0.94; P=0.019) were identified as
independent predictors of 30-day mortality (coded yes=1, no=0).
Thirty-day mortality was 100% (10/10) among patients with GCS scores
of 5 on the day of intubation, 86% (18/21) among patients with GCS
scores of 6 who experienced neurological deterioration after
intubation, and 25% (5/20) among patients with GCS scores of 6 who had
stable or improved deficits after intubation (P<0.0001,
2 test)
(Figure).
|
|
Cost-Effectiveness Analysis
Mean cost of hospitalization after intubation was
$27 300±21 500 (range, $2600 to $87 000). Compared with those who
died, patients who survived to 30 days had a significantly longer ICU
length of stay (median, 8 versus 3 days; P=0.02) and
hospital length of stay (median, 38.5 versus 6 days;
P<0.0001) and higher postintubation hospital costs (mean,
$46 700 versus $17 000; P<0.0001). The duration of MV was
not different between survivors and nonsurvivors (median, 4.5 versus 4
days; P=0.82).
The cost of hospitalization per patient discharged alive was $83 400.
In the baseline analysis, 1.72 life-years were saved per
patient intubated, at a cost of $37 600 per life-year, and 0.37 QALYs
were saved, at a cost of $174 200 per QALY (Table 4). In a 1-way sensitivity
analysis, both cost per life-year and cost per QALY were mildly
sensitive to survival and discounting assumptions and moderately
sensitive to economic assumptions. However, cost per QALY was extremely
sensitive to value/preference utility assumptions. Assumption of
maximal utility values resulted in a 56% reduction in cost per QALY
saved compared with the baseline scenario, whereas assumption of
minimal utility values resulted in a net deficit of QALYs. The relative
cost-effectiveness of MV for stroke compared with other
cerebrovascular25 33 34 35 and critical care
interventions11 12 13 36 is shown in Table 5.
|
|
|
Discussion |
|---|
|
TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
|---|
In this community-based study, 10% of stroke patients were treated with MV. Two thirds of these patients died during their hospitalization, and most survivors were profoundly disabled. In a multivariate analysis, deep coma on the day of intubation and neurological deterioration after intubation were identified as predictors of 30-day mortality. Compared with other conditions treated in ICUs, MV for stroke was cost-effective for prolonging life. However, compared with other interventions for cerebrovascular disease, MV was not cost-effective for preserving quality of life.
Thirty-day mortality in our patients was 65% (34/52), which is consistent with reported hospital mortality rates of 49% to 93% for intubated stroke patients.1 2 3 4 5 6 7 8 9 10 Variations in mortality between studies may result from differences in when and where the study was performed, patient demographics, criteria for and timing of intubation, access to ICU care, aggressiveness of medical management, and the frequency of withholding or withdrawing care. The highest mortality rates (>90%) were reported in an older study of patients treated between 1976 and 19867 and by a group who intubated only 2% of ischemic stroke patients and did not treat ventilated patients in an ICU.4 Stroke subtype did not significantly influence survival in our patients; other studies have also failed to identify differences in mortality between ventilated patients with hemorrhagic and ischemic stroke.1 2 4 6 8
Functional outcome among the patients who survived to discharge in our
study was poor. At 1 year, of 27% (n=14) who were still alive, half
were profoundly disabled, and <10% were functionally independent
(Table 2). Others have reported more favorable outcomes after MV
for stroke. The proportion of hospital survivors discharged to home or
an ARF (as opposed to a SNF or hospice) was 55% to 61% in other
studies,1 6 compared with 41% in our study. Even more
striking, the combined proportion of survivors who were moderately
independent (BI=70) at long-term follow-up was 53% (66/125) in 6 other
studies of MV for stroke,1 2 3 5 8 9 compared with 17%
(2/12) at 1 year in our study, despite the fact that mean age and
preintubation GCS scores were similar. The reasons for this discrepancy
are unclear. The number of long-term survivors in our study was small,
which may have led to sample error. However, the potential effects of
"referral bias" when hospital-based cohorts are compared with our
community-based cohort, as well as the fact that our institution serves
many economically disadvantaged ethnic minorities, must also be
considered. Our patients may not have had the same financial resources,
access to care, and level of motivation to pursue aggressive
rehabilitation as patients treated in other studies.
Under baseline assumptions (Table 1), the incremental cost of
hospital and posthospital care for our patients was $37 600 per year
of life saved and $174 300 per QALY saved. Our estimates of cost per
life-year and QALY saved were moderately sensitive to economic
assumptions, whereas cost per QALY was extremely sensitive to
value/preference assumptions: in a 1-way sensitivity analysis,
use of minimal utility values resulted in a net deficit of QALYs (Table 4). Within a clinical context, this means it is theoretically
possible that MV for severe stroke results in an excess of human
suffering, at tremendous expense. Previous research confirms that
persons assigning values to ranges of health states consider some
states to be worse than death,37 which presumably is why a
large proportion of non-brain-dead neuro-ICU patients who die have life
support withdrawn.14 Of note, the range of utilities we
tested was based on the preferences of healthy
outpatients31 rather than disabled stroke survivors, who
might assign higher values to states of severe impairment than
individuals who are in perfect health (the "bargaining down"
effect).
Compared with other cerebrovascular and critical care interventions, MV
for stroke appears to be relatively cost-effective for prolonging life
but not for maintaining quality of life (Table 5). Most critical
care cost-effectiveness studies have used a zero-life assumption and
expressed their results in terms of life-years saved, because data
regarding functional outcome and utilities for calculating QALYs were
not available. In terms of life-years saved, MV for stroke is
considerably less expensive than conditions that carry poor prospects
of long-term survival, such as advanced age, cancer, and
AIDS.11 12 13 On the other hand, interventions for
cerebrovascular disease have been uniformly subjected to cost-utility
analyses, and all appear to be less expensive than MV in terms
of QALYs saved. This reflects the fact that under baseline assumptions,
many severely impaired long-term survivors in our study were assigned
utility values near zero.
Accurate prediction of survival among stroke patients who require MV is
important. In a multivariate analysis, we found
that a GCS score of 5 (present in 20% of patients) and
neurological deterioration after intubation (present in 40%) were
predictors of 30-day mortality (P<0.0001,
Figure). Depressed level of consciousness has been
associated with increased mortality in other studies of MV for
stroke,1 2 8 but the effect of clinical improvement
or deterioration on outcome has not been analyzed before,
despite the strong influence of this variable on clinical decision
making. Other reported predictors of increased mortality include loss
of brain stem reflexes,1 2 6 8 older
age,1 6 8 bradycardia,2 early
intubation,1 6 emergent intubation for neurological
deterioration,3 6 8 9 and male sex (among ischemic
stroke patients).6 We did not record the presence or
absence of pupillary responses or other brain stem reflexes in our
patients.
Several weaknesses of this study deserve mention. First, we have probably underestimated the true cost of hospital and posthospital care in our patients. Only hospital costs, which constituted 42% of overall costs, were directly measured from our database. Posthospital costs for rehabilitation and SNF care were estimated on the basis of nationwide data in patients who may have had less overall disability, fewer rehabilitation needs, and lower-intensity nursing care than our study population. We also did not include physician fees, which may represent up to 10% of total hospital costs in stroke patients,38 and costs associated with recurrent hospitalization. Second, the overall level of disability in our multiethnic urban population was more severe than in previous studies of MV for stroke, which may limit the generalizability of our findings. Finally, the fact that life support was actively withdrawn from 4 of the 34 patients who died (12%) may have biased our analysis of mortality predictors, in that the variables we identified (deep coma and deterioration) may have influenced clinical decision making and led to a "self-fulfilling prophesy." Had life-support been aggressively maintained in these patients, our results may have been different.
In conclusion, our results and those of others1 2 3 4 5 6 7 8 9 10 have implications regarding clinical decision making for patients with life-threatening stroke. Patients and surrogates should be informed that approximately two thirds of those who are intubated for stroke die in the hospital and that as many as half who survive may remain profoundly disabled. Deep coma, loss of brain stem reflexes,1 2 6 8 and neurological deterioration after intubation are predictors of early mortality, and these criteria may be helpful for deciding whether to withhold or withdraw life support. Large multicenter studies of diverse patient populations are needed to more precisely define predictors of mortality or good functional outcome in stroke patients treated with MV.
|
Acknowledgments |
|---|
This work was supported by grants from the National Institute of Neurological Disorders and Stroke (RO1 NS 27517, RO1 NS 29993, and T32 NS 07153). The authors thank J.P. Mohr, MD, MS, director of cerebrovascular research, Joseph Bates, BA, for bibliographic assistance, and Richard Greene, MD, for valuable input regarding the cost-benefit analysis.
|
Footnotes |
|---|
Reprints requests to Stephan A. Mayer, MD, Division of Critical Care Neurology, Neurological Institute, 710 W 168th St, Unit 39, New York, NY 10032.
Received April 24, 2000; revision received July 5, 2000; accepted July 5, 2000.
|
References |
|---|
|
TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
|---|
1. Bushnell CD, Phillips-Bute BG, Laskowitz DT, Lynch JR, Chilukuri V, Borel CO. Survival and outcome after endotracheal intubation for stroke. Neurology. 1999;52:1374–1381.
2. Burtin P, Bollaert PE, Feldmann L, Nace L, Lelarge P, Bauer P, Larcan A. Prognosis of stroke patients undergoing mechanical ventilation. Intensive Care Med. 1994;20:32–36.[Medline] [Order article via Infotrieve]
3. Cruz-Flores S, Thompson DW, Burch CM, Eicholz KM. Outcome of patients with ischemic stroke requiring mechanical ventilation. Neurology. 1997;48 (suppl):A307. Abstract.
4.
el-Ad B, Bornstein NM, Fuchs P, Korczyn AD. Mechanical
ventilation in stroke patients: is it worthwhile? Neurology. 1996;47:657–659.
5.
Grotta J, Pasteur W, Khwaja G, Hamel T, Fisher M,
Ramirez A. Elective intubation for neurologic deterioration after
stroke. Neurology. 1995;45:640–644.
6.
Gujjar AR, Deibert E, Manno EM, Duff S, Diringer MN.
Mechanical ventilation for ischemic stroke and
intracerebral hemorrhage: indications, timing,
and outcome. Neurology. 1998;51:447–451.
7. Ludwigs UG, Baehrendtz S, Wanecek M, Matell G. Mechanical ventilation in medical and neurological diseases: 11 years of experience. J Intern Med. 1991;229:117–124.[Medline] [Order article via Infotrieve]
8.
Steiner T, Mendoza G, De Georgia M, Schellinger P,
Holle R, Hacke W. Prognosis of stroke patients requiring mechanical
ventilation in a neurological critical care unit. Stroke. 1997;28:711–715.
9. Wijdicks EF, Scott JP. Causes and outcome of mechanical ventilation in patients with hemispheric ischemic stroke. Mayo Clin Proc. 1997;72:210–213.[Abstract]
10.
Wijdicks EFM, Scott JP. Outcome in patients with acute
basilar artery occlusion requiring mechanical ventilation.
Stroke. 1996;27:1301–1303.
11.
Cohen IL, Lambrinos J, Fein IA. Mechanical ventilation
for the elderly patient in intensive care: incremental changes and
benefits. JAMA. 1993;269:1025–1029.
12.
Schapira DV, Studnicki J, Bradham DD, Wolff P, Jarrett
A. Intensive care, survival, and expense of treating critically ill
cancer patients. JAMA. 1993;269:783–786.
13.
Wachter RM, Luce JM, Safrin S, Berrios DC, Charlebois
E, Scitovsky AA. Cost and outcome of intensive care for patients with
AIDS, Pneumocystis carinii pneumonia, and severe respiratory
failure. JAMA. 1995;273:230–235.
14.
Mayer SA, Kossoff SB. Withdrawal of life support in the
neurological intensive care unit. Neurology. 1999;52:1602–1609.
15. Rieke K, Schwab S, Krieger D, von Kummer R, Aschoff A, Schochardt V, Hacke W. Decompressive surgery in space-occupying hemispheric infarction: results of an open, prospective trial. Crit Care Med. 1995;23:1576–1587.[Medline] [Order article via Infotrieve]
16.
Gönner F, Remonda L, Mattle H, Sturzenegger M,
Ozdoba C, Lövblad K-O, Baumgartner R, Bassetti C, Schroth G.
Local intra-arterial thrombolysis in acute
ischemic stroke. Stroke. 1998;29:1894–1900.
17.
Schwab S, Schwarz S, Spranger M, Keller E, Bertram M,
Hacke W. Moderate hypothermia in the treatment of patients with severe
middle cerebral artery infarction. Stroke. 1998;29:2461–2466.
18.
Sacco RL, Boden-Albala B, Gan R, Chen X, Kargman DE,
Shea S, Paik MC, Hauser WA. Stroke incidence among black, white and
Hispanic residents of an urban community: the Northern Manhattan Stroke
Study. Am J Epidemiol. 1998;147:259–268.
19. Goldstein LB, Bertels C, Davis JN. Interrater reliability of the NIH Stroke Scale. Arch Neurol. 1989;39:638–643.
20. Jennett B, Bond M. Assessment of outcome after severe brain damage: a practical scale. Lancet. 1975;1:480–484.[Medline] [Order article via Infotrieve]
21. Mahoney FI, Barthel DW. Functional evaluation: the Barthel Index. Md Med J. 1965;14:61–65.
22. Drummond MF, O’Brien B, Stoddart GL, Torrance GW. Methods for the Economic Evaluation of Health Care Programmes. New York, NY: Oxford University Press; 1997.
23. Bureau of Labor and Statistics. US Consumer Price Index, 1998. Available at: http://stats.bls.gov/top20.html. Accessed August 1, 1999.
24. Lee JA, Huber J, Stason WB. Poststroke rehabilitation in older Americans: the Medicare experience. Med Care. 1996;34:811–825.[Medline] [Order article via Infotrieve]
25.
Fagan SC, Morgenstern LB, Petitta A, Ward RE, Tilley
BC, Marler JR, Levine SR, Broderick JP, Kwiatkowski TG, Frankel M,
Brott TG, Walker MD. Cost-effectiveness of tissue
plasminogen activator for acute
ischemic stroke. Neurology. 1998;50:883–890.
26. Weiner JM, Illston LH, Hanley RJ. Sharing the Burden: Strategies for Public and Private Long-Term Care Insurance. Washington, DC: Brookings Institute; 1993.
27. National Center for Health Statistics. Expectation of life at single years of age, by race and sex: United States, 1996. Available at: http://www.cdc.gov/nchswww/fastats/lifexpec.htm. Accessed August 1, 1999.
28. Oster G, Huse DM, Lacey MJ, Epstein AM. Cost-effectiveness of ticlopidine in preventing stroke in high-risk patients. Stroke. 1994;25:1149–1156.[Abstract]
29. Whisnant JP. Natural history of transient ischemic attack and ischemic stroke. In: Whisnant JP, ed. Stroke: Populations, Cohorts, and Clinical Trials. Boston, Mass: Butterworth-Heinemann; 1993.
30.
Sacco RL, Shi T, Zamanillo MC, Kargman DE. Predictors
of mortality and recurrence after hospitalized cerebral
infarction in an urban community: the Northern Manhattan Stroke Study.
Neurology. 1994;44:626–634.
31. Solomon NA, Glick HA, Russo CJ, Lee J, Schulman KA. Patient preferences for stroke outcomes. Stroke. 1994;25:1721–1725.[Abstract]
32.
Wolfe CDA, Taub NA, Woodrow EJ, Burney PGJ. Assessment
of scales of disability and handicap for stroke patients.
Stroke. 1991;22:1242–244.
33.
McNamara RL, Lima JAC, Whelton PK, Powe NR.
Echocardiographic identification of
cardiovascular sources of emboli to guide clinical
management of stroke: a cost-effectiveness analysis. Ann
Intern Med. 1997;127:775–787.
34.
Lee TT, Solomon NA, Heidenreich PA, Oehlert J, Garber
A. Cost-effectiveness of screening for carotid stenosis in
asymptomatic persons. Ann Intern Med. 1997;126:337–346.
35. Kuntz KM, Kent C. Is carotid endarterectomy cost-effective? An analysis of symptomatic and asymptomatic patients. Circulation. 1996;94(suppl II):II-194–II-198.
36.
Mark DB, Hlatky MA, Califf RM, Naylor CD, Lee KL,
Armstrong PW, Barbash G, White H, Simoons ML, Nelson CL, Clapp-Channing
N, Knight D, Harrell FE, Simes J, Topol EJ. Cost effectiveness of
thrombolytic therapy with tissue
plasminogen activator as compared with
streptokinase for acute myocardial infarction. N Engl J
Med. 1995;332:1418–1424.
37. Patrick DL, Starks HE, Cain KC, Uhlmann RF, Pearlman RA. Measuring preferences for health states worse than death. Med Decis Making. 1994;14:9–18.
38. Mitchell JB, Ballard DJ, Whisnant JP, Ammering CJ, Samsa GP, Matchar DB. What role do neurologists play in determining the costs and outcomes of stroke patients? Neurology. 1996;27:1937–1943.
This article has been cited by other articles:
 |
|
 |
|
  R. Luengo-Fernandez, A. M. Gray, and P. M. Rothwell Costs of Stroke Using Patient-Level Data: A Critical Review of the Literature Stroke, February 1, 2009; 40(2): e18 - e23. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 R. G. Holloway, C. G. Benesch, W. S. Burgin, and J. B. Zentner Prognosis and Decision Making in Severe Stroke JAMA, August 10, 2005; 294(6): 725 - 733. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. R. Fulgham, T. J. Ingall, L. G. Stead, H. J. Cloft, E. F. M. Wijdicks, and K. D. Flemming Management of Acute Ischemic Stroke Mayo Clin. Proc., November 1, 2004; 79(11): 1459 - 1469. [Abstract] [PDF]
|
|
|
|
 |
|
 C Foerch, K R Kessler, D A Steckel, H Steinmetz, and M Sitzer Survival and quality of life outcome after mechanical ventilation in elderly stroke patients J. Neurol. Neurosurg. Psychiatry, July 1, 2004; 75(7): 988 - 993. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R Dziewas, M Ritter, M Schilling, C Konrad, S Oelenberg, D G Nabavi, F Stogbauer, E B Ringelstein, and P Ludemann Pneumonia in acute stroke patients fed by nasogastric tube J. Neurol. Neurosurg. Psychiatry, June 1, 2004; 75(6): 852 - 856. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. F. Hanley Review of Critical Care and Emergency Approaches to Stroke Stroke, February 1, 2003; 34(2): 362 - 364. [Full Text] [PDF]
|
|
|
|
|
|
S. A. Mayer Ultra-Early Hemostatic Therapy for Intracerebral Hemorrhage Stroke, January 1, 2003; 34(1): 224 - 229. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
E. J. Roth, L. Lovell, R. L. Harvey, R. K. Bode, and A. W. Heinemann Stroke Rehabilitation: Indwelling Urinary Catheters, Enteral Feeding Tubes, and Tracheostomies Are Associated With Resource Use and Functional Outcomes Stroke, July 1, 2002; 33(7): 1845 - 1850. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. Georgiadis, S. Schwarz, R. W. Baumgartner, R. Veltkamp, and S. Schwab Influence of Positive End-Expiratory Pressure on Intracranial Pressure and Cerebral Perfusion Pressure in Patients With Acute Stroke Stroke, September 1, 2001; 32(9): 2088 - 2092. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. R. Leker, T. Ben-Hur, and S. A. Mayer Re: Cost and Outcome of Mechanical Ventilation for Life-Threatening Stroke Response Stroke, June 1, 2001; 32 (6): 1443 - 1448. [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||