Abstract
IntroductionDue to resource limitations, few critical care interventions have been rigorously evaluated with adequately powered randomized clinical trials (RCTs). There is a need to improve the efficiency of RCTs in critical care so that more definitive high quality RCTs can be completed with the available resources. The objective of this study was to validate and demonstrate the utility of a novel composite outcome measure, persistent organ dysfunction (POD) plus death, for clinical trials of critically ill patients.MethodsWe performed a secondary analysis of a dataset from a prospective randomized trial involving 38 intensive care units (ICUs) in Canada, Europe, and the United States. We define POD as the persistence of organ dysfunction requiring supportive technologies during the convalescent phase of critical illness and it is present when a patient has an ongoing requirement for vasopressors, dialysis, or mechanical ventilation at the outcome assessments time points. In 600 patients enrolled in a randomized trial of nutrition therapy and followed prospectively for six months, we evaluated the prevalence of POD and its association with outcome.ResultsAt 28 days, 2.3% of patients had circulatory failure, 13.7% had renal failure, 8.7% had respiratory failure, and 27.2% had died, for an overall prevalence of POD + death = 46.0%. Of survivors at Day 28, those with POD, compared to those without POD, had a higher mortality rate in the six-month follow-up period, had longer ICU and hospital stays, and a reduced quality of life at three months. Given these rates of POD + death and using a two-sided Chi-squared test at alpha = 0.05, we would require 616 patients per arm to detect a 25% relative risk reduction (RRR) in mortality, but only 286 per arm to detect the same RRR in POD + mortality.ConclusionsPOD + death may be a valid composite outcome measure and compared to mortality endpoints, may reduce the sample size requirements of clinical trials of critically ill patients. Further validation in larger clinical trials is required.
Highlights
Due to resource limitations, few critical care interventions have been rigorously evaluated with adequately powered randomized clinical trials (RCTs)
Patients without persistent organ dysfunction (POD) at Day 28 had lower baseline Charlson Comorbidity scores, Acute Physiology and Chronic Health Evaluation (APACHE) Acute Physiology and Chronic Health Evaluation II (II) scores, and Sequential Organ Failure Assessment (SOFA) scores compared to survivors with POD
We have shown that about a quarter of survivors at Day 28 will still have a need for on-going support from life sustaining technologies in an Intensive care unit (ICU) (POD)
Summary
Few critical care interventions have been rigorously evaluated with adequately powered randomized clinical trials (RCTs). Due to resource limitations, few critical care interventions have been rigorously evaluated with adequately powered RCTs. There is a need to improve the efficiency of RCTs in critical care so that more definitive high quality RCTs can be completed with the available resources. In cardiology trials, non-fatal myocardial infarctions, hospitalizations, episodes of revascularizations, and stroke have been combined with death in the form of a composite endpoint. This approach avoids multiple tests of significance and its impact on type 1 errors when endpoints are tested individually
Sign-in/Register to view highlights & summary Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a callDisclaimer: All third-party content on this website/platform is and will remain the property of their respective owners and is provided on "as is" basis without any warranties, express or implied. Use of third-party content does not indicate any affiliation, sponsorship with or endorsement by them. Any references to third-party content is to identify the corresponding services and shall be considered fair use under The CopyrightLaw.
