Journal of Rehabilitation Medicine 51-11 | Page 66

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Cochrane Corner
(physician- versus nurse-led, face-to-face versus re-
mote, timing of follow-up service); differences related
to country (high-income versus low- and middle-income
countries); and effect of delirium, which can affect cog-
nitive function, and how follow-up services may have
different effects for these participants.
SEARCH METHODOLOGY AND UP-TO-
DATENESS OF THE COCHRANE REVIEW?
For this review a search was performed in CENTRAL,
MEDLINE, Embase and CINAHL on 7 November 2017.
Clinical trials registers for ongoing studies were also
searched, and backward and forward citation searching
of relevant articles was performed. Selection criteria were
randomised and non-randomised studies with adult partici-
pants, who had been discharged from hospital following an
ICU stay. Studies that compared an ICU follow-up service
using a structured programme and coordinated by a healt-
hcare professional versus no follow-up service or standard
care (which provided no follow-up service) were included.
WHAT ARE THE MAIN RESULTS OF THE
COCHRANE REVIEW?
The review included 5 studies (4 randomised studies with
1,297 participants; one non-randomised study with 410
participants) involving 1,707 ICU survivors in total with
different illness severities and varying health conditions.
The studies were all conducted in high-income countries:
Denmark, Germany, Sweden, UK and US. Follow-up
services were nurse-led in 4 or led by a multidisciplinary
team in one of the studies. Face-to-face (at home or in a
clinic) or telephone consultations or both were included
in the studies with at least one consultation once a week,
once a month or at 6 months in each study and up to
8 consultations in two studies. Each follow-up service
included participants’ needs assessment with different
designs of consultations in studies and with referrals to
specialists for support if needed.
The review found low-certainty evidence that
follow-up services for improving long-term outcomes
may make little or no difference to HRQoL at 12 months
in ICU survivors [SMD (standardised mean difference)
–0.0, 95% CI (confidence interval) –0.1 to 0.1] (one study
with 286 participants). Five studies showed moderate-
certainty evidence that follow-up services probably also
make little or no difference to all-cause mortality up to
twelve months following discharge from ICU [RR (risk
ratio) 0.96, 95% CI 0.76 to 1.22; 4 studies with 1,289
participants) and in one non-randomised study 79/259
and 46/151 deaths in the intervention and the control
group, respectively] and 4 studies showed low-certainty
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evidence that they may make little or no difference to
posttraumatic stress disorder (PTSD) (SMD –0.05, 95%
CI –0.19 to 0.10;3 studies with 703 participants and one
non-randomised study reported less chance of having
PTSD when the intervention was used).
It is uncertain whether a follow-up service had an ef-
fect in reducing depression and anxiety [3 studies (two
randomised and one non-randomised) with 843 partici-
pants], in improving physical function (4 studies with
1,297 participants), cognitive function (4 studies with
1,297 participants), or in increasing the ability to return
to work or education (one study with 386 participants)
(very low-certainty of evidence). No studies reported
adverse effects.
The secondary objectives could not be assessed because
insuff icient studies were found to justify subgroup
analysis.
HOW DID THE AUTHORS CONCLUDE?
Because insufficient evidence was found, from a limi-
ted number of studies, it was not possible to determine
whether ICU follow-up services are effective in iden-
tifying and addressing the unmet health needs of ICU
survivors. Due to insufficient studies and limited data, the
authors were unable to look at the differences between
certain designs of follow-up services as to whether one
design is better than another, or whether follow-up servi-
ces are more effective for some individuals with varying
health conditions. The authors found 5 ongoing studies
which are not included in this review; these ongoing
studies may increase certainty in the effect in future up-
dates. They anticipate that future studies may also vary
in design. They propose robustly designed preferably
randomised studies for future research and consideration
of only one variable (the follow-up service) compared
to standard care which would increase confidence that
the effect is due to the intervention studied rather than
concomitant treatments.
WHAT ARE THE IMPLICATIONS OF THE
COCHRANE EVIDENCE FOR PRACTICE IN
REHABILITATION?
The review discussed above was inconclusive on the ef-
fectiveness of ICU follow-up services. Follow-up services
are one method to deal with PICS, but several preventive
and treatment strategies are in use and have been studied.
NICE produced a guideline on Rehabilitation after critical
illness as early as 2009 (6). They recommend for example:
• For patients at risk of physical and non-physical mor-
bidity, perform a comprehensive clinical assessment
to identify their current rehabilitation needs. This