Psychiatric Outcomes in ICU Patients With Family Visitation
2022; Elsevier BV; Volume: 162; Issue: 3 Linguagem: Inglês
10.1016/j.chest.2022.02.051
ISSN1931-3543
AutoresStephana J. Moss, Brianna K. Rosgen, Filipe R. Lucini, Karla D. Krewulak, Andrea Soo, Christopher J. Doig, Scott B. Patten, Henry T. Stelfox, Kirsten M. Fiest,
Tópico(s)Intensive Care Unit Cognitive Disorders
ResumoBackgroundLack of family visitation in the ICU can have long-term consequences on patients in the ICU after discharge. The effect of family visitation on the incidence of patient psychiatric disorders is unknown.Research QuestionWhat is the association between family visitation in the ICU and incidence of psychiatric outcomes in patients in the ICU 1 year after hospital discharge?Study Design and MethodsThis study assessed a population-based retrospective cohort of adult patients admitted to the ICU from January 1, 2014, through May 30, 2017, surviving to hospital discharge with ICU length of stay of ≥ 3 days. To be eligible, patients needed to have minimum of 5 years of administrative data before ICU admission and a minimum of 1 year of follow-up data after hospital discharge. An internally validated algorithm that interpreted natural language in health records determined patients with or without in-person family (ie, relatives, friends) visitation during ICU stay. The primary outcome was risk of an incidence of psychiatric disorder (composite outcome), including anxiety, depressive, trauma- and stressor-related, psychotic, and substance use disorders, identified using coding algorithms for administrative databases. Propensity scores were used in inverse probability weighted logistic regression models, and average treatment effects were converted to risk ratios (RRs) with 95% CIs. Secondary outcomes were incidences of diagnoses by type of psychiatric disorder.ResultsWe included 14,344 patients with (96% [n = 13,771]) and without (4.0% [n = 573]) in-person family visitation who survived hospital discharge. More than one-third of patients received a diagnosis of any psychiatric disorder within 1 year after discharge (34.9%; 95% CI, 34.1%-35.6%). Patients most often received diagnoses of anxiety disorders (17.5%; 95% CI, 16.9%-18.1%) and depressive disorders (17.2%; 95% CI, 16.6%-17.9%). After inverse probability weighting of 13,731 patients, in-person family visitation was associated with a lower risk of received a diagnosis of any incident psychiatric disorder within 1 year after discharge (RR, 0.79; 95% CI, 0.68-0.92).InterpretationICU family visitation is associated with a decreased risk of psychiatric disorders in critically ill patients up to 1 year after hospital discharge. Lack of family visitation in the ICU can have long-term consequences on patients in the ICU after discharge. The effect of family visitation on the incidence of patient psychiatric disorders is unknown. What is the association between family visitation in the ICU and incidence of psychiatric outcomes in patients in the ICU 1 year after hospital discharge? This study assessed a population-based retrospective cohort of adult patients admitted to the ICU from January 1, 2014, through May 30, 2017, surviving to hospital discharge with ICU length of stay of ≥ 3 days. To be eligible, patients needed to have minimum of 5 years of administrative data before ICU admission and a minimum of 1 year of follow-up data after hospital discharge. An internally validated algorithm that interpreted natural language in health records determined patients with or without in-person family (ie, relatives, friends) visitation during ICU stay. The primary outcome was risk of an incidence of psychiatric disorder (composite outcome), including anxiety, depressive, trauma- and stressor-related, psychotic, and substance use disorders, identified using coding algorithms for administrative databases. Propensity scores were used in inverse probability weighted logistic regression models, and average treatment effects were converted to risk ratios (RRs) with 95% CIs. Secondary outcomes were incidences of diagnoses by type of psychiatric disorder. We included 14,344 patients with (96% [n = 13,771]) and without (4.0% [n = 573]) in-person family visitation who survived hospital discharge. More than one-third of patients received a diagnosis of any psychiatric disorder within 1 year after discharge (34.9%; 95% CI, 34.1%-35.6%). Patients most often received diagnoses of anxiety disorders (17.5%; 95% CI, 16.9%-18.1%) and depressive disorders (17.2%; 95% CI, 16.6%-17.9%). After inverse probability weighting of 13,731 patients, in-person family visitation was associated with a lower risk of received a diagnosis of any incident psychiatric disorder within 1 year after discharge (RR, 0.79; 95% CI, 0.68-0.92). ICU family visitation is associated with a decreased risk of psychiatric disorders in critically ill patients up to 1 year after hospital discharge. Take-home PointsResearch Question: What is the association between family visitation in the ICU and incidence of psychiatric outcomes in ICU patients 1 year after hospital discharge?Results: More than one-third of patients received a diagnosis of incidence of any psychiatric disorder within 1 year after discharge (34.9%; 95% CI, 34.1%-35.6%). Patients most often received a diagnosis of incidence of anxiety disorders (17.5%; 95% CI, 16.9%-18.1%) and incidence of depressive disorders (17.2%; 95% CI, 16.6%-17.9%). In-person family visitation was associated with lower risk of receiving a diagnosis of any incident psychiatric disorder within 1 year after discharge (relative risk, 0.79; 95% CI, 0.68-0.92).Interpretation: ICU family visitation is associated with decreased risk of psychiatric disorders in patients with critical illness up to 1 year after hospital discharge.ICUs provide treatment to patients fighting for their lives. Survivors of critical illness are at risk of a cluster of physical, cognitive, and psychiatric problems that arise or worsen after ICU discharge, known as postintensive care syndrome.1Needham D.M. Davidson J. Cohen H. et al.Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders' conference.Crit Care Med. 2012; 40: 502-509Crossref PubMed Scopus (1243) Google Scholar The prevalence of psychiatric disorders in those discharged alive from the ICU is high, including depressive disorders (32%-40%) and anxiety disorders (19%-37%), as well as posttraumatic stress disorder (19%-22%), that can last up to 8 years after hospital discharge.2Serrano P. Kheir Y.N.P. Wang S. Khan S. Scheunemann L. Khan B. Aging and postintensive care syndrome family: a critical need for geriatric psychiatry.Am J Geriatr Psychiatry. 2019; 27: 446-454Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar, 3Davydow D.S. Gifford J.M. Desai S.V. Needham D.M. Bienvenu O.J. Posttraumatic stress disorder in general intensive care unit survivors: a systematic review.Gen Hosp Psychiatry. 2008; 30: 421-434Crossref PubMed Scopus (450) Google Scholar, 4Rabiee A. Nikayin S. Hashem M.D. et al.Depressive symptoms after critical illness: a systematic review and meta-analysis.Crit Care Med. 2016; 44: 1744-1753Crossref PubMed Scopus (197) Google Scholar, 5Nikayin S. Rabiee A. Hashem M.D. et al.Anxiety symptoms in survivors of critical illness: a systematic review and meta-analysis.Gen Hosp Psychiatry. 2016; 43: 23-29Crossref PubMed Scopus (191) Google Scholar The care a patient receives in the ICU can portend their health trajectory after hospital discharge.6Needham D.M. Kamdar B.B. Stevenson J.E. Rehabilitation of mind and body after intensive care unit discharge: a step closer to recovery.Crit Care Med. 2012; 40: 1340-1341Crossref PubMed Scopus (10) Google ScholarFamily members (ie, relatives, friends) of patients with critical illness are essential members of the ICU care team who often act as surrogate decision-makers and emotional supports during and after critical illness.7Tate J.A. Devito Dabbs A. Hoffman L.A. Milbrandt E. Happ M.B. Anxiety and agitation in mechanically ventilated patients.Qual Health Res. 2012; 22: 157-173Crossref PubMed Scopus (65) Google Scholar,8Jackson J.C. Mitchell N. Hopkins R.O. Cognitive functioning, mental health, and quality of life in ICU survivors: an overview.Crit Care Clin. 2009; 25 (x): 615-628Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar The Society of Critical Care Medicine Guidelines for Patient and Family-Centred Care9Nassar Junior A.P. Besen B. Robinson C.C. Falavigna M. Teixeira C. Rosa R.G. Flexible versus restrictive visiting policies in ICUs: a systematic review and meta-analysis.Crit Care Med. 2018; 46: 1175-1180Crossref PubMed Scopus (100) Google Scholar recommends including family members in ICU patient care to improve experiences (eg, satisfaction)10Davidson J.E. Aslakson R.A. Long A.C. et al.Guidelines for family-centered care in the neonatal, pediatric, and adult ICU.Crit Care Med. 2017; 45: 103-128Crossref PubMed Scopus (651) Google Scholar,11Family visitation in the adult intensive care unit.Crit Care Nurse. 2017; 37: 88Google Scholar and outcomes (eg, distress)9Nassar Junior A.P. Besen B. Robinson C.C. Falavigna M. Teixeira C. Rosa R.G. Flexible versus restrictive visiting policies in ICUs: a systematic review and meta-analysis.Crit Care Med. 2018; 46: 1175-1180Crossref PubMed Scopus (100) Google Scholar,12Westphal G.A. Moerschberger M.S. Vollmann D.D. et al.Effect of a 24-h extended visiting policy on delirium in critically ill patients.Intensive Care Med. 2018; 44: 968-970Crossref PubMed Scopus (15) Google Scholar among ICU patients and their family members. Guidelines recommend regular visitation between family members and patients in the ICU,10Davidson J.E. Aslakson R.A. Long A.C. et al.Guidelines for family-centered care in the neonatal, pediatric, and adult ICU.Crit Care Med. 2017; 45: 103-128Crossref PubMed Scopus (651) Google Scholar which can occur in many ways such as during family meetings, patient care rounds, and informal updates.13Au S.S. Roze des Ordons A.L. Amir Ali A. Soo A. Stelfox H.T. Communication with patients' families in the intensive care unit: a point prevalence study.J Crit Care. 2019; 54: 235-238Crossref PubMed Scopus (16) Google ScholarIncluding family members in provision of care improves communication and builds trust.14Hurst H. Griffiths J. Hunt C. Martinez E. A realist evaluation of the implementation of open visiting in an acute care setting for older people.BMC Health Serv Res. 2019; 19: 867Crossref PubMed Scopus (15) Google Scholar Families know patients best and may recognize subtle changes earlier than health care professionals, especially when the patient cannot actively participate in discussion.15Goldfarb M.J. Bibas L. Bartlett V. Jones H. Khan N. Outcomes of patient- and family-centered care interventions in the ICU: a systematic review and meta-analysis.Crit Care Med. 2017; 45: 1751-1761Crossref PubMed Scopus (128) Google Scholar Lack of family visitation in the ICU can have long-term consequences on such patients after hospital discharge, including problems with accessing support and coping with rehabilitation, poor mental health, and more serious (and costly) psychiatric disorders.16Raphael J.L. Kessel W. Patel M. Unintended consequences of restrictive visitation policies during the COVID-19 pandemic: implications for hospitalized children.Pediatr Res. 2021; 89: 1333-1335Crossref PubMed Scopus (8) Google Scholar, 17Abrams E.M. Shaker M. Oppenheimer J. Davis R.S. Bukstein D.A. Greenhawt M. The challenges and opportunities for shared decision making highlighted by COVID-19.J Allergy Clin Immunol Pract. 2020; 8: 2474-2480.e2471Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar, 18Dorman-Ilan S. Hertz-Palmor N. Brand-Gothelf A. et al.Anxiety and depression symptoms in COVID-19 isolated patients and in their relatives.Front Psychiatry. 2020; 11581598Crossref PubMed Scopus (28) Google Scholar, 19Nelson R. No-visitor policies cause anxiety and distress for patients with cancer.Lancet Oncol. 2020; 21https://www.thelancet.com/pdfs/journals/lanonc/PIIS1470-2045(20)30690-2.pdfDate accessed: February 9, 2021Abstract Full Text Full Text PDF Scopus (3) Google Scholar, 20Samrah S.M. Al-Mistarehi A.-H. Aleshawi A.J. et al.Depression and coping among COVID-19-infected individuals after 10 days of mandatory in-hospital quarantine, Irbid, Jordan.Psychol Res Behav Manag. 2020; 13: 823-830Crossref PubMed Scopus (28) Google Scholar Gaps exist in the study of the association of family member visitation on patient outcomes; a limitation of the published work to date is the absence of research formally evaluating the effect of family visitation on the incidence of patient psychiatric disorders. We obtained a large multicenter population-based cohort of patients with critical illness admitted to the ICU for up to 1 year after hospital discharge to examine the association between family visitation in the ICU and patient psychiatric outcomes after hospital discharge.Study Design and MethodsStudy DesignWe used a multicenter, inverse probability-weighted, population-based retrospective cohort study to determine the association between family visitation (ie, relatives, including friends) in the ICU (exposure) and psychiatric outcomes in medical or surgical patients in the ICU, including: (1) a composite measure of incidence of psychiatric outcomes (any) and (2) measures of incidence of psychiatric outcomes by diagnostic type. This study is reported according to the Strengthening the Reporting of Observational Studies in Epidemiology guidelines.Study Setting and PopulationConsecutive adult patients (≥ 18 years of age) admitted to any (of 14) medical-surgical ICUs (within 14 hospitals) with electronic medical records in Alberta, Canada, from January 1, 2014, through May 31, 2017, who survived to hospital discharge were included. The ICUs are closed units staffed by accredited intensive care physicians to provide therapies such as vasoactive medications, invasive monitoring, and mechanical ventilation. Patients were excluded if they died in the ICU or in the hospital associated with the index ICU admission; if their home residence was located outside of Alberta (as determined by their provincial health care number), to ensure that follow-up data after ICU discharge were available; if they had an ICU length of stay of < 3 days, because this is the median ICU length of stay for patients who have undergone surgery and those with (intentional) overdose (who often are transferred quickly without family visitation). The primary cohort comprised individuals with a minimum of 5 years of data before the index ICU admission (to exclude pre-existing psychiatric disorders) and with a minimum of 1 year of follow-up starting from hospital discharge.Data SourcesWe used data from four administrative databases previously used for research purposes (e-Table 1). Prospective data for adult patients in the ICU were captured in eCritical (iMDsoft) clinical information systems.21Brundin-Mather R. Soo A. Zuege D.J. et al.Secondary EMR data for quality improvement and research: a comparison of manual and electronic data collection from an integrated critical care electronic medical record system.J Crit Care. 2018; 47: 295-301Crossref PubMed Scopus (59) Google Scholar To ascertain psychiatric disorders, data from eCritical were linked to three population-based administrative databases maintained by Alberta Health Services that record each contact with the health care system over time (additional details e-Appendix 1).22Brown K.N. Soo A. Faris P. Patten S.B. Fiest K.M. Stelfox H.T. Association between delirium in the intensive care unit and subsequent neuropsychiatric disorders.Crit Care. 2020; 24 (476-476)Crossref Scopus (9) Google Scholar,23Stelfox H.T. Soo A. Niven D.J. et al.Assessment of the safety of discharging select patients directly home from the intensive care unit: a multicenter population-based cohort study.JAMA Intern Med. 2018; 178: 1390-1399Crossref PubMed Scopus (36) Google Scholar Databases were linked deterministically using a unique provincial health care number.Exposure MeasuresThe primary exposure was family visitation (ie, relatives, including friends) in the ICU. Family visitation was operationalized as physical presence (excluding telephone calls) of family (ie, relatives, friends, or individuals important to the patient) as reported by the bedside nurse in a free-text progress note in eCritical. We used an internally validated rule-based algorithm that dichotomized patients who received (ever or never) in-person family visitation at any time during ICU admission (sensitivity, 0.86 [95% CI, 0.75-0.97]; specificity, 0.91 [95% CI, 0.87-0.94]; area under the receiver operating characteristic curve, 0.88 [95% CI, 0.82-0.94]).24Lucini F.R. Krewulak K.D. Fiest K.M. et al.Natural language processing to measure the frequency and mode of communication between healthcare professionals and family members of critically ill patients.J Am Med Inform Assoc. 2021; 28: 541-548Crossref PubMed Scopus (6) Google Scholar More information on the algorithm is presented in e-Appendix 1.Outcome MeasuresThe primary outcome measure was risk of an incident psychiatric disorder (composite outcome), including anxiety, depressive, trauma- and stressor-related, psychotic, and substance use disorders. Secondary outcomes were diagnostic types of incident psychiatric disorders. Patients with critical illness were classified as having a diagnosis of any incidence of a psychiatric disorder if they had one or more documented psychiatric disorders identified through International Classification of Diseases, Ninth and Tenth Revisions, codes captured in the discharge abstract database, the National Ambulatory Care Reporting System, or physician claims databases within 5 years before the index ICU admission.Covariate MeasuresPatient demographic, clinical, and hospital covariates (e-Table 1) that might affect the relationship between family visitation and the selected outcomes were determined a priori based on clinical experience and previous studies.25Brookhart M.A. Schneeweiss S. Rothman K.J. Glynn R.J. Avorn J. Stürmer T. Variable selection for propensity score models.Am J Epidemiol. 2006; 163: 1149-1156Crossref PubMed Scopus (1289) Google Scholar, 26Austin P.C. Stuart E.A. Moving towards best practice when using inverse probability of treatment weighting (IPTW) using the propensity score to estimate causal treatment effects in observational studies.Stat Med. 2015; 34: 3661-3679Crossref PubMed Scopus (1770) Google Scholar, 27Gacouin A. Maamar A. Fillatre P. et al.Patients with preexisting psychiatric disorders admitted to ICU: a descriptive and retrospective cohort study.Ann Intensive Care. 2017; 7 (Published online ahead of print 3 January 2017.)https://doi.org/10.1186/s13613-016-0221-xCrossref Scopus (12) Google Scholar Additional detail on covariate measures is in e-Appendix 1.Statistical AnalysisPre-existing psychiatric disorders were identified within 5 years before the index ICU admission. We excluded from the cohort pre-existing psychiatric disorders, rather than patients with psychiatric disorders. That is, patients were retained in the cohort if they underwent a pre-existing visit for a psychiatric disorder, but their outcomes were assessed only for psychiatric disorders for which they had no previous visits.Follow-up for psychiatric disorders began at hospital discharge and lasted until death or end of follow-up (May 31, 2018). Baseline characteristics are presented as frequencies and percentages for categorical variables and medians with interquartile ranges (IQRs) for continuous variables. Incident psychiatric disorders are presented as percentages with 95% CIs and P values where a two-sided P value of < .05 was considered statistically significant.Propensity scores were created for a cohort of patients with and without family visitation (ie, the treatment).28Rosenbaum P.R. Rubin D.B. The central role of the propensity score in observational studies for causal effects.Biometrika. 1983; 70: 41-55Crossref Scopus (16645) Google Scholar Propensity scores were based on covariates given their real or potential relationship with the exposure and outcomes.29Stuart E.A. Matching methods for causal inference: a review and a look forward.Stat Sci. 2010; 25: 1-21Crossref PubMed Scopus (2603) Google Scholar Overlap of propensity score distribution between exposure groups (visited or not visited) were assessed by graphical plots. A standardized difference of ≥ 0.1 (10%) indicated significant imbalance between baseline covariates (e-Table 2).30Austin P.C. Balance diagnostics for comparing the distribution of baseline covariates between treatment groups in propensity-score matched samples.Stat Med. 2009; 28: 3083-3107Crossref PubMed Scopus (2869) Google Scholar For the primary outcome analyses, propensity scores were used in inverse probability-weighted logistic regression models (that reweight patients based on the propensity score to make them more representative of the population; teffects package, StataCorp), and average treatment effects were converted to risk ratios (RRs) with 95% CIs.30Austin P.C. Balance diagnostics for comparing the distribution of baseline covariates between treatment groups in propensity-score matched samples.Stat Med. 2009; 28: 3083-3107Crossref PubMed Scopus (2869) Google Scholar A separate treatment effects analysis was conducted to assess sensitivity of RRs to ICU clustering or multiple ICU admissions for some patients. Propensity scores were included as an independent variable in a multivariate propensity-adjusted mixed-effects logistic regression models as an alternative to the inverse probability-weighted models.31Harrison X.A. Donaldson L. Correa-Cano M.E. et al.A brief introduction to mixed effects modelling and multi-model inference in ecology.PeerJ. 2018; 6: e4794Crossref PubMed Scopus (850) Google Scholar Mixed-effects regression models are an extension of simple regression models to allow both fixed and random effects and are particularly useful when nonindependence exists in the data that arises from hierarchical structure. In the present study, using a mixed-effects model allowed us to account systematically for item-level variability (ICU clustering) and subject-level variability (ICU readmission). Subgroup analysis was used to evaluate the impact of the frequency of family visitations on the incidence of psychiatric disorders. The frequency of family visits per number of ICU days admitted was stratified into quartiles. Logistic regression models were used to estimate the RR (95% CI) of psychiatric disorder incidence for each quartile of family visitation frequency compared with patients with no family visitation.Ethical ApprovalThis study was approved by the University of Calgary Conjoint Health Research Ethics Board (Identifier: REB17-0389). Given the use of administrative data, requirement for informed consent was waived.ResultsParticipantsFrom January 1, 2014 through May 31, 2017, 28,073 patients in Alberta were admitted to one of 14 mixed medical-surgical ICUs (Fig 1). After excluding those with an ICU length of stay of < 3 days (n = 10,509) and those who died in the ICU or hospital (n = 3,220), the cohort for analysis comprised 14,344 patients who survived to hospital discharge. Ninety-six percent of patients (n = 13,771) received a documented in-person family visit (ie, were visited), and 4.0% of patients (n = 573) did not received a documented in-person family visit (ie, were not visited). Because of missing covariate information for 618 patients (4.3%) and violation of the overlap assumption for 1 patient (< 0.01%), propensity scores were calculated for 13,725 patients (95.7%): 13,237 patients (96.4%) who were visited and 488 patients (3.6%) who were not visited. The area under the receiver operating characteristic curve for fitting of the propensity score model was 0.77 (R2 = 0.11).Most patients in the cohort were admitted to the ICU from the hospital (98.8%; ie, only 1.2% of patients were transfers) and had a medical diagnosis (61.8%), with a median Acute Physiology and Chronic Health Evaluation II score on admission of 20 (IQR, 14-25) (Table 1). The most common organ support interventions among patients were mechanical ventilation (70.3%) and vasopressors (50.6%). Patients who were visited were comparably sicker, with longer ICU stays. Median ICU length of stay was longer in patients who were visited in-person by family (6.3 days; IQR, 4.3-10.6 days) compared with patients who were not visited in-person by family (4.3 days; IQR, 3.7-6.2 days). Median hospital length of stay for visited patients (17.4 days; IQR, 9.4-35.2 days) was longer compared with that for patients who were not visited (11.8 days; IQR, 6.9-21.0 days). Among visited patients, the median Acute Physiology and Chronic Health Evaluation II score on admission was 20 (IQR, 15-25), compared with a score of 15 (IQR, 10-20) for patients who were not visited. Patients who were visited represented primarily nonsurgical admissions (77.5%) and had a medical diagnosis (62.3%).Table 1Characteristics of Included Patients by Type of Family Visitation in the ICUCharacteristicTotal (N = 14,344)Not Visited (n = 573)Visited (n = 13,771)P ValueAge, y59 (46-69)59 (48-68)59 (46-69).57Male sex8,380 (58.4)394 (68.8)7,986 (58.0)< .01ICU length of stay, d6.2 (4.2-10.3)4.3 (3.7-6.2)6.3 (4.3-10.6)< .01Length of hospital stay,an = 95 missing values. d17.0 (9.3-34.7)11.8 (6.9-21.0)17.4 (9.4-35.2)< .01APACHE score II20.0 (14.0-25.0)15.0 (10.0-20.0)20.0 (15.0-25.0)< .01 III65.0 (47.0-85.0)49.0 (34.0-64.0)66 (48.0-86.0)< .01SOFA scorebn = 413 missing values. Discharge7 (4-9)4 (1-6)7 (4-10)< .01 Admission1 (0-3)0 (0-2)1 (0-3)< .01GCS scorecn = 413 missing values.14 (10-15)15 (14-15)14 (10-15)< .01Charlson comorbidity index.31 08,576 (59.8)349 (60.9)8,227 (59.7) 14,293 (29.9)180 (31.4)4,113 (29.9) 2+1,475 (10.3)44 (7.7)1,431 (10.4)Organ support interventions Invasive mechanical ventilation10,085 (70.3)207 (36.1)9,878 (71.7)< .01 Noninvasive mechanical ventilation2,344 (16.3)64 (11.7)2,280 (16.6)< .01 Vasopressors7,256 (50.6)144 (25.1)7,112 (51.6)< .01 Continuous renal replacement therapy859 (6.0)8 (1.4)851 (6.1)< .01Admission categorydn = 293 missing values..03 Medical8,868 (61.8)292 (51.0)8,576 (62.3) Surgical2,675 (18.7)116 (20.3)2,559 (18.6) Trauma1,194 (8.3)44 (7.7)1,150 (8.4) Neurologic1,314 (9.2)46 (8.0)1,268 (9.2)Admission typeen = 214 missing values..06 Nonsurgical11,051 (77.0)382 (66.7)10,669 (77.5) Emergency surgery2,260 (15.8)58 (10.1)2,202 (16.0) Elective surgery745 (5.2)59 (10.3)686 (5.0)Location admitted fromfn = 426 missing values..54 Hospital14,177 (98.8)567 (99.0)13,610 (98.8) Home or community76 (0.6)2 (0.3)74 (0.5) Unspecified91 (0.6)4 (0.7)87 (0.6)Location discharged togn = 197 missing values..11 Hospital13,806 (96.3)560 (97.7)13,246 (96.2) Home or community341 (2.4)8 (1.4)333 (2.4) Unspecified197 (1.4)5 (0.9)192 (1.4)Readmitted to ICU within 12 mo.91 Yes934 (6.5)38 (6.6)896 (6.5) No13,410 (93.5)535 (93.4)12,875 (93.5)Hospital type.38 Tertiary4,327 (30.2)135 (23.6)4,192 (30.4) Community7,925 (55.2)277 (48.3)7,648 (55.5) Regional2,092 (14.6)161 (28.1)1,931 (14.0)Teaching hospital status< .01 Yes8,185 (57.1)427 (74.5)7,758 (56.3) No6,159 (42.9)146 (25.5)6,013 (43.7)Data are presented as No. (%) or median (interquartile range), unless otherwise indicated. APACHE = Acute Physiology and Chronic Health Evaluation II; GCS = Glasgow Coma Scale; SOFA = Sequential Organ Failure Assessment.a n = 95 missing values.b n = 413 missing values.c n = 413 missing values.d n = 293 missing values.e n = 214 missing values.f n = 426 missing values.g n = 197 missing values. Open table in a new tab Psychiatric OutcomesPsychiatric outcomes after hospital discharge were not different in patients with in-person family visitation compared with patients without in-person family visitation in outcomes that were not adjusted by propensity scores (Table 2). More than one-third of all patients had a diagnosis of an incidence of any psychiatric disorder within 1 year after discharge (34.9%; 95% CI, 34.1%-35.6%). Overall, patients most often had a diagnosis of incident anxiety disorders (17.5%; 95% CI, 16.9%-18.1%) and incident depressive disorders (17.2%; 95% CI, 16.6%-17.9%). Within 1 year after hospital discharge, 34.9% (95% CI, 34.2%-35.7%) of patients who were visited in person by family had received a diagnosis of any incident psychiatric disorder, compared with 34.0% (95% CI, 30.3%-38.0%) of patients without in-person family visitation (P = .65).Table 2Incidence of Psychiatric Disorders Receiving a Diagnosis Within 1 Year After Hospital Discharge Among 14,344 Adult Survivors of Critical IllnessDisorder TypeTotal (N = 14,344)Not Visited (n = 573)Visited (n = 13,771)P ValueaTests of proportions between groups.Any psychiatric disorderbDenotes anxiety, depressive, trauma- and stressor-related, substance use, and psychotic disorders.34.9 (34.1-35.6)34.0 (30.3-38.0)34.9 (34.2-35.7).65Anxiety disorders17.5 (16.9-18.1)15.2 (12.5-18.4)17.6 (17.0-18.2).14Depressive disorders17.2 (16.6-17.9)17.6 (14.7-21.0)17.2 (16.6-17.9).81Trauma- and stressor-related disorders5.3 (4.9-5.6)3.7 (2.3-5.6)5.3 (5.0-5.7).08Substance use disorders3.9 (3.6-4.2)4.4 (3.0-6.4)3.8 (3.5-4.2).52Psychotic disorders6.7 (6.3-7.1)4.2 (2.8-6.2)6.8 (6.4-7.3).01Suicide attempts or self-harm events1.5 (1.3-1.7)1.7 (0.9-3.2)1.5 (1.3-1.7).63Values are percentages with associated 95% CIs.a Tests of proportions between groups.b Denotes anxiety, depressive, trauma- and stressor-related, substance use, and psychotic disorders. Open table in a new tab After conditioning on the propensity score by inverse probability weighting to obtain an unbiased estimation of the treatment effect (ie, family visitation), a decreased risk of an incidence of any (ie, composite outcome) psychiatric disorder was seen within 1 year after hospital discharge with an RR (risk of psychiatric disorders in visited patients to risk of psychi
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