critically ill patient may suffer functional , social and mental alterations including 
 impairment of cognition , memory and concentration after intensive care unit ( icu ) and 
 hospital discharge1 , 2 . the recovery is often slow and prolonged and alterations may 
 persist after leaving the hospital . patients frequently need continuous support from family 
 and caregivers after coming back home , mainly those who have received prolonged invasive 
 mechanical ventilation ( imv)3 , 4 . in addition to all the alterations from icu stay , icu 
 survival comes along with impact in the short and the long - term quality of life ( qol ) after 
 discharge1 , 5 . in a study conducted in a scottish teaching hospital , icu survivors presented lower scores 
 of physical aspects of sf-36 three months after icu discharge when compared to their score 
 before admission to icu . a slow improvement of the physical aspects up to six months was 
 observed , and baseline score was achieved after 12 months6 . in the united states of america ( usa ) , 66 patients who survived 
 acute respiratory distress syndrome ( ards ) presented low score in the sf36 questionnaire in 
 all domains except social functioning , role - emotional and mental health one year after 
 discharge7 . in another study in the usa , 
 ards survivors presented decreased qol in physical functioning , physical ability to maintain 
 their roles , bodily pain , general health and vitality one year after recovering8 . reduction in qol caused by icu admission 
 was also pointed in icu survivors in netherlands9 . in the united kingdom , older icu survivors presented higher score for the mental component 
 of sf-36 but not for physical component10 . a spanish study showed that 61% of elderly patients who survived icu 
 persisted with lower qol score 12 months after hospital discharge11 . the knowledge of physical and mental alteration due to icu stay is important to improve the 
 assistance of critical patients . however , the qol of critically ill patients after icu and 
 hospital discharge has been addressed mostly in developed countries6,7,8,9,10,11 . in the few studies 
 conducted in developing countries , qol was reported as declined in survivors of critically 
 ill patients after acute respiratory distress syndrome ( ards ) due h1n1 virus , acute kidney 
 injury and severe sepsis12,13,14 . on top of that , 
 the percentage of mortality in tertiary hospital in india was reported still high for 
 elderly patients15 . under particular realities of life habits , health care system and rehabilitation settings 
 for each country , the recovery of post critically ill patients may be looked considering 
 this particular scenario . therefore , the objective of this follow - up study was to evaluate the qol of critically ill 
 survivors in a developing country over the time after hospital discharge and to assess the 
 influence of clinical variables on quality of life . this was a prospective longitudinal study , which was approved by the ethics committee from 
 clinical hospital , medical school of university of sao paulo ( no . 1159/07 ) and conducted in 
 a large tertiary public hospital in sao paulo , brazil . patients or close relatives were 
 contacted during hospital stay and received oral and written information about the study ; a 
 signed consent form was obtained while patients were still in the hospital . since patients were interviewed by telephone 
 call , those patients who were not contacted during hospital stay received information about 
 the study and were invited to participate in the study when the telephone contact was made . we consulted the ethics committee from clinical hospital of medical school of university of 
 sao paulo , who stated that once the patient had agreed to answer the telephone call and 
 respond the questionnaire , it implied that he / she consented to participate in the study . the inclusion criteria for this study were medical and/or surgical patients living in the 
 city of sao paulo , admitted to the icu at the clinical hospital of the university of sao 
 paulo between may 2010 and january 2011 , who were 18  years old or older , and who were 
 submitted to at least 24 hours of imv . patients with cognitive deficit , aphasia and 
 tracheotomy , patients with previous neurological condition , neurological deficit after icu 
 and amputation of limbs were excluded . from the patients records , the following data were 
 collected : age , gender , severity of disease score ( acute physiology and chronic 
 health evaluation score  apache ii score ) , type of icu admission ( clinical or 
 surgical ) , duration of imv , icu length of stay and hospital length of stay . the apache ii 
 measures the severity of disease within the first 24 hours following patient s icu 
 admission16 . the evaluation of the qol was performed by using the medical outcomes study 36item short 
 form health survey ( sf-36 ) . the sf-36 is validated in brazil , has good acceptance , 
 reliability , validity in icu patients and has good adaptability to be applied by telephone 
 call6 , 17,18,19 . the sf-36 comprises eight domains : physical functioning , 
 role - physical , bodily pain , general health , vitality , social functioning , role - emotional , 
 and mental health . the domains physical functioning , role - physical , bodily pain and general 
 health compound the physical component and the domains vitality , social functioning , 
 role - emotional and mental health compound the mental component . the sf-36 score ranges from 
 0 to 100 , and 0 is the worst and 100 is the best score for qol7 , 20 . patients qol was 
 assessed by telephone calls at the first , third and sixth month after hospital 
 discharge . the quantitative variables are described as median and 
 interquartile range ( iqr ) or mean and standard deviation ( sd ) and the qualitative variables 
 are presented as frequency and percentage . the assessment of sf-36 over time was performed 
 for physical and mental component using anova with repeated measures and tukey post - hoc 
 test ; time of assessment , age category ( < 60  years old or  60  years old ) , and apache ii 
 category (  or > 14 ) were used as factors . age was categorized according to the brazilian 
 law for elderly people , and apache ii was categorized according to the median calculated for 
 the apache ii for the studied population . 142 
 ( 32.9% ) patients were excluded during their icu stay . in the ward 142 ( 49.1% ) were lost : 
 seven patients due to refusal , 26 patients transferred to other hospital , 58 were 
 transferred to long - term care hospitals , and 51 died . among the 147 ( 50.9% ) patients who 
 received hospital discharge and therefore were considered eligible for this study , the 
 follow - up was completed for 75 patients at the first month , 71 at the third month and 68 at 
 the sixth month . out of the 147 eligible patients , 72 patients did not complete the first follow - up : six 
 died , two refused to participate , 17 were readmitted to the hospital , and 47 patients could 
 not be contacted . the reasons for failing contact included incorrect or nonexistent 
 telephone number in the patient s records and absence of response . the descriptive analysis of age , length of imv , length of icu and hospital stay and apache 
 ii of the studied population is shown in table 
 1table 1.demographic and clinical characteristics of the studied population and lost 
 patients after icu dischargecharacteristicsstudied populationlost ( in the ward)n=75n=142age , mean  sd 50.2  17.153.25  18.3 < 60 years , n ( % ) 46 ( 61.4)90 ( 63.4) 60 years , n ( % ) 29 ( 38.6)52 ( 36.6)gender - male , n ( % ) 45 ( 60.0)91 ( 64.1)apache ii score , median ( iqr)14.0 ( 11.017.0)15.0 ( 11.019.0)type of admission , n ( % ) clinical32 ( 42.7)32 ( 22.5)*surgical43 ( 57.3)110 ( 77.5)neurosurgery13 ( 30.2)38 ( 34.5)abdominal12 ( 27.9)20 ( 18.2)vascular8 ( 18.6)10 ( 9.1)others 10 ( 23.3)42 ( 38.2)imv length of time ( days ) , median ( iqr)4.0 ( 3.08.0)7.0 ( 3.715.0)*icu length of stay ( days ) , median ( iqr)13.0 ( 7.017.0)16.5 ( 10.028.0)*hospital length of stay ( days ) , median ( iqr)29.0 ( 20.048.0)35.5 ( 22.055.2)the mann - whitney u - test was applied for continuous variables and the  
 test for the categorical variables . apache ii score : acute physiology and chronic 
 health evaluation score ; imv : mechanical ventilation ; icu : intensive care unit ; data 
 expressed in mean , sd : standard deviation ; median , iqr : interquartile range 
 ( 25th75th ) and n ( % ) . * statistical significance . the mann - whitney u - test was applied for continuous variables and the  
 test for the categorical variables . apache ii score : acute physiology and chronic 
 health evaluation score ; imv : mechanical ventilation ; icu : intensive care unit ; data 
 expressed in mean , sd : standard deviation ; median , iqr : interquartile range 
 ( 25th75th ) and n ( % ) . * statistical significance due to the large number of lost patients , a complementary analysis was performed between 
 the studied population and the lost patients in the ward by applying the mann - whitney u test 
 to compare quantitative data and  test to compare qualitative data . statistically differences were found for the following variables : type of admission 
 ( p=0.002 ) , imv length of time ( p=0.001 ) and icu length of stay ( p=0.002 ) . the clinical and 
 demographic characteristics for the studied population and for those who were lost after icu 
 discharge and before hospital discharge are also reported in table 1 . the mean score of each domain of the sf-36 of all subjects at the first , third and sixth 
 month this graph 
 shows the evolution of the each sf-36 domain for all the patients 1 , 3 and 6 months 
 after hospital discharge . notice that the score increases over time and that the 
 role - physical was the most compromised component . pf : physical functioning , rp : role - physical , bp : bodily pain , gh : 
 general health , vt : vitality , sf : social functioning , re : role - fmotional , mh : mental 
 health . qol : quality of life , which shows a progressive increase on the score of all domains after hospital 
 discharge ; it is noteworthy that the domain role - physical was the most compromised . this graph 
 shows the evolution of the each sf-36 domain for all the patients 1 , 3 and 6 months 
 after hospital discharge . notice that the score increases over time and that the 
 role - physical was the most compromised component . pf : physical functioning , rp : role - physical , bp : bodily pain , gh : 
 general health , vt : vitality , sf : social functioning , re : role - fmotional , mh : mental 
 health . qol : quality of life anova and tukey post - hoc test showed that both physical and mental component presented 
 significant improvement over time , with p=0.01 for the comparison of mental component 
 between third and sixth month and p<0.001 for all of other comparison , as demonstrated in 
 table 2table 2.median values for the physical and mental components at 1st , 3rd and 6th month 
 assessment for the total of subjectscharacteristics1st month3rd month6th monthphysical component43.0 ( 32.456.5)55.0 ( 41.669.9)74.4 ( 53.187.7)mental component51.7 ( 36.472.4)63.3 ( 48.087.3)77.8 ( 60.689.2)sf-36 : study 36-item short form health survey , pc : physical component score , mc : 
 mental component score . statistical significance was obtained for all time assessment 
 comparison by anova with repeated measures and tukey post - hoc test . statistical 
 significance of p=0.01 was obtained for comparison of mental component between third 
 and sixth months . for all other comparison , statistical significance level was 
 p<0.001 .. sf-36 : study 36-item short form health survey , pc : physical component score , mc : 
 mental component score . statistical significance was obtained for all time assessment 
 comparison by anova with repeated measures and tukey post - hoc test . statistical 
 significance of p=0.01 was obtained for comparison of mental component between third 
 and sixth months . for all other comparison , the physical component was influenced by the age ( p=0.03 ) but not by apache ii ( p=0.825 ) . the mental component was not influenced by age ( p=0.736 ) or apache ii ( p=0.594 ) . neither the 
 physical component nor the mental components were influenced by the length of imv , icu 
 length of stay and hospital length of stay . the particular realities of life habits , health care system and rehabilitation settings for 
 each country may interfere in the recovery of post critically ill patient21 . while in developed countries qol in post 
 critical patients has been verified after six months to two years in general1,2,3,4,5,6,7,8 , in 
 developing countries there are very few studies in this area21 and the existent studies show results from specific population . patients who survived ards due to h1n1 virus in argentina presented decline in all domains 
 of qol after six months . in that study , lung function was also assessed and found to be 
 compromised , but no correlation between lung function and qol was found . however , the number 
 of subjects was small , only 11 patients were included in that study . a brazilian study13 assessed qol of 
 critically ill survivors who presented acute kidney injury . it was a large cohort study , 
 which found that chronic kidney injury , septic shock , older age and longer icu stay were 
 related to worse qol . in our study , we also found the influence of age on qol , but not of 
 other analyzed clinical variables . another brazilian study14 evaluated qol of sepsis survivors , and also found moderate decline 
 in qol , which was influenced by age . although single centered , our study included both clinical and surgical patients , with 
 different diagnosis , thus our results reflect the outcome of a generalized population . in our study both physical and mental components of sf-36 improved significantly over time 
 after hospital discharge , as was also found by cuthbertson et al6 . the physical component was influenced by the age ( elderly , 
 i.e. , 60  years old , vs. non - elderly , i.e. , < 60  years old ) but not by apache ii , imv 
 duration , icu and hospital length of stay . this suggests that despite of socioeconomic 
 differences with possible variations in health status and outcomes across the world21 , 22 , physical component is more compromised than mental component as also 
 reported by hofhuis et al9 . moreover , the 
 influence of age has been encountered in other studies , including those from developing 
 countries13 , 14 . the impact of icu stay in the qol seems to be even stronger in elderly patients . compared 
 to young patients , older icu survivors in the united kingdom presented higher score in the 
 mental component of sf-36 but not for physical component10 . besides having their qol declined , older patients seem to be less 
 resilient to the recovery ; a spanish study showed that elderly patients who survived icu 
 were discharged home with decline in qol , 12 months afterwards the qol score was worse than 
 before hospital admission for 61% of patients11 . in a recent research about social indicators in brazil , the number of elderly and the life 
 expectance are growing23 following the 
 global changes . the increase in elderly population has also provided an elevation in the 
 number of icu admission11 , 24 . nevertheless , in this study we observed a considerable 
 number of elderly patients . in brazil , some studies describe that elderly account for 1118% 
 of total hospitalization . in our study , the included selected population presented 38.6% of 
 patients aged above 60  years old25 , 26 . the focus in the physical activity in 
 hospitalized elderly is on the rise27 ; 
 our results corroborates and suggest that the process of holistic rehabilitation of elderly 
 should be emphasized during the hospitalization stay , with the purpose of minimize the qol 
 impairment after hospital discharge . previous studies have shown that acute events such as hospitalization may lead to the 
 development or the worsening of disability28 , 29 and that it occurs commonly . as shown in 
 our results , the physical component of the sf-36 survey seems to be more compromised than 
 the mental component . therefore , aspects related to functional status and physical 
 impairment may directly influence their qol . hospital care and should be focused in 
 promoting the reduction of hospitalization - associated disability30 . it has been reported that the care of the critical patient differs from country to country 
 due to differences in the socioeconomic status , health care system and regions , and that 
 people with worse socioeconomic status have poor health state compared to those with higher 
 socioeconomic status22 , 31 , 32 . brazil is a 
 huge country where these differences can be seen especially between states from 
 north / northeast and south / southeast23 . the fact that our study was conducted in the southeast , one of the most developed regions of 
 brazil23 , may have led to similar study 
 results of developed countries , even though the study was conducted in a public 
 hospital . in our study , a large number of deaths was observed after icu discharge ; it is important to 
 observe that our study included a selected population . besides , more than half of patients 
 who died had been readmitted to the icu . readmission in the icu after discharge to the ward 
 results in a high risk of hospital mortality33,34,35 . 
 among other factors such as age and severity of the disease , early discharge from the icu 
 may be associated to the icu readmission . however , the present study was not designed to 
 evaluate this issue . for the lost patients after icu discharge in our study , the variables for imv and icu 
 length of stay were higher than for the studied group . this finding may be explained by the 
 fact that the number of surgical patients , specially neurosurgical , constitutes a larger 
 proportion than in the studied group , and factors such as the need for sedation and clinical 
 instability might have provided a higher imv length of time and , hence , a higher icu length 
 of stay . however , despite that , the results obtained from the studied population showed that 
 length of imv , icu stay and hospital stay did not influence sf-36 score . this study was conducted in a tertiary hospital . in brazil , the health system model allows 
 that such hospitals receive patients from a large variety of regions , and sometimes it makes 
 it difficult to contact patients . besides the high percentage of losses in the 
 hospitalization period , another limitation of this study was the missing data of patients 
 after discharge . reaching those patients was a challenge considering communication 
 conditions due to the wrong / lack of telephone number . unfortunately , this is a reality 
 encountered in developing countries , which affects not only the health system itself but 
 also affects the feasibility of clinical researches with longitudinal design . another limitation of the study was that although it seems that physical component persists 
 with lower values than mental components in each time point of evaluation , we did not 
 perform a specific analysis to compare the scores of physical and mental components . finally , since we only included patients who received hospital discharge and who did not 
 present neurological conditions , the studied population may have unintentionally included 
 the ones with better profile for clinical resolution and qol recovery , similarly to the 
 developed countries . our findings suggest that survivors of critical illness in a developing country present a 
 deterioration of qol , which improves over time for both physical and mental component . qol 
 was not influenced by apache ii , imv length of time , icu and hospital length of stay , but 
 the physical component of qol was influenced by age .
[ purpose ] to evaluate the quality of life of critical illness survivors in a developing 
 country over the time after hospital discharge and to assess the influence of clinical 
 variables on quality of life . 
 [ subjects and methods ] a prospective longitudinal study was 
 conducted in a large , tertiary , public hospital in sao paulo , brazil . 
 we included patients 
 18  years old , hospitalized in the intensive care unit with 24 hours of invasive 
 mechanical ventilation . 
 quality of life was assessed using the medical outcomes study 
 36-item short form health survey , which was applied by telephone interview at the first , 
 third and sixth months after hospital discharge . [ results ] 75 patients 
 were included in 
 the study . 
 quality of life improved progressively after hospital discharge ; role - physical 
 was the most compromised domain . 
 the physical component was influenced by the age . 
 quality 
 of life was not influenced by apache ii categorization , length of invasive mechanical 
 ventilation , intensive care unit stay or hospital stay . 
 [ conclusion ] survivors of critical 
 illness in a developing country present poor quality of life , which improves over time . 
 age influenced the physical component of quality of life .