A Kersten

Variation in critical care services across North America and Western Europe

Objective:Critical care represents a large percentage of healthcare spending in developed countries. Yet, little is known regarding international variation in critical care services. We sought to understand differences in critical care delivery by comparing data on the distribution of services in eight countries. Design:Retrospective review of existing national administrative data. We identified sources of data in each country to provide information on acute care hospitals and beds, intensive care units and beds, intensive care admissions, and definitions of intensive care beds. Data were all referenced and from as close to 2005 as possible. Setting:United States, France, United Kingdom, Canada, Belgium, Germany, The Netherlands, and Spain. Patients:Not available. Interventions:None. Measurements and Main Results:No standard definition existed for acute care hospital or intensive care unit beds across countries. Hospital beds varied three-fold from 221/100,000 population in the United States to 593/100,000 in Germany. Adult intensive care unit beds also ranged seven-fold from 3.3/100,000 population in the United Kingdom to 24.0/100,000 in Germany. Volume of intensive care unit admissions per year varied ten-fold from 216/100,000 population in the United Kingdom to 2353/100,000 in Germany. The ratio of intensive care unit beds to hospital beds was highly correlated across all countries except the United States (r = .90). There was minimal correlation between the number of intensive care unit beds per capita and health care spending per capita (r = .45), but high inverse correlation between intensive care unit beds and hospital mortality for intensive care unit patients across countries (r = −.82). Conclusions:Absolute critical care services vary dramatically between countries with wide differences in both numbers of beds and volume of admissions. The number of intensive care unit beds per capita is not strongly correlated with overall health expenditure, but does correlate strongly with mortality. These findings demonstrate the need for critical care data from all countries, as they are essential for interpretation of studies, and policy decisions regarding critical care services.

Haloperidol use is associated with lower hospital mortality in mechanically ventilated patients.

Objective:To determine whether haloperidol use is associated with lower mortality in mechanically ventilated patients. Design:Retrospective cohort analysis. Setting:A large tertiary care academic medical center. Patients:A total of 989 patients mechanically ventilated for >48 hrs. Measurements and Main Results:We compared differences in hospital mortality between patients who received haloperidol within 2 days of initiation of mechanical ventilation and those who never received haloperidol. Despite similar baseline characteristics, patients treated with haloperidol had significantly lower hospital mortality compared with those who never received haloperidol (20.5% vs. 36.1%; p = .004). The lower associated mortality persisted after adjusting for age, comorbidity, severity of illness, degree of organ dysfunction, admitting diagnosis, and other potential confounders. Conclusions:Haloperidol was associated with significantly lower hospital mortality. These findings could have enormous implications for critically ill patients. Because of their observational nature and the potential risks associated with haloperidol use, they require confirmation in a randomized, controlled trial before being applied to routine patient care.

Health-related quality of life before, 1 month after, and 9 months after intensive care in medical cardiovascular and pulmonary patients.

ObjectiveAssessment of health-related quality of life before, 1 month after, and 9 months after an intensive care unit stay using an established generic instrument, the Medical Outcome Survey Short Form-36 (SF-36). DesignProspective, observational study. SettingUniversity hospital medical intensive care unit. PatientsTwo hundred forty-five patients with predominantly cardiovascular and pulmonary disorders. InterventionsNone. Measurements and Main ResultsDemographic data, Simplified Acute Physiology Score (SAPS) II, and Sepsis-Related Organ Failure Assessment (SOFA) were obtained. All adult survivors staying in the intensive care unit for >24 hrs were eligible. Pre-intensive care unit status was obtained for 245 patients (179 males, mean age 64 yrs, mean intensive care unit stay 3 days, SAPS II 26 ± 10), and 153 patients completed all three questionnaires. In this cohort, none of the eight health dimensions of the SF-36 showed impaired functioning after 9 months compared with baseline values. Physical and emotional role deteriorated after 1 month but returned to baseline thereafter. Notably, the mental health summary scale did not change during the course of the study, whereas the physical health summary scale consistently improved over time. Patients older than the median of 66 yrs rated their physical functioning lower. No association with SAPS II or SOFA and SF-36 was found. ConclusionQuality of life after intensive care unit is a dynamic process, with some functions improving shortly after intensive care unit discharge and others deteriorating but returning at least to baseline values later on. In this patient population, the SF-36 was independent from measures of severity of illness or morbidity. Health-related quality of life represents a feasible method to collect patients’ individual views in contrast to surrogate measures of outcome.

Growth of intensive care unit resource use and its estimated cost in Medicare

Objective:The past 10–15 yrs brought significant changes in the United States healthcare system. Effects on Medicare intensive care unit use and costs are unknown. Intensive care unit costs are estimated using the Russell equation with a ratio of intensive care unit to floor cost per day, or “R value,” of 3, which may no longer be valid. We sought to determine contemporary Medicare intensive care unit resource use, costs, and R values; whether these vary by patient and hospital characteristics; and the impact of updated values on estimated intensive care unit costs. Design:Retrospective analysis of Medicare Inpatient Prospective Payment System hospitalizations from 1994 to 2004 using Medicare Provider Analysis and Review files. Setting:All nonfederal acute care US hospitals paid through the Inpatient Prospective Payment System. Subjects:Inpatient prospective payment system hospitalizations from 1994 to 2004 (n = 121,747, 260). Interventions:None. Measurements and Main Results:We examined resource use and costs (adjusted to y2004

Relationship of insurance type and treatment of severe status asthmaticus in working-age adults

), calculating intensive care unit and floor costs directly and using these to generate year-specific R values. By 2004, 33% of Medicare hospitalizations had intensive care unit or coronary care unit care, with more than half of the increase in total hospitalizations because of additional intensive care unit hospitalizations. Adjusted intensive care unit cost per day remained stable (

RIFLE criteria for acute kidney injury are associated with hospital mortality in critically ill patients: a cohort analysis

2,616 vs.

Clinical evaluation of the new RIFLE criteria for acute renal failure

2,575; 1994 vs 2004), yet adjusted floor cost per day rose substantially (

World Resources in Critical Care Study: a survey of critical care research and resources in eight countries

1,027 vs.

ICU use of haloperidol prior to the 2002 SCCM sedation and analgesia guidelines.

1,488) driven by decreased floor length of stay. Annual adjusted Medicare intensive care unit costs increased 36% to

Rising use of intensive care unit services in Medicare

32.3B, largely because of increased utilization. R values decreased progressively from 2.55 to 1.73, were lower for surgical vs. medical admissions and survivors vs. nonsurvivors, but varied little by hospital characteristics. An R value of 3 overestimated Medicare intensive care unit costs by 17.6% (