Who is responsible for follow-up after critical illness? - GP, ICU and patient perspectives

Who is responsible for follow-up after critical illness? - GP, ICU and patient perspectives | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Who is responsible for follow-up after critical illness? - GP, ICU and patient perspectives Jonathan Stewart, Joshua Anderson, Richard Mayne, Judy Bradley, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7509538/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 14 Nov, 2025 Read the published version in Critical Care → Version 1 posted 9 You are reading this latest preprint version Abstract Background Critical illness is associated with a range of physical, psychological, medical and social sequalae. It is unclear from existing clinical guidance who should be responsible for follow-up of these sequalae following hospital discharge. Aim To explore the views of views of UK general practitioners (GPs), intensive care medicine (ICM) consultants, and patients on responsibility for follow-up care for critical illness survivors following hospital discharge. Methods Mixed-methods study based in the UK. Data were collected from UK ICM consultants, GPs and patients using online questionnaires, interviews, and focus groups. Analysis was informed by the Consolidated Framework for Implementation Research (CFIR). Results There was a lack of clarity within and between groups on who is responsible for follow-up. We identified various potential explanations for the lack of consensus including variable awareness of critical illness survivorship, ambiguity within clinical guidelines, lack of clarity on the boundaries of critical illness morbidity, evolving roles of healthcare providers, and significant workload and resource pressures within the UK healthcare system. Conclusion The experiences of healthcare professionals and patients indicate the current lack of clarity could negatively impacting patient care and outcomes. Consensus is required on how we should define the boundaries of critical illness sequalae, and which clinical groups are responsible for care across the various transitions of care experienced by intensive care unit (ICU) survivors. Figures Figure 1 Background Critical illness is usually defined as sickness which is severe enough to require advanced organ support within an intensive care unit (ICU). Between 75 and 90% of people admitted to ICU with a critical illness survive to hospital discharge ( 1 – 4 ). Survivors of critical illness commonly experience long term physical, psychological, and cognitive sequalae ( 5 ), which may persist for more than five years after leaving hospital ( 6 , 7 ). They commonly develop new and worsening of existing medical conditions ( 8 ). Polypharmacy is common following ICU, and is an independent predictor of poor outcomes ( 9 ). Critical illness is also associated with significant social disruption, including financial and employment problems ( 10 , 11 ). There is currently a lack of evidence on the optimal health and social care system design to support recovery after critical illness ( 12 – 14 ). In the UK, delivery of ICU follow-up services after hospital discharge varies widely, and most existing services are run by ICU staff ( 15 ). However, general practice (GP) teams, as core primary care providers, are usually considered to be primary responsible for continuity and coordination of services in the community ( 16 ), and may therefore become default care providers in the absence of other support. In the absence of definitive evidence, UK guidance was developed outlining potential approaches to ICU follow-up ( 17 , 18 ). This suggests responsibility for the coordination of care should sit with post ICU recovery services, led by ICU teams in the initial phase after hospital discharge, until they have discharged the patient back to the GP team. National Institute for Health and Care Excellence (NICE) guidance advises that the ICU team should “liaise with primary/community care for the functional reassessment at two to three months after the patient's discharge from critical care”, which should be performed by an “appropriately-skilled healthcare professional(s) who is familiar with the patient's critical care problems and rehabilitation care pathway”. Views of clinicians and patients may differ on who they think is best placed to provide care following hospital discharge. Previous research from one of the authors found neither Australian GPs nor ICU consultants felt best placed to run post-ICU follow-up services ( 19 ). In this study, we aimed to investigate the views of UK general practitioners (GPs), intensive care medicine (ICM) consultants and patients, on responsibility for follow-up care for critical illness survivors following hospital discharge. We particularly wanted to examine previously unexplored areas including follow-up of new and existing conditions, medicine management and social sequalae. Methods Study design Mixed methods study comprising an online questionnaire, semi-structured interviews, and focus groups. The study was informed by the Consolidated Framework for Implementation Research (CFIR) ( 20 ). Study participants were UK GPs, ICM consultants and people with personal experience of critical illness recovery (defined as adults (≥ 18 years) who had experienced a critical illness (defined as requiring advance organ support within an intensive care unit) and survived to hospital discharge. The study received ethical approval by the Queen’s University Belfast Faculty of Medicine, Health and Life Sciences Faculty Research Ethics Committee (MHLS 22_128). Data collection Online questionnaire An online questionnaire was developed which consisted of a clinical vignette followed by 11 questions (Supplementary Fig. 1). Questions related to a range of potential sequalae of critical illness, and answers consisted of potential health and social care teams that may play a role in early and long-term patient follow-up. The questionnaire was developed and pilot tested with input and feedback from clinical and academic partners from Belfast Health and Social Care Trust and Queen’s University Belfast and was revised prior to distribution. The online questionnaire was disseminated between November 2022 and January 2023 via email by Wilmington Healthcare to a random sample of 5000 GPs within the database, by the Royal College of General Practitioners (RCGP) Research Ready to 800 GPs within their mailing list, and to a closed social media group of 1500 GPs from Northern Ireland. The questionnaire was disseminated to UK ICM consultants by email via the Faculty of Intensive Care Medicine and the Intensive Care Society. Interviews and focus groups UK GPs and ICM consultants were recruited to semi-structured interviews via the clinical and academic network of the research team. Interviews were conducted with a purposive sample of staff based on their known expertise in supporting patient recovery after critical illness (Supplementary Fig. 2). Critical illness survivors were recruited via ICUSteps, a UK based charity who support patients following ICU admission ( 21 ). For interviews we aimed to recruit up to a maximum of 20 healthcare professionals and 10 people with lived experience of critical illness. We aimed to complete two focus groups each with 5 attendees. Our sample size calculation was guided by Malterud et al, and the concept of ‘information power’ ( 22 ). The sample size was felt to be appropriate as the interviews and focus groups had clear aims and applied an established theoretical framework to data collection and analysis. Following consent, semi-structured interviews were conducted virtually between April and June 2023 with GPs, ICM consultants and patients via Microsoft Teams facilitated by one researcher, trained and experienced in qualitative interviewing techniques (JS). Participants were aware of JS roles as a General Practitioner and research fellow interested in improving outcomes following critical illness. Following initial analysis, two focus groups were conducted with patients in November 2023. The aim of the focus groups was to discuss the findings of the interviews, including the optimal healthcare system design to support critical illness recovery. Interviews and focus groups were recorded and transcribed verbatim into Microsoft Word. Data Analysis Online questionnaire Data was collected via Microsoft Forms and subsequently transferred to Microsoft Excel for analysis. Data was then transferred to R software for cleaning and analysis. The descriptive statistics of respondents are presented based on their role. Interviews and focus groups Qualitative data was transferred to NVIVO for analysis (NVIVO Version 20). Analysis was conducted using framework analysis ( 30 ), which provides a five-step approach to organizing and analysing qualitative data. The domains of the CFIR ( 31 ) and Template for Intervention Description and Replication (TIDieR) informed analysis. Data from a sample of interview and focus group transcripts were initially independently coded by two researchers (JS and RM). JS and RM are General Practitioners with experience of qualitative research methods. Coding was compared and any disagreements discussed and resolved before analysis of the full dataset. Triangulation Building on initial data from the quantitative and qualitative sources on who different participant groups felt are responsible for different aspects of follow-up, qualitative data as was extracted to provide potential explanations for these views, including the differences within and between participant groups. Utililising and expanding of the domains of CFIR, potential factors to explain differing views on remit and responsibilities were grouped under factors related to specific sequalae and contextual factors at the level of staff delivering following, the setting where follow-up is delivered and wider system contextual factors (Fig. 1). The study was reported according to the consolidated criteria for reporting qualitative research (COREQ) standards ( 23 ). Results The questionnaire was completed by 152 respondents (69.1% were ICM consultants and 26.9% were GPs) (Supplementary Table 1). Interviews were subsequently completed with 9 ICM consultants and 5 GPs and 13 patients. Following initial analysis 2 workshops were completed with 3 and 5 patients respectively. Follow-up of specific sequalae following hospital discharge There was variation between and within groups in terms of their understanding on who should provide follow-up for various potential critical illness sequalae following hospital discharge (Supplementary Figs. 3a – 2g). Medical GP and ICM consultant questionnaire respondents and interviewees recognised a distinction between pre-existing and new medical conditions. For follow-up of the index medical condition responsible for the ICU admission (chronic obstructive pulmonary disease (COPD), in the case of the clinical vignette) and new conditions (acute heart failure and renal failure in the clinical vignette), GPs most commonly responded follow-up should be provided by a hospital specialist, GP, or community specialist team (e.g. community respiratory or heart failure team) (Supplementary Figs. 3a, 3c and 3d). Similarly, ICM consultants most commonly responded follow-up should be provided by a hospital specialist, GP, or community specialist team (e.g. community heart failure team). However, nearly 40% of ICM consultants believed they had a role in follow-up of the index condition (Supplementary Fig. 3a). “There are two ways of looking at it. One way is critical care, admission related medical illness, which is new and possibly indirectly or directly due to critical care and two is worsening of the underlying medical conditions.” ICU03 For existing conditions and new and existing medications, there was greater agreement that follow-up was part of the ‘day job’ for GPs (GP01) (Supplementary Figs. 3b and 3e), and ICU team may not manage these conditions; “If they're a patient living in the community in their own home and they don't have a heart failure nurse then obviously that's where GP is placed to assess this cohort.” GP05 However, ICM consultant interviewees recognised that these comorbidities and medications are often poorly optimised during the critical illness, highlighting the importance of optimisation prior to and following ICU discharge; “We almost certainly don't manage comorbidities in the setting of an acute severe illness particularly well.” ICU04 . “We're often quite bad in ICU at stopping or telling the sort of downstream carers why we've sometimes started these drugs and when we think they should be stopped.” ICU05 Patients also highlighted medicines reconciliation does not always occur; “I’m still on such and such a drug, and the medics were saying “you should have been off that within four weeks” and this was two to three years down the line” (P06) Despite the above, some GP and ICM consultant interviewees believed there was a limited medical role during follow-up, compared to other multidisciplinary team members; “ I would say the number of discrete physical or medical problems is relatively small” ICU02 “Our role in terms of actually managing medical problems…recently diagnosed, is very limited. There’s more of a role for the physio, the OT, for the social worker” GP01 Physical There was a greater degree of uncertainty regarding which team was responsible for arranging follow-up of new functional impairments such as physical weakness (Supplementary Fig. 3f). Nearly 60% of ICM consultant and GP questionnaire respondents believed community teams (e.g. physiotherapy) should provide early follow-up. However, nearly 50% of ICM consultants also believed it was within their remit to arrange early follow-up, compared to less than 15% of GPs seeing this as a role of ICU teams. Psychological Patients consistently identified access to psychological support as important for their recovery; “I think this psychology support was massively key… that was just as important as the physical stuff” P13 Some ICM consultant interview participants stated they lacked an understanding of how to access psychological support, and would signpost patients to see their GP; “That business of knowing how to access psychological support, you know, an awful lot of the time, ‘you're going to have to go to your GP’.” ICU04 Socioeconomic For follow-up of new social and financial issues, questionnaire respondents most commonly believed this should be done by social workers (around 40% of GPs and 50% of ICM medical), however nearly a third of both groups believed it fell within the remit of GPs (Supplementary Fig. 3g). Some GPs recognised their existing knowledge of the patients may enable them to identify patients who are particularly vulnerable following hospital discharge such as self-employed, socio-economically deprived, low health literacy or inadequate social support. ICM consultants recognised secondary care teams may lack an understanding of the impact of the patient’s social context; “An awful lot of hospital-based consultants have absolutely no understanding of the environment that patients live in and how that impacts upon their ability to recover.” ICU 04 Potential explanations for lack of clarity on responsibility of care GPs, ICM consultants and patients highlighted potential explanations for a lack of clarity on remit and responsibility following hospital discharge. Understanding of evolving roles GPs and ICM consultants acknowledged they lacked understanding of each other’s roles. Some ICM consultants perceived GPs as the default providers following hospital discharge and would signpost patients to see their GP for certain issues (e.g. for psychological sequalae). This conflicted with some GPs who believed the default position should be secondary care teams arranging any required follow-up where possible; “Just as long as they're not sending me letters. ‘Please do an ECG in this patient’…Do it yourself.” GP01 GPs, ICM consultants and patients highlighted that the long-term relationship between GPs and their patients could be harnessed to ensure continuity of care, care coordination, facilitation of recovery and prevention of deterioration following hospital discharge. “You're still responsible for coordinating care on the community.” GP03 “Trying to prevent deterioration and getting people that sort of the appropriate care. I just don't really see how anybody could say that's not it's not the role of a GP” GP05 “So many different specialties. Different departments talking to me on their bit, but not as a whole and my GP, thank goodness, is brilliant, but had I not had a good GP that listened to me and connect all the pieces, I'd be utterly lost.” P08 However, participants recognised that the paradigm of a single-family GP who knows each patient and their family is evolving; “Nowadays one doesn't have GP. There's a team of people and you get the person who happens to be available on that day.” P06 “They don't always see the familiar family doctor that they may have done in generations gone by.” ICU04 Some GPs believed a lack of clarity on the boundaries of their remit as the role of their speciality evolves; “You will get I suppose different views… the role is changing quite a lot, and people aren't really sure what the role of the GP is at the moment… people might be annoyed at getting away from that kind of old way.” GP02 Awareness of ICU sequalae Patients and ICM consultants commonly believed that GPs lack experience of common ICU sequalae; “That sense of the GP not really knowing what to do. Not really having that experience” P12 “How well does a GP understand the sequelae of critical illness or critical care?” ICU02 “A lot of patients end up just back in primary care with no real coordination of all of the care that they need and with primary care providers, who I guess, have got varying degrees of experience of these sorts of patients.” ICU05 While ICM consultants may have greater understanding of ICU sequelae, they may lack understanding of how patients can access the services to address these complications, particularly following hospital discharge; “We often signpost to the GP and then don't give them the information that they need… my understanding the primary care is gonna be very limited.” ICU 04 GPs highlighted that their capability to deliver high quality care following hospital discharge was often limited by inadequate communication from secondary care, and where communication did occur there was often an unrealistic expectation that GPs would carry out follow-up that either didn’t fall within their remit or could have been arranged by secondary care. “It's about good communication. It's about a consistent approach to that, and it's about the GP feeling that they're part of a continuum of care” GP04 Healthcare system capacity An important potential driver for GP views on whether they are responsible for provision of follow-up of survivors of critical illness is their pre-existing workload. All groups recognised a current lack of capacity within UK general practice due to lack of resources and increasing workload; “We obviously don't have time or resources to contact these people individually.” GP03 Some GPs highlighted the importance of their funding model, and the need for additional funding and resources if GPs are expected to provide follow-up care beyond that which is covered by their existing contractual arrangements; “If we're going above and beyond that… We need to look at the resource. We need to look at the planning” GP04 Other GPs highlighted that given critical illness survivors are a relatively rare high risk patient cohort, their care should be prioritised despite limited available resources; ““I think it's it would be reasonable if it's something you deal with day-to-day. These are our high-risk patients, so I don't see why that would be an annoyance to add to your workload.” GP02 GPs agreed that any follow-up they were asked to provide should add value to the patients care journey; “If it's meaningful work… and make a difference to this patient, I'm very happy to do it.” GP01 There was also recognition of the limited capacity within hospital services. Some ICM consultants viewed delivery of care in primary care as more cost effective; “so much depends on things like the resources available” ICU05 “Primary care is gonna be cheaper than secondary care” ICU07 Patients also highlighted the impact lack of resources had on ability of hospital and GP services to provide follow-care; “A lot of it’s down to the hospital staff are overstretched. They haven't got the time to spend with the patients. And when you're in the community, at the GP, they haven't got time to sit down and go through it in fine detail with you.” P09 Transitions of care Patients, GPs and ICM consultants all acknowledged multiples issues related to transitions between healthcare specialities and settings; “Transitions between care are particular fault lines….Quite often these are complex patients who've got multiple complex needs that don't easily fit into one specialist domain.” ICU02 ICM consultant interviewees highlighted the potential pitfall of moving from a generalist ICU to a specialist hospital ward; “When you're in intensive care, you get a very general approach to your care because I guess we're all generalists, but as soon as the patient no longer needs critical care, you end up with some sort of ology looking after you” ICU 05 Participants commonly highlighted the need for clear communication between settings; “I was still having breathing problems, so they had to make the link between the ICU and the geriatric ward” (P02) Discussion Research over the past three decades has identified an increasingly diverse range of potential sequalae that critical illness survivors can experience compared to other patients. The evidence for how best to mitigate these complications is lacking, particularly following hospital discharge. Existing guidelines, from both within and outside the ICU context, advocate for provision of certain follow-up ( 18 , 24 ). However, it is often ambiguous regarding which clinical group is responsible for arranging and delivery of this follow-up. This study aimed to explore the views of key stakeholders (ICM consultants, GPs and patients) on who they feel should take the lead. We found significant variation within and between speciality groups, and views often diverged significantly from the existing guidance ( 17 , 18 ). Specific critical illness sequalae The key take home message was considerable variation within and between participants groups regarding who they understood to be responsible for various potential sequalae following critical illness. There was relative consensus that existing medical problems and medications continued to fall within the remit of General Practice and once optimised the long-term follow-up of these issues fell within the remit of GPs. However, there was considerable variation in terms of the views of who was responsible for optimising the care of new medical conditions and medications. This is important and may help explain why multimorbidity (the presence of two of more medical conditions) and polypharmacy (the prescribing of multiple medications, often 5 or more) are some of the strongest predictors of hospital readmission ( 8 , 25 – 28 ). Our own work identified a variety of patient and healthcare system factors which might explain why multimorbidity is associated with worse outcomes following critical illness ( 8 ). Social context appears to play a particularly important role. Socioeconomic sequalae of critical illness, and the impact of psychosocial factors on critical illness outcomes, have gained significant recent interest ( 11 , 29 , 30 ). Participants believed social workers should take the lead on follow-up of socio-economic sequalae. However, they also believed GPs are in a unique position to understand how a patient’s psycho-social context impacts their health outcome, which corresponds with previous work on the core attributes of general practice ( 16 ). New physical weakness was one of the most contentious sequalae. Unlike new and worsened existing medical conditions, physical weakness is now more widely recognised as a direct consequence of critical illness within what is often known as post intensive care syndrome (PICS) ( 31 ). The discrepancy between GP and ICU teams may relate to lack of GP recognition of PICS and the varied existing services which have been developed across the UK, usually by ICU teams, to mitigate it ( 15 , 32 – 35 ). This also highlights the potential limitations of PICS in diverting attention from wider critical illness sequelae ( 17 , 36 ). Potential explanations for lack of consensus We identified a number of important factors which may help explain why there is lack of consensus on who is responsible for provision of follow-up following ICU. Firstly, there is currently no consensus on how broadly we define ‘critical illness sequalae’. When it was initially coined, PICS focused on physical, mental health and cognitive problems which could be directly attributed to critical illness, including treatment ( 37 ). Previous research has demonstrated a lack of awareness amongst GPs of these complications ( 32 , 33 , 35 ). As already discussed, there is increasing acceptance that critical illness has much broader determinants and sequalae including multimorbidity, polypharmacy and socio-economic factors ( 38 ), which commonly fall within the remit of general practice. However, there is a lack of evidence from clinical trials for interventions that general practice led interventions to address these problems improve outcomes ( 16 , 39 – 41 ). It is vital to have clarity on the boundaries of critical illness sequalae, and whether we include wider health and social care consequences. Secondly, there is lack of consensus on who is responsible for and has the capacity to provide continuity and coordination of care for the multiple following physical, psychological, medical and social sequalae following critical illness hospitalisation. Historically GPs have been considered responsible for continuity and coordination of care in the community ( 42 , 43 ). Previous research indicates continuity of care in general practice leads to better health outcomes, including lower mortality rates, fewer hospital admissions, improved patient experience, and more cost-effective care ( 44 , 45 ). However, participants highlighted that the well documented workload pressures in UK general practice have led to a more transactional model of General Practice in the UK, which without prioritisation of this high-risk cohort, is likely inadequate to meet their needs. However, even when GPs work alongside ICU staff to prioritise critical illness survivors, previous research suggests this may not improve outcomes. A previous study which evaluated a primary care based intervention which combined case management by ICU nurses and support for primary care physicians did not find any improvement in mental health related outcomes among survivors of sepsis and septic shock ( 46 ). However, there is also a lack of evidence of ICU team led follow-up, and a recent study found an intensivist-led multidisciplinary model of follow-up following hospital discharge was associated with worse quality of life one year after ICU discharge ( 47 ). We likely need to rethink how we deliver care for this patient cohort. If we continue to make assumptions about the role of certain professional groups in regard to provision follow-up, including the ubiquitous role of general practitioners, there will continue to be significant variation in care provision for patients. In our previous work which examined factors to consider when designing the optimal approach to supporting ICU recovery following hospital discharge, we identified the need to consider how best to balance the development of new bespoke services, which may not be compatible with or cost-effective for healthcare systems, against integration with existing healthcare systems including the patients GP, which may not be readily available due to lack of resources ( 48 ). This study provides further evidence that future intervention designs should consider how to best harness this balance across the continuum of care to ensure a personalised holistic approach which identifies and addresses unmet patient needs, and which is compatible with existing healthcare systems. Strengths and limitations Integration of data from quantitative and qualitative sources enabled us to gain more in-depth perspectives from clinicians and patients located in different regions across the UK. Templates for semi-structured interview and focus group questions were informed by the responses to the initial questionnaire, which provided deeper qualitative insights. ICM consultants, GPs and patients who have experienced being discharged from ICU are all key stakeholders in defining how to deliver optimal care to patients being discharged into the community post ICU. However, staff who agreed to participate may have represented a group who are more experienced with sequalae of critical illness, or with more positive attitudes towards it. There was a low response rate to the online questionnaire from GPs, which impacted the generalisability of the findings. This may reflect the identified workload and funding pressures within primary care currently or could be due to a lack of interest and engagement amongst GPs in this area. Conclusions There is a lack of conclusive clarity regarding which professional groups are responsible for arranging and deliver follow-up care for the various complex and interconnected sequalae experienced by ICU survivors. We identified various potential explanations including a lack of understanding of professional roles and responsibilities, lack of capacity and workload pressures within the UK healthcare system, and a lack of clarity on how broadly we define the boundaries of critical illness sequalae. Further work is required involving all stakeholders to obtain consensus on the boundaries of professional responsibilities and critical illness sequalae, and to design and test comprehensive pathways of care which identity and address unmet patient needs, with the aim of improving outcomes for patients and their families. Declarations Ethics approval and consent to participate The study received ethical approval by the Queen’s University Belfast Faculty of Medicine, Health and Life Sciences Faculty Research Ethics Committee (MHLS 22_128). Interview and focus group participants provided informed consent. Consent for publication Participants provided consent for the results of the project to be published and used for educational purposes and understood they would not be identifiable in any data published in relation to this project. Availability of data and materials Raw data from this project will not be made available. Competing interests None to declare. Funding HSC Research and Development Office, Public Health Agency, Northern Ireland (EAT/5675/21) Authors’ contributions The study was conceived by JS, DM, JB and NH. JS and JA completed analysis of the quantitative data. JS and RM completed analysis of the qualitative data. JS drafted the manuscript which was reviewed and approved by all authors. Acknowledgements None References Intensive Care National Audit Research Centre. ICNARC Case Mix Programme Summary (2019-2020). 2020. Doherty Z, Kippen R, Bevan D, Duke G, Williams S, Wilson A, et al. Long-term outcomes of hospital survivors following an ICU stay: A multi-centre retrospective cohort study. PLOS ONE. 2022;17(3):e0266038. Zimmerman JE, Kramer AA, Knaus WA. Changes in hospital mortality for United States intensive care unit admissions from 1988 to 2012. Critical Care. 2013;17(2):R81. Wunsch H, Guerra C, Barnato AE, Angus DC, Li G, Linde-Zwirble WT. Three-Year Outcomes for Medicare Beneficiaries Who Survive Intensive Care. 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BMJ Open. 2021;11(5):e048392-e. Gehrke-Beck S, Gensichen J, Turner KM, Heintze C, Schmidt KF. General practitioners’ views and experiences in caring for patients after sepsis: a qualitative interview study. BMJ Open. 2021;11(2):e040533. Liou A, Schweickert WD, Files DC, Bakhru RN. A Survey to Assess Primary Care Physician Awareness of Complications Following Critical Illness. Journal of Intensive Care Medicine. 2023;38(8):760-7. White C, Connolly B, Rowland MJ. Rehabilitation after critical illness. BMJ. 2021;373:n910-n. Needham DM, Davidson J, Cohen H, Hopkins RO, Weinert C, Wunsch H, et al. Improving long-term outcomes after discharge from intensive care unit: Report from a stakeholders' conference*. Critical Care Medicine. 2012;40(2):502-9. Herridge MS, Azoulay É. Outcomes after Critical Illness. New England Journal of Medicine. 2023;388(10):913-24. Skou ST, Mair FS, Fortin M, Guthrie B, Nunes BP, Miranda JJ, et al. Multimorbidity. Nature Reviews Disease Primers. 2022;8(1):48. National Institute for Health and Care Excellence (NICE). Multimorbidity: clinical assessment and management 2016. Keller MS, Qureshi N, Mays AM, Sarkisian CA, Pevnick JM. Cumulative Update of a Systematic Overview Evaluating Interventions Addressing Polypharmacy. JAMA Network Open. 2024;7(1):e2350963-e. Jeffers H, Baker M. Continuity of care: still important in modern-day general practice. British Journal of General Practice. 2016;66(649):396-7. Stokes T, Tarrant C, Mainous AG, Schers H, Freeman G, Baker R. Continuity of Care: Is the Personal Doctor Still Important? A Survey of General Practitioners and Family Physicians in England and Wales, the United States, and the Netherlands. The Annals of Family Medicine. 2005;3(4):353-9. Adler R, Vasiliadis A, Bickell N. The relationship between continuity and patient satisfaction: a systematic review. Family Practice. 2010;27(2):171-8. Baker R, Freeman GK, Haggerty JL, Bankart MJ, Nockels KH. Primary medical care continuity and patient mortality: a systematic review. British Journal of General Practice. 2020;70(698):e600-e11. Schmidt K, Worrack S, Von Korff M, Davydow D, Brunkhorst F, Ehlert U, et al. Effect of a Primary Care Management Intervention on Mental Health–Related Quality of Life Among Survivors of Sepsis: A Randomized Clinical Trial. JAMA. 2016;315(24):2703-11. Sharshar T, Grimaldi-Bensouda L, Siami S, Cariou A, Salah AB, Kalfon P, et al. A randomized clinical trial to evaluate the effect of post-intensive care multidisciplinary consultations on mortality and the quality of life at 1 year. Intensive Care Medicine. 2024;50(5):665-77. Stewart J, Pauley E, Wilson D, Bradley J, Hart N, McAuley D. Factors to consider when designing post-hospital interventions to support critical illness recovery: Systematic review and qualitative evidence synthesis. J Intensive Care Soc. 2025;26(1):80-95. Additional Declarations No competing interests reported. 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Stewart","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5ElEQVRIiWNgGAWjYBAC9gYow769+QADI4THjFcLYwNEXsKA51gCqVokcgyI1NJ//uBjnpp7deYMOR9v8+5gkOdv4DE2wKtlRjKzMc+xYgnLhrObrXnPMBjOOMBjnIBfCzObdA5bggTDwd5t0rxtDIwbGHiMD+B32GH23zn/gFoO8zwDabEnqEWwIZmNObctQcLgGA8bSEsiSAteh0lLJBtL/+1LkJzZw2ZsOfeMRPKMw2zFeL3Px3/w4ccZ3xL4+eUfP7zxdoeNbX9782YJfFpQgAQY4Y8VTC2jYBSMglEwCjABAHtVQeFdlITiAAAAAElFTkSuQmCC","orcid":"","institution":"Queen’s University Belfast","correspondingAuthor":true,"prefix":"","firstName":"Jonathan","middleName":"","lastName":"Stewart","suffix":""},{"id":511452058,"identity":"fbeb3aa8-1158-4fde-9a6f-899d7ff28689","order_by":1,"name":"Joshua Anderson","email":"","orcid":"","institution":"Queen’s University Belfast","correspondingAuthor":false,"prefix":"","firstName":"Joshua","middleName":"","lastName":"Anderson","suffix":""},{"id":511452059,"identity":"418f6df9-7905-4db2-ab6e-fa0967e93c45","order_by":2,"name":"Richard Mayne","email":"","orcid":"","institution":"Queen's University Belfast","correspondingAuthor":false,"prefix":"","firstName":"Richard","middleName":"","lastName":"Mayne","suffix":""},{"id":511452061,"identity":"5b407b10-231f-46a1-82a6-2eacce3364c4","order_by":3,"name":"Judy Bradley","email":"","orcid":"","institution":"Queen’s University Belfast","correspondingAuthor":false,"prefix":"","firstName":"Judy","middleName":"","lastName":"Bradley","suffix":""},{"id":511452062,"identity":"2693161b-e65c-4fb1-8472-813e76352afd","order_by":4,"name":"Nigel Hart","email":"","orcid":"","institution":"Queen’s University Belfast","correspondingAuthor":false,"prefix":"","firstName":"Nigel","middleName":"","lastName":"Hart","suffix":""},{"id":511452063,"identity":"6652818c-439f-4ebe-8fe7-bb6688c8580e","order_by":5,"name":"Nina Leggett","email":"","orcid":"","institution":"Western Health","correspondingAuthor":false,"prefix":"","firstName":"Nina","middleName":"","lastName":"Leggett","suffix":""},{"id":511452064,"identity":"78042caf-fa0d-46c8-b433-4d55e2adaec3","order_by":6,"name":"Danny McAuley","email":"","orcid":"","institution":"Queen’s University Belfast","correspondingAuthor":false,"prefix":"","firstName":"Danny","middleName":"","lastName":"McAuley","suffix":""}],"badges":[],"createdAt":"2025-09-01 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16:08:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1088818,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7509538/v1/c3d69077-04a0-4420-b62f-6998cf106e8e.pdf"},{"id":91194412,"identity":"b328ce7b-34d3-44e5-8ecc-63dbe547029b","added_by":"auto","created_at":"2025-09-12 14:52:29","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":689621,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterialsV1.027.08.2025.docx","url":"https://assets-eu.researchsquare.com/files/rs-7509538/v1/060a4275dc521f5ec6b28b82.docx"},{"id":91190781,"identity":"07bf0b81-b38e-41af-8da1-1b21f1d21b6f","added_by":"auto","created_at":"2025-09-12 14:36:29","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":31609,"visible":true,"origin":"","legend":"","description":"","filename":"COREQchecklist01.09.25.docx","url":"https://assets-eu.researchsquare.com/files/rs-7509538/v1/4d4b58941412d553f5939b14.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Who is responsible for follow-up after critical illness? - GP, ICU and patient perspectives","fulltext":[{"header":"Background","content":"\u003cp\u003eCritical illness is usually defined as sickness which is severe enough to require advanced organ support within an intensive care unit (ICU). Between 75 and 90% of people admitted to ICU with a critical illness survive to hospital discharge (\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Survivors of critical illness commonly experience long term physical, psychological, and cognitive sequalae (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), which may persist for more than five years after leaving hospital (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). They commonly develop new and worsening of existing medical conditions (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Polypharmacy is common following ICU, and is an independent predictor of poor outcomes (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Critical illness is also associated with significant social disruption, including financial and employment problems (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThere is currently a lack of evidence on the optimal health and social care system design to support recovery after critical illness (\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). In the UK, delivery of ICU follow-up services after hospital discharge varies widely, and most existing services are run by ICU staff (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). However, general practice (GP) teams, as core primary care providers, are usually considered to be primary responsible for continuity and coordination of services in the community (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), and may therefore become default care providers in the absence of other support.\u003c/p\u003e\u003cp\u003eIn the absence of definitive evidence, UK guidance was developed outlining potential approaches to ICU follow-up (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). This suggests responsibility for the coordination of care should sit with post ICU recovery services, led by ICU teams in the initial phase after hospital discharge, until they have discharged the patient back to the GP team. National Institute for Health and Care Excellence (NICE) guidance advises that the ICU team should \u0026ldquo;liaise with primary/community care for the functional reassessment at two to three months after the patient's discharge from critical care\u0026rdquo;, which should be performed by an \u0026ldquo;appropriately-skilled healthcare professional(s) who is familiar with the patient's critical care problems and rehabilitation care pathway\u0026rdquo;. Views of clinicians and patients may differ on who they think is best placed to provide care following hospital discharge. Previous research from one of the authors found neither Australian GPs nor ICU consultants felt best placed to run post-ICU follow-up services (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn this study, we aimed to investigate the views of UK general practitioners (GPs), intensive care medicine (ICM) consultants and patients, on responsibility for follow-up care for critical illness survivors following hospital discharge. We particularly wanted to examine previously unexplored areas including follow-up of new and existing conditions, medicine management and social sequalae.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design\u003c/h2\u003e\u003cp\u003eMixed methods study comprising an online questionnaire, semi-structured interviews, and focus groups. The study was informed by the Consolidated Framework for Implementation Research (CFIR) (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Study participants were UK GPs, ICM consultants and people with personal experience of critical illness recovery (defined as adults (\u0026ge;\u0026thinsp;18 years) who had experienced a critical illness (defined as requiring advance organ support within an intensive care unit) and survived to hospital discharge. The study received ethical approval by the Queen\u0026rsquo;s University Belfast Faculty of Medicine, Health and Life Sciences Faculty Research Ethics Committee (MHLS 22_128).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003eOnline questionnaire\u003c/h2\u003e\u003cp\u003eAn online questionnaire was developed which consisted of a clinical vignette followed by 11 questions (Supplementary Fig.\u0026nbsp;1). Questions related to a range of potential sequalae of critical illness, and answers consisted of potential health and social care teams that may play a role in early and long-term patient follow-up. The questionnaire was developed and pilot tested with input and feedback from clinical and academic partners from Belfast Health and Social Care Trust and Queen\u0026rsquo;s University Belfast and was revised prior to distribution.\u003c/p\u003e\u003cp\u003eThe online questionnaire was disseminated between November 2022 and January 2023 via email by Wilmington Healthcare to a random sample of 5000 GPs within the database, by the Royal College of General Practitioners (RCGP) Research Ready to 800 GPs within their mailing list, and to a closed social media group of 1500 GPs from Northern Ireland. The questionnaire was disseminated to UK ICM consultants by email via the Faculty of Intensive Care Medicine and the Intensive Care Society.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eInterviews and focus groups \u003c/h3\u003e\n\u003cp\u003eUK GPs and ICM consultants were recruited to semi-structured interviews via the clinical and academic network of the research team. Interviews were conducted with a purposive sample of staff based on their known expertise in supporting patient recovery after critical illness (Supplementary Fig.\u0026nbsp;2). Critical illness survivors were recruited via ICUSteps, a UK based charity who support patients following ICU admission (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eFor interviews we aimed to recruit up to a maximum of 20 healthcare professionals and 10 people with lived experience of critical illness. We aimed to complete two focus groups each with 5 attendees. Our sample size calculation was guided by Malterud et al, and the concept of \u0026lsquo;information power\u0026rsquo; (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). The sample size was felt to be appropriate as the interviews and focus groups had clear aims and applied an established theoretical framework to data collection and analysis.\u003c/p\u003e\u003cp\u003eFollowing consent, semi-structured interviews were conducted virtually between April and June 2023 with GPs, ICM consultants and patients via Microsoft Teams facilitated by one researcher, trained and experienced in qualitative interviewing techniques (JS). Participants were aware of JS roles as a General Practitioner and research fellow interested in improving outcomes following critical illness. Following initial analysis, two focus groups were conducted with patients in November 2023. The aim of the focus groups was to discuss the findings of the interviews, including the optimal healthcare system design to support critical illness recovery. Interviews and focus groups were recorded and transcribed verbatim into Microsoft Word.\u003c/p\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cdiv id=\"Sec8\" class=\"Section3\"\u003e\u003ch2\u003eOnline questionnaire\u003c/h2\u003e\u003cp\u003eData was collected via Microsoft Forms and subsequently transferred to Microsoft Excel for analysis. Data was then transferred to R software for cleaning and analysis. The descriptive statistics of respondents are presented based on their role.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\n\u003ch3\u003eInterviews and focus groups\u003c/h3\u003e\n\u003cp\u003eQualitative data was transferred to NVIVO for analysis (NVIVO Version 20). Analysis was conducted using framework analysis (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e), which provides a five-step approach to organizing and analysing qualitative data. The domains of the CFIR (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) and Template for Intervention Description and Replication (TIDieR) informed analysis. Data from a sample of interview and focus group transcripts were initially independently coded by two researchers (JS and RM). JS and RM are General Practitioners with experience of qualitative research methods. Coding was compared and any disagreements discussed and resolved before analysis of the full dataset.\u003c/p\u003e\n\u003ch3\u003eTriangulation\u003c/h3\u003e\n\u003cp\u003eBuilding on initial data from the quantitative and qualitative sources on who different participant groups felt are responsible for different aspects of follow-up, qualitative data as was extracted to provide potential explanations for these views, including the differences within and between participant groups. Utililising and expanding of the domains of CFIR, potential factors to explain differing views on remit and responsibilities were grouped under factors related to specific sequalae and contextual factors at the level of staff delivering following, the setting where follow-up is delivered and wider system contextual factors (Fig.\u0026nbsp;1).\u003c/p\u003e\u003cp\u003eThe study was reported according to the consolidated criteria for reporting qualitative research (COREQ) standards (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe questionnaire was completed by 152 respondents (69.1% were ICM consultants and 26.9% were GPs) (Supplementary Table\u0026nbsp;1). Interviews were subsequently completed with 9 ICM consultants and 5 GPs and 13 patients. Following initial analysis 2 workshops were completed with 3 and 5 patients respectively.\u003c/p\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eFollow-up of specific sequalae following hospital discharge\u003c/h2\u003e\u003cp\u003eThere was variation between and within groups in terms of their understanding on who should provide follow-up for various potential critical illness sequalae following hospital discharge (Supplementary Figs.\u0026nbsp;3a \u0026ndash; 2g).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eMedical\u003c/h2\u003e\u003cp\u003eGP and ICM consultant questionnaire respondents and interviewees recognised a distinction between pre-existing and new medical conditions. For follow-up of the index medical condition responsible for the ICU admission (chronic obstructive pulmonary disease (COPD), in the case of the clinical vignette) and new conditions (acute heart failure and renal failure in the clinical vignette), GPs most commonly responded follow-up should be provided by a hospital specialist, GP, or community specialist team (e.g. community respiratory or heart failure team) (Supplementary Figs.\u0026nbsp;3a, 3c and 3d). Similarly, ICM consultants most commonly responded follow-up should be provided by a hospital specialist, GP, or community specialist team (e.g. community heart failure team). However, nearly 40% of ICM consultants believed they had a role in follow-up of the index condition (Supplementary Fig.\u0026nbsp;3a).\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;There are two ways of looking at it. One way is critical care, admission related medical illness, which is new and possibly indirectly or directly due to critical care and two is worsening of the underlying medical conditions.\u0026rdquo; ICU03\u003c/em\u003e\u003c/p\u003e\u003cp\u003eFor existing conditions and new and existing medications, there was greater agreement that follow-up was part of the \u003cem\u003e\u0026lsquo;day job\u0026rsquo;\u003c/em\u003e for GPs \u003cem\u003e(GP01)\u003c/em\u003e (Supplementary Figs.\u0026nbsp;3b and 3e), and ICU team may not manage these conditions;\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;If they're a patient living in the community in their own home and they don't have a heart failure nurse then obviously that's where GP is placed to assess this cohort.\u0026rdquo; GP05\u003c/em\u003e\u003c/p\u003e\u003cp\u003eHowever, ICM consultant interviewees recognised that these comorbidities and medications are often poorly optimised during the critical illness, highlighting the importance of optimisation prior to and following ICU discharge;\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We almost certainly don't manage comorbidities in the setting of an acute severe illness particularly well.\u0026rdquo; ICU04\u003c/em\u003e.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We're often quite bad in ICU at stopping or telling the sort of downstream carers why we've sometimes started these drugs and when we think they should be stopped.\u0026rdquo; ICU05\u003c/em\u003e\u003c/p\u003e\u003cp\u003ePatients also highlighted medicines reconciliation does not always occur;\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I\u0026rsquo;m still on such and such a drug, and the medics were saying \u0026ldquo;you should have been off that within four weeks\u0026rdquo; and this was two to three years down the line\u0026rdquo; (P06)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eDespite the above, some GP and ICM consultant interviewees believed there was a limited medical role during follow-up, compared to other multidisciplinary team members;\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eI would say the number of discrete physical or medical problems is relatively small\u0026rdquo; ICU02\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Our role in terms of actually managing medical problems\u0026hellip;recently diagnosed, is very limited. There\u0026rsquo;s more of a role for the physio, the OT, for the social worker\u0026rdquo; GP01\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003ePhysical\u003c/h2\u003e\u003cp\u003eThere was a greater degree of uncertainty regarding which team was responsible for arranging follow-up of new functional impairments such as physical weakness (Supplementary Fig.\u0026nbsp;3f). Nearly 60% of ICM consultant and GP questionnaire respondents believed community teams (e.g. physiotherapy) should provide early follow-up. However, nearly 50% of ICM consultants also believed it was within their remit to arrange early follow-up, compared to less than 15% of GPs seeing this as a role of ICU teams.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003ePsychological\u003c/h2\u003e\u003cp\u003ePatients consistently identified access to psychological support as important for their recovery;\u003c/p\u003e\u003cp\u003e\u0026ldquo;I think this psychology support was massively key\u0026hellip; that was just as important as the physical stuff\u0026rdquo; P13\u003c/p\u003e\u003cp\u003eSome ICM consultant interview participants stated they lacked an understanding of how to access psychological support, and would signpost patients to see their GP;\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;That business of knowing how to access psychological support, you know, an awful lot of the time, \u0026lsquo;you're going to have to go to your GP\u0026rsquo;.\u0026rdquo; ICU04\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eSocioeconomic\u003c/h2\u003e\u003cp\u003eFor follow-up of new social and financial issues, questionnaire respondents most commonly believed this should be done by social workers (around 40% of GPs and 50% of ICM medical), however nearly a third of both groups believed it fell within the remit of GPs (Supplementary Fig.\u0026nbsp;3g). Some GPs recognised their existing knowledge of the patients may enable them to identify patients who are particularly vulnerable following hospital discharge such as self-employed, socio-economically deprived, low health literacy or inadequate social support. ICM consultants recognised secondary care teams may lack an understanding of the impact of the patient\u0026rsquo;s social context;\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;An awful lot of hospital-based consultants have absolutely no understanding of the environment that patients live in and how that impacts upon their ability to recover.\u0026rdquo; ICU\u003c/em\u003e 04\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003ePotential explanations for lack of clarity on responsibility of care\u003c/h2\u003e\u003cp\u003eGPs, ICM consultants and patients highlighted potential explanations for a lack of clarity on remit and responsibility following hospital discharge.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eUnderstanding of evolving roles\u003c/h2\u003e\u003cp\u003eGPs and ICM consultants acknowledged they lacked understanding of each other\u0026rsquo;s roles. Some ICM consultants perceived GPs as the default providers following hospital discharge and would signpost patients to see their GP for certain issues (e.g. for psychological sequalae). This conflicted with some GPs who believed the default position should be secondary care teams arranging any required follow-up where possible;\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Just as long as they're not sending me letters. \u0026lsquo;Please do an ECG in this patient\u0026rsquo;\u0026hellip;Do it yourself.\u0026rdquo; GP01\u003c/em\u003e\u003c/p\u003e\u003cp\u003eGPs, ICM consultants and patients highlighted that the long-term relationship between GPs and their patients could be harnessed to ensure continuity of care, care coordination, facilitation of recovery and prevention of deterioration following hospital discharge.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;You're still responsible for coordinating care on the community.\u0026rdquo; GP03\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Trying to prevent deterioration and getting people that sort of the appropriate care. I just don't really see how anybody could say that's not it's not the role of a GP\u0026rdquo; GP05\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;So many different specialties. Different departments talking to me on their bit, but not as a whole and my GP, thank goodness, is brilliant, but had I not had a good GP that listened to me and connect all the pieces, I'd be utterly lost.\u0026rdquo; P08\u003c/em\u003e\u003c/p\u003e\u003cp\u003eHowever, participants recognised that the paradigm of a single-family GP who knows each patient and their family is evolving;\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Nowadays one doesn't have GP. There's a team of people and you get the person who happens to be available on that day.\u0026rdquo; P06\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;They don't always see the familiar family doctor that they may have done in generations gone by.\u0026rdquo; ICU04\u003c/em\u003e\u003c/p\u003e\u003cp\u003eSome GPs believed a lack of clarity on the boundaries of their remit as the role of their speciality evolves;\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;You will get I suppose different views\u0026hellip; the role is changing quite a lot, and people aren't really sure what the role of the GP is at the moment\u0026hellip; people might be annoyed at getting away from that kind of old way.\u0026rdquo; GP02\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eAwareness of ICU sequalae\u003c/h2\u003e\u003cp\u003ePatients and ICM consultants commonly believed that GPs lack experience of common ICU sequalae;\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;That sense of the GP not really knowing what to do. Not really having that experience\u0026rdquo; P12\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;How well does a GP understand the sequelae of critical illness or critical care?\u0026rdquo; ICU02\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;A lot of patients end up just back in primary care with no real coordination of all of the care that they need and with primary care providers, who I guess, have got varying degrees of experience of these sorts of patients.\u0026rdquo; ICU05\u003c/em\u003e\u003c/p\u003e\u003cp\u003eWhile ICM consultants may have greater understanding of ICU sequelae, they may lack understanding of how patients can access the services to address these complications, particularly following hospital discharge;\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We often signpost to the GP and then don't give them the information that they need\u0026hellip; my understanding the primary care is gonna be very limited.\u0026rdquo; ICU 04\u003c/em\u003e\u003c/p\u003e\u003cp\u003eGPs highlighted that their capability to deliver high quality care following hospital discharge was often limited by inadequate communication from secondary care, and where communication did occur there was often an unrealistic expectation that GPs would carry out follow-up that either didn\u0026rsquo;t fall within their remit or could have been arranged by secondary care.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It's about good communication. It's about a consistent approach to that, and it's about the GP feeling that they're part of a continuum of care\u0026rdquo; GP04\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eHealthcare system capacity\u003c/h2\u003e\u003cp\u003eAn important potential driver for GP views on whether they are responsible for provision of follow-up of survivors of critical illness is their pre-existing workload. All groups recognised a current lack of capacity within UK general practice due to lack of resources and increasing workload;\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We obviously don't have time or resources to contact these people individually.\u0026rdquo; GP03\u003c/em\u003e\u003c/p\u003e\u003cp\u003eSome GPs highlighted the importance of their funding model, and the need for additional funding and resources if GPs are expected to provide follow-up care beyond that which is covered by their existing contractual arrangements;\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;If we're going above and beyond that\u0026hellip; We need to look at the resource. We need to look at the planning\u0026rdquo; GP04\u003c/em\u003e\u003c/p\u003e\u003cp\u003eOther GPs highlighted that given critical illness survivors are a relatively rare high risk patient cohort, their care should be prioritised despite limited available resources;\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026ldquo;I think it's it would be reasonable if it's something you deal with day-to-day. These are our high-risk patients, so I don't see why that would be an annoyance to add to your workload.\u0026rdquo; GP02\u003c/em\u003e\u003c/p\u003e\u003cp\u003eGPs agreed that any follow-up they were asked to provide should add value to the patients care journey;\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;If it's meaningful work\u0026hellip; and make a difference to this patient, I'm very happy to do it.\u0026rdquo; GP01\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThere was also recognition of the limited capacity within hospital services. Some ICM consultants viewed delivery of care in primary care as more cost effective;\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;so much depends on things like the resources available\u0026rdquo;\u003c/em\u003e ICU05\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Primary care is gonna be cheaper than secondary care\u0026rdquo; ICU07\u003c/em\u003e\u003c/p\u003e\u003cp\u003ePatients also highlighted the impact lack of resources had on ability of hospital and GP services to provide follow-care;\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;A lot of it\u0026rsquo;s down to the hospital staff are overstretched. They haven't got the time to spend with the patients. And when you're in the community, at the GP, they haven't got time to sit down and go through it in fine detail with you.\u0026rdquo; P09\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003eTransitions of care\u003c/h2\u003e\u003cp\u003ePatients, GPs and ICM consultants all acknowledged multiples issues related to transitions between healthcare specialities and settings;\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Transitions between care are particular fault lines\u0026hellip;.Quite often these are complex patients who've got multiple complex needs that don't easily fit into one specialist domain.\u0026rdquo; ICU02\u003c/em\u003e\u003c/p\u003e\u003cp\u003eICM consultant interviewees highlighted the potential pitfall of moving from a generalist ICU to a specialist hospital ward;\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;When you're in intensive care, you get a very general approach to your care because I guess we're all generalists, but as soon as the patient no longer needs critical care, you end up with some sort of ology looking after you\u0026rdquo; ICU 05\u003c/em\u003e\u003c/p\u003e\u003cp\u003e Participants commonly highlighted the need for clear communication between settings;\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I was still having breathing problems, so they had to make the link between the ICU and the geriatric ward\u0026rdquo; (P02)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eResearch over the past three decades has identified an increasingly diverse range of potential sequalae that critical illness survivors can experience compared to other patients. The evidence for how best to mitigate these complications is lacking, particularly following hospital discharge. Existing guidelines, from both within and outside the ICU context, advocate for provision of certain follow-up (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). However, it is often ambiguous regarding which clinical group is responsible for arranging and delivery of this follow-up. This study aimed to explore the views of key stakeholders (ICM consultants, GPs and patients) on who they feel should take the lead. We found significant variation within and between speciality groups, and views often diverged significantly from the existing guidance (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e\u003cdiv id=\"Sec23\" class=\"Section2\"\u003e\u003ch2\u003eSpecific critical illness sequalae\u003c/h2\u003e\u003cp\u003eThe key take home message was considerable variation within and between participants groups regarding who they understood to be responsible for various potential sequalae following critical illness. There was relative consensus that existing medical problems and medications continued to fall within the remit of General Practice and once optimised the long-term follow-up of these issues fell within the remit of GPs. However, there was considerable variation in terms of the views of who was responsible for optimising the care of new medical conditions and medications. This is important and may help explain why multimorbidity (the presence of two of more medical conditions) and polypharmacy (the prescribing of multiple medications, often 5 or more) are some of the strongest predictors of hospital readmission (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan additionalcitationids=\"CR26 CR27\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Our own work identified a variety of patient and healthcare system factors which might explain why multimorbidity is associated with worse outcomes following critical illness (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Social context appears to play a particularly important role. Socioeconomic sequalae of critical illness, and the impact of psychosocial factors on critical illness outcomes, have gained significant recent interest (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Participants believed social workers should take the lead on follow-up of socio-economic sequalae. However, they also believed GPs are in a unique position to understand how a patient\u0026rsquo;s psycho-social context impacts their health outcome, which corresponds with previous work on the core attributes of general practice (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eNew physical weakness was one of the most contentious sequalae. Unlike new and worsened existing medical conditions, physical weakness is now more widely recognised as a direct consequence of critical illness within what is often known as post intensive care syndrome (PICS) (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). The discrepancy between GP and ICU teams may relate to lack of GP recognition of PICS and the varied existing services which have been developed across the UK, usually by ICU teams, to mitigate it (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan additionalcitationids=\"CR33 CR34\" citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). This also highlights the potential limitations of PICS in diverting attention from wider critical illness sequelae (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\u003ch2\u003ePotential explanations for lack of consensus\u003c/h2\u003e\u003cp\u003eWe identified a number of important factors which may help explain why there is lack of consensus on who is responsible for provision of follow-up following ICU. Firstly, there is currently no consensus on how broadly we define \u0026lsquo;critical illness sequalae\u0026rsquo;. When it was initially coined, PICS focused on physical, mental health and cognitive problems which could be directly attributed to critical illness, including treatment (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). Previous research has demonstrated a lack of awareness amongst GPs of these complications (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). As already discussed, there is increasing acceptance that critical illness has much broader determinants and sequalae including multimorbidity, polypharmacy and socio-economic factors (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e), which commonly fall within the remit of general practice. However, there is a lack of evidence from clinical trials for interventions that general practice led interventions to address these problems improve outcomes (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan additionalcitationids=\"CR40\" citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). It is vital to have clarity on the boundaries of critical illness sequalae, and whether we include wider health and social care consequences.\u003c/p\u003e\u003cp\u003eSecondly, there is lack of consensus on who is responsible for and has the capacity to provide continuity and coordination of care for the multiple following physical, psychological, medical and social sequalae following critical illness hospitalisation. Historically GPs have been considered responsible for continuity and coordination of care in the community (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). Previous research indicates continuity of care in general practice leads to better health outcomes, including lower mortality rates, fewer hospital admissions, improved patient experience, and more cost-effective care (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). However, participants highlighted that the well documented workload pressures in UK general practice have led to a more transactional model of General Practice in the UK, which without prioritisation of this high-risk cohort, is likely inadequate to meet their needs. However, even when GPs work alongside ICU staff to prioritise critical illness survivors, previous research suggests this may not improve outcomes. A previous study which evaluated a primary care based intervention which combined case management by ICU nurses and support for primary care physicians did not find any improvement in mental health related outcomes among survivors of sepsis and septic shock (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e). However, there is also a lack of evidence of ICU team led follow-up, and a recent study found an intensivist-led multidisciplinary model of follow-up following hospital discharge was associated with worse quality of life one year after ICU discharge (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eWe likely need to rethink how we deliver care for this patient cohort. If we continue to make assumptions about the role of certain professional groups in regard to provision follow-up, including the ubiquitous role of general practitioners, there will continue to be significant variation in care provision for patients. In our previous work which examined factors to consider when designing the optimal approach to supporting ICU recovery following hospital discharge, we identified the need to consider how best to balance the development of new bespoke services, which may not be compatible with or cost-effective for healthcare systems, against integration with existing healthcare systems including the patients GP, which may not be readily available due to lack of resources (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). This study provides further evidence that future intervention designs should consider how to best harness this balance across the continuum of care to ensure a personalised holistic approach which identifies and addresses unmet patient needs, and which is compatible with existing healthcare systems.\u003c/p\u003e\u003cdiv id=\"Sec25\" class=\"Section3\"\u003e\u003ch2\u003eStrengths and limitations\u003c/h2\u003e\u003cp\u003eIntegration of data from quantitative and qualitative sources enabled us to gain more in-depth perspectives from clinicians and patients located in different regions across the UK. Templates for semi-structured interview and focus group questions were informed by the responses to the initial questionnaire, which provided deeper qualitative insights. ICM consultants, GPs and patients who have experienced being discharged from ICU are all key stakeholders in defining how to deliver optimal care to patients being discharged into the community post ICU. However, staff who agreed to participate may have represented a group who are more experienced with sequalae of critical illness, or with more positive attitudes towards it. There was a low response rate to the online questionnaire from GPs, which impacted the generalisability of the findings. This may reflect the identified workload and funding pressures within primary care currently or could be due to a lack of interest and engagement amongst GPs in this area.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThere is a lack of conclusive clarity regarding which professional groups are responsible for arranging and deliver follow-up care for the various complex and interconnected sequalae experienced by ICU survivors. We identified various potential explanations including a lack of understanding of professional roles and responsibilities, lack of capacity and workload pressures within the UK healthcare system, and a lack of clarity on how broadly we define the boundaries of critical illness sequalae. Further work is required involving all stakeholders to obtain consensus on the boundaries of professional responsibilities and critical illness sequalae, and to design and test comprehensive pathways of care which identity and address unmet patient needs, with the aim of improving outcomes for patients and their families.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study received ethical approval by the Queen\u0026rsquo;s University Belfast Faculty of Medicine, Health and Life Sciences Faculty Research Ethics Committee (MHLS 22_128). Interview and focus group participants provided informed consent.\u0026nbsp;\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants provided consent for the results of the project to be published and used for educational purposes and understood they would not be identifiable in any data published in relation to this project.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRaw data from this project will not be made available.\u0026nbsp;\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone to declare.\u0026nbsp;\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHSC Research and Development Office, Public Health Agency, Northern Ireland (EAT/5675/21)\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conceived by JS, DM, JB and NH. JS and JA completed analysis of the quantitative data. JS and RM completed analysis of the qualitative data. JS drafted the manuscript which was reviewed and approved by all authors.\u0026nbsp;\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eIntensive Care National Audit Research Centre. ICNARC Case Mix Programme Summary (2019-2020). 2020.\u003c/li\u003e\n\u003cli\u003eDoherty Z, Kippen R, Bevan D, Duke G, Williams S, Wilson A, et al. Long-term outcomes of hospital survivors following an ICU stay: A multi-centre retrospective cohort study. PLOS ONE. 2022;17(3):e0266038.\u003c/li\u003e\n\u003cli\u003eZimmerman JE, Kramer AA, Knaus WA. Changes in hospital mortality for United States intensive care unit admissions from 1988 to 2012. 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BMJ Quality and Safety. 2018;27(11):915-27.\u003c/li\u003e\n\u003cli\u003eLone NI, Gillies MA, Haddow C, Dobbie R, Rowan KM, Wild SH, et al. Five-Year Mortality and Hospital Costs Associated with Surviving Intensive Care. American Journal of Respiratory and Critical Care Medicine. 2016;194(2):198-208.\u003c/li\u003e\n\u003cli\u003eLone NI, Lee R, Salisbury L, Donaghy E, Ramsay P, Rattray J, et al. Predicting risk of unplanned hospital readmission in survivors of critical illness: a population-level cohort study. Thorax. 2019;74(11):1046-54.\u003c/li\u003e\n\u003cli\u003eMcPeake J, Quasim T, Henderson P, Leyland AH, Lone NI, Walters M, et al. Multimorbidity and Its Relationship With Long-Term Outcomes After Critical Care Discharge: A Prospective Cohort Study. CHEST. 2021;0(0).\u003c/li\u003e\n\u003cli\u003eBoehm LM, Danesh V, Eaton TL, McPeake J, Pena MA, Bonnet KR, et al. Multidisciplinary ICU Recovery Clinic Visits: A Qualitative Analysis of Patient-Provider Dialogues. CHEST. 2023;163(4):843-54.\u003c/li\u003e\n\u003cli\u003eMcPeake J, Mikkelsen ME, Quasim T, Hibbert E, Cannon P, Shaw M, et al. Return to Employment after Critical Illness and Its Association with Psychosocial Outcomes. A Systematic Review and Meta-Analysis. Annals of the American Thoracic Society. 2019;16(10):1304-11.\u003c/li\u003e\n\u003cli\u003eHerridge MS, Chu LM, Matte A, Tomlinson G, Chan L, Thomas C, et al. The RECOVER Program: Disability Risk Groups and 1-Year Outcome after 7 or More Days of Mechanical Ventilation. American Journal of Respiratory and Critical Care Medicine. 2016;194(7):831-44.\u003c/li\u003e\n\u003cli\u003eVlake JH, Wils E-J, van Bommel J, Gommers D, van Genderen ME, Korevaar TIM, et al. Familiarity with the post-intensive care syndrome among general practitioners and opportunities to improve their involvement in ICU follow-up care. Intensive Care Medicine. 2022;48(8):1090-2.\u003c/li\u003e\n\u003cli\u003eCastro-Avila AC, Jefferson L, Dale V, Bloor K. 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Improving long-term outcomes after discharge from intensive care unit: Report from a stakeholders\u0026apos; conference*. Critical Care Medicine. 2012;40(2):502-9.\u003c/li\u003e\n\u003cli\u003eHerridge MS, Azoulay \u0026Eacute;. Outcomes after Critical Illness. New England Journal of Medicine. 2023;388(10):913-24.\u003c/li\u003e\n\u003cli\u003eSkou ST, Mair FS, Fortin M, Guthrie B, Nunes BP, Miranda JJ, et al. Multimorbidity. Nature Reviews Disease Primers. 2022;8(1):48.\u003c/li\u003e\n\u003cli\u003eNational Institute for Health and Care Excellence (NICE). Multimorbidity: clinical assessment and management 2016.\u003c/li\u003e\n\u003cli\u003eKeller MS, Qureshi N, Mays AM, Sarkisian CA, Pevnick JM. Cumulative Update of a Systematic Overview Evaluating Interventions Addressing Polypharmacy. JAMA Network Open. 2024;7(1):e2350963-e.\u003c/li\u003e\n\u003cli\u003eJeffers H, Baker M. Continuity of care: still important in modern-day general practice. British Journal of General Practice. 2016;66(649):396-7.\u003c/li\u003e\n\u003cli\u003eStokes T, Tarrant C, Mainous AG, Schers H, Freeman G, Baker R. Continuity of Care: Is the Personal Doctor Still Important? A Survey of General Practitioners and Family Physicians in England and Wales, the United States, and the Netherlands. The Annals of Family Medicine. 2005;3(4):353-9.\u003c/li\u003e\n\u003cli\u003eAdler R, Vasiliadis A, Bickell N. The relationship between continuity and patient satisfaction: a systematic review. Family Practice. 2010;27(2):171-8.\u003c/li\u003e\n\u003cli\u003eBaker R, Freeman GK, Haggerty JL, Bankart MJ, Nockels KH. Primary medical care continuity and patient mortality: a systematic review. British Journal of General Practice. 2020;70(698):e600-e11.\u003c/li\u003e\n\u003cli\u003eSchmidt K, Worrack S, Von Korff M, Davydow D, Brunkhorst F, Ehlert U, et al. Effect of a Primary Care Management Intervention on Mental Health\u0026ndash;Related Quality of Life Among Survivors of Sepsis: A Randomized Clinical Trial. JAMA. 2016;315(24):2703-11.\u003c/li\u003e\n\u003cli\u003eSharshar T, Grimaldi-Bensouda L, Siami S, Cariou A, Salah AB, Kalfon P, et al. A randomized clinical trial to evaluate the effect of post-intensive care multidisciplinary consultations on mortality and the quality of life at 1 year. Intensive Care Medicine. 2024;50(5):665-77.\u003c/li\u003e\n\u003cli\u003eStewart J, Pauley E, Wilson D, Bradley J, Hart N, McAuley D. Factors to consider when designing post-hospital interventions to support critical illness recovery: Systematic review and qualitative evidence synthesis. J Intensive Care Soc. 2025;26(1):80-95.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"critical-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cric","sideBox":"Learn more about [Critical Care](http://ccforum.biomedcentral.com/)","snPcode":"13054","submissionUrl":"https://submission.nature.com/new-submission/13054/3","title":"Critical Care","twitterHandle":"@Crit_Care","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7509538/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7509538/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eCritical illness is associated with a range of physical, psychological, medical and social sequalae. It is unclear from existing clinical guidance who should be responsible for follow-up of these sequalae following hospital discharge.\u003c/p\u003e\u003ch2\u003eAim\u003c/h2\u003e\u003cp\u003eTo explore the views of views of UK general practitioners (GPs), intensive care medicine (ICM) consultants, and patients on responsibility for follow-up care for critical illness survivors following hospital discharge.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eMixed-methods study based in the UK. Data were collected from UK ICM consultants, GPs and patients using online questionnaires, interviews, and focus groups. Analysis was informed by the Consolidated Framework for Implementation Research (CFIR).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThere was a lack of clarity within and between groups on who is responsible for follow-up. We identified various potential explanations for the lack of consensus including variable awareness of critical illness survivorship, ambiguity within clinical guidelines, lack of clarity on the boundaries of critical illness morbidity, evolving roles of healthcare providers, and significant workload and resource pressures within the UK healthcare system.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eThe experiences of healthcare professionals and patients indicate the current lack of clarity could negatively impacting patient care and outcomes. Consensus is required on how we should define the boundaries of critical illness sequalae, and which clinical groups are responsible for care across the various transitions of care experienced by intensive care unit (ICU) survivors.\u003c/p\u003e","manuscriptTitle":"Who is responsible for follow-up after critical illness? - GP, ICU and patient perspectives","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-12 14:36:25","doi":"10.21203/rs.3.rs-7509538/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-24T08:55:36+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-23T07:50:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"36547780660614606477035184384259329212","date":"2025-09-20T22:18:37+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-13T09:02:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"85573236657344125841624424785863832316","date":"2025-09-07T15:37:22+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-05T12:44:56+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-04T01:50:03+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-04T01:49:50+00:00","index":"","fulltext":""},{"type":"submitted","content":"Critical Care","date":"2025-09-01T14:24:02+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"critical-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cric","sideBox":"Learn more about [Critical Care](http://ccforum.biomedcentral.com/)","snPcode":"13054","submissionUrl":"https://submission.nature.com/new-submission/13054/3","title":"Critical Care","twitterHandle":"@Crit_Care","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cab428cd-5e36-4189-bd1f-6b5e5da8bfca","owner":[],"postedDate":"September 12th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-11-17T16:03:21+00:00","versionOfRecord":{"articleIdentity":"rs-7509538","link":"https://doi.org/10.1186/s13054-025-05724-w","journal":{"identity":"critical-care","isVorOnly":false,"title":"Critical Care"},"publishedOn":"2025-11-14 15:58:23","publishedOnDateReadable":"November 14th, 2025"},"versionCreatedAt":"2025-09-12 14:36:25","video":"","vorDoi":"10.1186/s13054-025-05724-w","vorDoiUrl":"https://doi.org/10.1186/s13054-025-05724-w","workflowStages":[]},"version":"v1","identity":"rs-7509538","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7509538","identity":"rs-7509538","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}