KEY ARTICLES ...

Johnson S, Nenov VI, Martin NA, Becker DP The neurosurgical intensive care unit in an era of health care reform. Neurosurg Clin N Am 1994;5:829-35

Health care reform, public concern, and managed care will create an environment that demands highly creative strategies to deliver quality care while reducing costs. Patient satisfaction and outcomes will take on a high priority. To meet this challenge, the neurosurgical ICU of the future will be designed with a patient-focused theme wherein the physical environment embodies healing and humanism. Services will be brought to the patient rather than the patient accommodating the system. Patients and families will be the directors of their own care. Staff and families will have access to a highly sophisticated clinical information system, and learning for staff at all levels will be a part of everyday life in the ICU. Unit management will be within a framework of shared governance wherein the power base is with the direct care givers, and decision and policy making happens at the point closest to the patient. Patient outcomes will be a result of a highly organized collaborative model that includes primary nursing, critical paths, and case management. Partnerships between nurses and unit support staff will create skill-mix changes that allow the nurse to spend less time on nonclinical unit maintenance-type functions and more time with the patient and family. This will have a positive fiscal impact as well as enhance patient satisfaction and outcomes.

Walleck CA Nursing and labor cost reduction. New Horiz 1994;2:291-5

The coming of healthcare reform requires healthcare providers and hospitals to rethink the goals and objectives of the healthcare delivery system of the United States. To lower increasing costs while preserving the ultimate quality of care is a tremendous challenge. Labor costs in health care are primary targets for cost-cutting. Professional nurses, the group of healthcare providers who take up most of the hospital budget, are being targeted in many settings as an expendable budget item. Critical care physicians and patients depend on professional nurses to meet the care needs in the ICU. Creative, innovative, cost-effective methods of delivering critical care services must be developed in order to meet the demands of an increasing patient population. Some trial models with the explicit goal of managing cost and delivering high-quality critical care are discussed.

Chang RW, Bihari DJ Outcome prediction for the individual patient in the ICU. Unfallchirurg 1994;97:199-204

A very difficult clinical problem facing surgeons is knowing when further treatment is futile and no longer appropriate in a patient who has developed severe complications after surgery and is being treated in an intensive care unit. It is now possible to prolong the process of dying among such patients. This results in unnecessary pain and loss of dignity for the patient, anguish and distress for the patient's relatives and is dehumanizing for the clinical and nursing staff. It has also tremendous implications in the use of limited health care resources. A computer model designed to aid this process has to have the following properties: it must reflect the dynamic pathophysiological process and be able to predict death with extreme accuracy and early in the clinical course. The Riyadh algorithm uses computerised dynamic trend analysis of daily organ failure scores (APACHE II score corrected for the number and duration of organ failures), noting the rate of change in score relative to that of the previous day and an absolute threshold to predict death has been developed for this purpose. The algorithm was developed by tracking the daily scores of 200 IUC patients until their death or discharge from the intensive care unit. It was subsequently validated perspectively on 831 patients. During the validation process, the clinicians were blinded to the predictions. There wer 290 deaths and the program predicted 109 deaths (38% of all deaths) with no false-positive predictions. Forty percent of the predictions were made within 48 h in the ICU and 74% within a week.(ABSTRACT TRUNCATED AT 250 WORDS).

Buist M Intensive care unit resource utilisation. Anaesth Intensive Care 1994;22:46-60

The cost-effectiveness of the Intensive Care Unit after three decades of development has yet to be demonstrated. Accurate ICU resource allocation is limited by our inability to measure cost-effectiveness. Measurement tools have been developed and refined that will give a prediction of in-hospital mortality of groups of critically ill patients. However, these measures will not predict with certainty individual patient outcomes, and take no account of quality of life. Methodology to examine long-term outcome and quality of life after intensive care is still in its infancy. Measurement of ICU cost is limited by a lack of cost-accounting models that not only reflect true cost but that are clinically applicable.

Wachter RM, Luce JM, Safrin S, Berrios DC, Charlebois E, Scitovsky AA Cost and outcome of intensive care for patients with AIDS, Pneumocystis carinii pneumonia, and severe respiratory failure. JAMA 1995;273:230-5

OBJECTIVE--To determine the costs and outcomes associated with intensive care unit (ICU) admission for patients with acquired immunodeficiency syndrome (AIDS)-related Pneumocystis carinii pneumonia (PCP), and severe respiratory failure. DESIGN--Survival and cost-effectiveness analysis. SETTING--A large municipal teaching hospital serving an indigent population. PATIENTS--Consecutive patients intubated and mechanically ventilated for AIDS, PCP, and respiratory failure from 1981 through 1991 (n = 113). The cohort was separated into three groups for analysis: patients admitted to the ICU in 1981 through 1985 (era I, n = 43), those admitted in 1986 through 1988 (era II, n = 33), and those admitted in 1989 through 1991 (era III, n = 37). MAIN OUTCOME MEASURES--Hospital charges and survival time; cost per year of life saved, using a zero-cost, zero-life assumption. RESULTS--Twenty-eight (25%) of the 113 patients mechanically ventilated for PCP and respiratory failure survived to hospital discharge: six (14%) of 43 in era I, 13 (39%) of 33 in era II, and nine (24%) of 37 in era III (P = .04). Post-ICU admission charges averaged $57,874 for the entire cohort, remaining relatively stable across the three eras. Cost of care for survivors was significantly more expensive than for those dying before discharge. The cost of ICU admission and subsequent hospitalization averaged $174,781 per year of life saved; $305,795 in era I, $94,528 in era II, and $215,233 in era III. Improved survival rates and shorter lengths of ICU stay led to the improved cost-effectiveness in era II, while the opposite trends resulted in worsening cost-effectiveness in recent years. The strongest predictors of hospital mortality in era III were low CD4 cell counts on hospital admission and the development of pneumothorax during mechanical ventilation. CONCLUSIONS--The cost-effectiveness of intensive care for patients with PCP and severe respiratory failure improved during the first 8 years of the AIDS epidemic but fell in recent years such that it is now below that of many accepted medical interventions.

Cohen IL, Lambrinos J, Fein IA Mechanical ventilation for the elderly patient in intensive care. Incremental changes and benefits [see comments] Comment in: JAMA 1993;270:JAMA 1993

OBJECTIVE--To evaluate the cost-effectiveness of prolonged mechanical ventilation in patients 80 years of age and older in the intensive care unit (ICU). DESIGN--A retrospective review of consecutive ICU patients requiring 3 or more days of mechanical ventilation. Cost-effectiveness analysis was performed by assessing incremental hospital charges from hospital billing records; charges were then related to years of life saved. A telephone survey was used to follow up hospital survivors for a minimum of 4 years after discharge. SETTING--A 20-bed medical-surgical ICU in a 420-bed, tertiary-care community teaching hospital. PATIENTS--The study included all patients aged 80 years or older taken from a comprehensive database of all patients admitted to the ICU requiring mechanical ventilation from April 1, 1985, through October 31, 1987 (n = 512). Of 59 potential candidates, 45 were found to have complete billing records and were the subject of further analysis. RESULTS--Of the 45 patients in the group under analysis, 10 survived to leave the hospital. Of these, two were alive and one could not be located at the time of follow-up. The charge per year of life saved is estimated to between $51,854 and $75,090 in 1985-1987 dollars. Of 22 patients whose age in years plus duration of mechanical ventilation in days totaled 100 or greater, only two survived hospitalization and neither was alive at follow-up. The cost per year of life saved in this subset of patients was $1181,308 in 1985-1987 dollars. One of these patients was discharged to a nursing home and died there 4.5 years later, after multiple hospital readmissions. The other patient died at home 2 months after hospital discharge. CONCLUSION--Based on hospital charges and life expectancy, the cost-effectiveness of prolonged mechanical ventilation in ICU patients age 80 years and over was poor in our population when the combination of age and duration of mechanical ventilation exceeded 100. Further studies using this type of analysis may prove valuable in both clinical and administrative

Rafkin HS, Hoyt JW Objective data and quality assurance programs. Current and future trends. Crit Care Clin 1994;10:157-77

As CCM has grown, the diversity of ICU patients, as well as that of ICU organization and structure, has grown. This growth has led to numerous questions regarding health care delivery in the ICU. These questions contributed to the development of systems that objectively evaluate the quality of health care delivery in ICUs. Severity of disease scoring systems have been developed and allow for a valid analysis of ICU performance at several levels. These systems should help intensivists determine how health care delivery can be optimized in ICUs. Despite the controversy that surrounds severity of disease scoring and prognostic systems, it is not unreasonable to suggest that, because of the feedback these systems would provide, health care delivery in the ICU would be improved through more extensive use of them at the present time. The information acquired through the use of objective scoring systems ultimately must be used to improve the efficiency of ICUs. The structure and organization of ICUs in the United States, as well as the training of those who treat ICU patients, are excessively diverse, and a more standardized approach to health care delivery in the ICU ultimately will be required. Present information suggests that decentralized ICUs with part-time ICU physicians result in poorer outcomes. The APACHE III study intends to explore these relationships in more detail. Certainly, more studies looking at these issues are needed, but we are at least beginning to answer the questions that resulted from the rapid growth of critical care in the 1980s. The SCCM data suggest two possible alternatives, not necessarily exclusive of each other: (1) A large percentage of ICUs may be obligated to undergo structural changes in the near future. (2) Regionalization of critical care, already present, may continue. Certain rural areas may find it more expedient to send the most critically ill patients to tertiary centers in nearby cities, as opposed to a wholesale upgrading of the delivery of care in their own ICUs. Ultimately, all hospitals will be obligated to provide patients access to the highest quality of critical care.

Attitudes of critical care medicine professionals concerning distribution of intensive care resources. The Society of Critical Care Medicine Ethics Committee. Crit Care Med 1994;22:358-62

OBJECTIVE: To determine critical care practitioners' attitudes about the importance of various factors in decisions to use intensive care, including age, prognosis, quality of life, patient preference, and medical condition. DESIGN: Cohort study. SETTING: The Annual Educational and Scientific Symposium of the Society of Critical Care Medicine. SUBJECTS: Participants at the symposium. RESULTS: A self-administered questionnaire was distributed and 600 (52%) of 1,148 registrants attending the symposium responded. Eighty-four percent of respondents were physicians and 11% were nurses. Physicians were internists (30%), surgeons (24%), pediatricians (22%), and anesthesiologists (19%); 58% were in academic practices. Very few respondents believed that age should be a criterion for limiting intensive care (12%). Quality of life as viewed by the patient, probability of surviving hospitalization, reversibility of the acute disorder, and nature of the chronic disorder were the factors that most respondents considered to be important in decisions to admit to the intensive care unit. The patient's social worth, previous psychiatric history, cost-benefit analysis, and cost to society were the factors most respondents considered of little importance. Over 40% of respondents would admit patients with a chronic vegetative state or a patient with metastatic carcinoma and a superimposed, life-threatening event. CONCLUSIONS: These results suggest that critical care providers, who must occasionally face difficult decisions about how to distribute limited resources among patients with competing needs, were not often inclined, at the time of this survey, to make choices based on estimates of who might benefit most. These critical care physicians' attitudes about triage may not support the optimal use of critical care resources.

Llodra-Calvo JC, Vazquez-Mata G, Bueno-Cavanillas A, Delgado-Rodriguez M, Galvez [Evaluation of the cost of an intensive medicine unit. Relationship between the cost and the severity of the disease] [Valoracion del coste de una unidad de medicina intensiva. R TT ;TT:TT - [Val

BACKGROUND: The evaluation of the costs of intensive care is a subject of interest at present, due to the high resources required by this area of health care services and the rhythm at which these costs increase. Such an evaluation has rarely been carried out in Spain. The aim of this study was to quantify the cost of medical care to critical patients in an Intensive Care Unit (ICU) in addition to evaluate the relationship between the severity of the disease and the short term result of intensive health care. METHODS: A prospective study was carried out in 1,184 patients admitted (February 1985-February 1986) to the ICU of the Hospital General de Especialidades Virgen de las Nieves in Granada (Spain). Variables collected were the severity of the patient (APACHE II), therapeutic intensity (TISS) received, diagnosis on admission and state on discharge. A detailed and individualized evaluation was performed concerning the costs of hospital stay and treatment in the ICU. RESULTS: The cost per patient per day in the ICU was found to 54,438 pesetas in 1988. A significant association was demonstrated with age, severity, therapeutic intensity and the result of the stay in the unit, being much higher in the patients who died in the ICU, particularly in those in whom the prognosis "a priori" was good. CONCLUSIONS: A significant relation was found between the cost and severity of the disease, with the maximum costs being found in patients in whom survival was expected but who died and vice versa.

Hardy KJ, Miller H, McNeil J, Shulkes A Measurement of surgical costs: a clinical analysis. Aust N Z J Surg 1994;64:607-11

Because of reduced health care funding it is becoming necessary for surgeons to take a greater interest in the costs of individual operations. This study reports costs directly measurable to the patient, and also the indirect costs of hospital overheads, an operating suite and teaching, which were 37, 10 and 15%, respectively (62%), of hospital budget. A scheme has been developed which could give surgeons a standard to report direct costs. Pre-admission, ward, operating room, recovery, intensive care and post-admission are defined as cost periods and the modalities of staff, equipment (capital, maintenance and replacement), imaging, laboratory and consumables apply to each. This strategy was applied to assess open cholecystectomy (OC) and laparoscopic cholecystectomy (LC) as an example. The direct costs for OC were $3706 and LC $2868, a difference of $838; the indirect and direct costs were OC $6004 and LC $4646, a difference of $1358. Thus indirect cost magnified the difference between the operations. Bed stay, density of nursing and use of disposable instruments were the major influence on direct costs. The individual cost advantage of a shorter bed stay may be countervailed by an increased hospital activity. The main patient benefit of new operations may be improved quality of life and more rapid return to work with prevention of salary losses. A method has been developed to define costs of a particular surgical operation with the purpose of stimulating surgeons' interest in this topic and developing a common style of reporting.(ABSTRACT TRUNCATED AT 250 WORDS).

Cohen IL, Booth FV Cost containment and mechanical ventilation in the United States. New Horiz 1994;2:283-90

In many ICUs, admission and discharge hinge on the need for intubation and ventilatory support. As few as 5% to 10% of ICU patients require prolonged mechanical ventilation, and this patient group consumes or = 50% of ICU patient days and ICU resources. Prolonged ventilatory support and chronic ventilator dependency, both in the ICU and non-ICU settings, have a significant and growing impact on healthcare economics. In the United States, the need for prolonged mechanical ventilation is increasingly recognized as separate and distinct from the initial diagnosis and/or procedure that leads to hospitalization. This distinction has led to improved reimbursement under the prospective diagnosis-related group (DRG) system, and demands more precise accounting from healthcare providers responsible for these patients. Using both published and theoretical examples, mechanical ventilation in the United States is discussed, with a focus on cost containment. Included in the discussion are ventilator teams, standards of care, management protocols, stepdown units, rehabilitation units, and home care. The expanding role of total quality management (TQM) is also presented.

Daffurn K, Bishop GF, Hillman KM, Bauman A Problems following discharge after intensive care. Intensive Crit Care Nurs 1994;10:244-51

Intensive care units (ICUs) are now present in most acute care hospitals. While long-term studies on patients admitted to these units have been performed to identify mortality, functional outcome and quality of life, there is little information on the recovery period in the weeks immediately following discharge. The aim of this study was to identify and describe the sequelae found in patients at 3 months after leaving the ICU. The study was conducted over a 6-month period during 1991, in a university teaching hospital in Sydney, Australia. 54 patients with a length stay (LOS) of greater than 48 hours in the ICU were included. Each patient was interviewed in an outpatient clinic attached to the ICU. Information collected included pre-admission details, reason for admission, treatments provided and complications encountered. General health state, social and employment details, functional status, referral patterns since discharge and recollection of ICU stay were studied. The major findings indicated that many of the patients interviewed were returning towards near normal general health, but were suffering mild to moderate physical and psychosocial sequelae. In the majority of cases the problems were not incapacitating. The predominant complaints were minor to severe pain, sleeping difficulties, tiredness and breathlessness. Financial problems were reported by a small number of patients. Depression, irritability or a feeling of loneliness were present in over one-third of the group. More than half the patients required referral for further assessment. 34% of patients had no recollection of their ICU stay. 16 patients (29.6%) reported unpleasant memories including nightmares and hallucinations.(ABSTRACT TRUNCATED AT 250 WORDS).

Burchardi H, Schuster HP, Zielmann S Cost containment: Europe. Germany. New Horiz 1994;2:364-74

The German healthcare system offers a social network guaranteeing almost complete healthcare coverage to the German population (prevention, treatment, and rehabilitation). The system is supported by a multistructured network of public and private healthcare insurers. Fees for public insurance are equally paid by employers and employees. Healthcare expenditures heavily impact the salary levels of employees and, as a result, production costs of employers. About one third of all national healthcare spending goes to hospital care. In 1991, there were ICUs in half of all German hospitals; 3.2% of all hospital beds were ICU beds. As in most countries, the expansion in national healthcare costs in the last decade has become a serious problem in Germany. At total of 8.1% of the entire German gross national product is spent on health care, which has led to drastic governmental healthcare reform that began in 1993. The key points of this reform are: a) strict limitations on hospital budgets at 1992 levels including a new structure of hospital financing; b) controlled reduction of expenditures for medical drugs (which were formerly at the highest level in Europe); and c) controlled restriction of regional distribution for physicians. In a large German university hospital (1,461 beds; 91 ICU beds) expenses for intensive care medicine comprise about 12% of all hospital spending (5,356 deutsche mark/patient). More than 60% of these expenses are for personnel; 37% go toward drugs and medical materials. There are several possible starting points for cost containment in intensive care medicine in Germany: a) a task-adapted, countrywide diffusion of ICUs within the different levels of hospitals; b) a more selective provision of intensive care medicine (primary as well as secondary) to patients, depending on patient needs; c) a centralized and task-oriented admission and discharge policy; and d) cost containment in the use of drug therapy by centralized hospital purchasing and by establishing strict, rational, therapeutic principles. Some examples of the author's personal experience follow. In all German hospitals, expenses for personnel are about 60% to 70%. These expenses are fixed by official, standard wages. Cost containment by further restricting the number of personnel impairs the care provided. Improvements in organization and management may contribute to a higher degree of personal motivation for employees and, in turn, may result in higher working efficiency.

Cella DF Quality of life: concepts and definition. J Pain Symptom Manage 1994;9:186-92

After years of second-class status, supportive care is increasingly being recognized for its importance. Included in this recognition is a concern for making more explicit the long-held conviction within medicine that no goal can logically be more important than optimal patient functioning and well-being. This effort to make more explicit the timeless value of medical care has evolved over the past two decades, and come to be labeled "quality of life" research. At its most fundamental level, quality of life is understood to be both subjective and multidimensional. Because it is subjective, it is best measured from the patient's perspective. Because it is multidimensional, its measurement requires the investigator to inquire about a range of areas of the patient's life, including physical well-being, functional ability, emotional well-being, and social well-being. The usual concern for symptom control, familiar to the palliative-care physician, can conceptually be expanded into a consideration of costs and benefits of various treatment options relative to their subjective perception of personal function and well-being. As our interest turns to the aggressive alleviation of specific ("target") symptoms, we must critically evaluate the complex relationships among symptom intensity, symptom duration, and overall quality of life.

Gefke K, Schroeder TV, Thisted B, Olsen PS, Perko MJ, Agerskov K, Roder O, Loren Abdominal aortic aneurysm surgery: survival and quality of life in patients requiring prolonged postoperative intensive therapy. Ann Vasc Surg 1994;8:137-43

The goal of this study was to identify patients who need longer care in the ICU (more than 48 hours) following abdominal aortic aneurysm (AAA) surgery and to evaluate the influence of perioperative complications on short- and long-term survival and quality of life. AAA surgery was performed in 553 patients, 51 (9%) of whom died within the first 48 hours. Of the 502 patients who survived for more than 48 hours, 109 required ICU therapy for more than 48 hours, whereas 393 patients were in the ICU for less than 48 hours. The incidence of preoperative risk factors was similar for the two groups. The cumulated survival rates for the two groups were 68% and 92% at 1 months, 52% and 88% at 1 year, and 60% and 33% at 6 years, respectively. This significant difference was primarily related to renal, pulmonary, and cardiac complications. However, assessment of the most severe complications and risk factors combined failed to permit identification of patients in whom the perioperative survival rate was 0%. Even 20% of patients with multiorgan failure survived for 6 months. Of those patients who needed ICU therapy for more than 48 hours, 41 (38%) were alive at the end of 1988. In response to a questionnaire, 78% stated that their quality of life had improved or was unchanged after surgery and had resumed working. These data justify a therapeutically aggressive approach, including ICU therapy following AAA surgery, despite failure of one or more organ systems.

Armstrong DK, Crisp CB Pharmacoeconomic issues of sedation, analgesia, and neuromuscular blockade in critical care. New Horiz 1994;2:85-93

Neuromuscular blocking agents (NMBAs) are commonly prescribed as adjunct therapy for many critically ill patients. Controversy exists regarding the appropriate long-term use of these agents, particularly since there are severe potential clinical consequences. The expanded use of NMBAs has had a significant effect on the cost of ICU care. One should determine whether or not NMBAs are being used as adjunct therapy, or as a replacement for optimal sedation and/or analgesia. This article reviews some of the indicative economic issues surrounding the use of sedatives, analgesics, and NMBAs in the critical care arena. Understanding the pharmacokinetic and pharmacodynamic differences of these agents can aid in drug selection and route of administration. Appropriate drug selection can influence the pharmacoeconomics of these agents in the ICU.

Diamond GA, Denton TA, Matloff JM Fee-for-benefit: a strategy to improve the quality of health care and control costs through reimbursement incentives. J Am Coll Cardiol 1993;22:343-52

OBJECTIVES. The purpose of this study was to determine whether reimbursement in direct proportion to expected therapeutic benefit is capable of improving the utilization and cost of health care. BACKGROUND. The benefit associated with a particular medical or surgical treatment varies widely from patient to patient. Nevertheless, payment to the provider of the treatment is essentially invariant under the current fee-for-service system. Under an alternative fee-for-benefit strategy, empiric data are used to construct a multivariate model to predict the expected benefit to an individual patient from a particular health care service on the basis of conventional clinical descriptors. The payers and the providers of the service then openly negotiate an explicit economic relation between expected benefit and monetary payment such that payment is directly proportional to benefit. METHODS. Computer simulations were performed to determine the potential impact of this fee-for-benefit strategy with respect to medical versus surgical treatment of coronary artery disease. RESULTS. Compared with conventional fee-for-service, fee-for-benefit resulted in a 12% improvement in patient benefit (quality-adjusted survival), a 22% reduction in provider payments and a 55% increase in cost/benefit (the ratio of benefit to payment). CONCLUSIONS. The incentives embodied in a fee-for-benefit strategy can be an effective mechanism for encouraging more appropriate health care utilization while simultaneously controlling health care costs.

Ridley S, Biggam M, Stone P A cost-utility analysis of intensive therapy. II: Quality of life in survivors. Anaesthesia 1994;49:192-6

A questionnaire designed to assess changes in quality of life was sent to 56 survivors of critical illness one year after their admission to an intensive therapy unit. Forty-one patients completed the questionnaire, and for the majority, quality of life remained unchanged (n = 25). However significant decreases in quality of life were found in those patients who previously enjoyed a good quality of life or were admitted with respiratory problems. Survivors also recorded significant decreases in five aspects of their perceived quality of life (ability to think and remember, seeing family, their contribution to society, activities outside work and income). As part of a previous study, the costs incurred by each of these patients had been measured so that changes in quality of life detected in this study could be combined to the individual costs and expressed as cost per quality adjusted life year. The cost of intensive therapy for a patient surviving for one year after acute respiratory or cardiovascular disease was 2600 pounds. The total hospital cost per quality adjusted life year was estimated at 7500 pounds, which places intensive therapy at the higher end of health programme costs. If the costs of nonsurvivors are included in the cost per quality adjusted life year calculation, the cost of intensive care increases considerably.

Teres D, Lemeshow S Why severity models should be used with caution. Crit Care Clin 1994;10:93-110; di

There are now two validated time points for predicting hospital mortality of ICU patients--at admission and at 24 hours. The best purposes include evaluation of high clinical performance ICUs and for patients being enrolled in clinical trials. For the latter purpose, the model must be calibrated in the individual hospital to ensure that the model is applicable. This can be estimated by using goodness-of-fit testing. There are fewer uses for physiology scores and increased emphasis on converting scores to probabilities. For individual patient application, the model should be demonstrated to have high discrimination, as measured by the area under the receiver operating characteristic curve, and high calibration, as defined by goodness-of-fit testing. Although models have improved substantially and are now based on much larger databases, there is considerable uncertainty in their application for insurance purposes, triage, regulatory applications, sanctions against individual physicians, and cost containment. Current models may not adequately describe important ICU conditions such as adult respiratory distress syndrome and multi-organ dysfunction occurring after 24 hours into ICU care. For family discussions regarding prognosis of individual patients, ICU severity models must be used cautiously at admission or after 24 hours, with the understanding of the strengths and weakness of estimating probabilities of hospital mortality. The mathematical link between physiology score and estimation of hospital mortality is established only for the time point of 24 hours after ICU admission. Calibration and discrimination of the admission and 24-hour models also must be performed within each hospital in which individual probabilities are presented to families. It may be possible to customize a probability model such as MPM to achieve a high level of calibration at the individual hospital level.

Zimmerman JE, Shortell SM, Knaus WA, Rousseau DM, Wagner DP, Gillies RR, Draper Value and cost of teaching hospitals: a prospective, multicenter, inception cohort study. Crit Care Med 1993;21:1432-42

OBJECTIVE: To examine variations in case-mix, structure, resource use, and outcome performance among teaching and nonteaching intensive care units (ICU). DESIGN: Prospective inception cohort study. PATIENTS: A consecutive sample of 15,297 patients at 35 hospitals, which compared 8,269 patients admitted to 20 teaching ICUs at 18 hospitals vs. 7,028 patients admitted to 17 non-teaching ICUs at 17 hospitals. INTERVENTIONS: None. MEASUREMENTS: We selected demographic, physiologic, and treatment information for an average of 415 patients at each ICU, and collected data on hospital and ICU structure. Outcomes were compared using ratios of observed to risk-adjusted predicted hospital death rates, ICU length of stay, and resource use. MAIN RESULTS: When compared to nonteaching ICUs, teaching ICUs had twice the number of physicians who regularly provided services and cared for significantly younger and more severely ill (p .001) patients. Risk-adjusted ICU length of stay was similar, but resource use was significantly (p .001) greater in teaching ICUs, with $3,000 (10.5%) of estimated total costs for an average ICU admission related to increased use of diagnostic testing and invasive procedures in teaching ICUs. Risk-adjusted hospital death rates were not significantly different (p = .1) between all teaching and nonteaching ICUs, but were significantly (p .05) better in four teaching ICUs, but in only one nonteaching ICU. The 14 hospitals that were members of the Council of Teaching Hospitals had significantly better risk-adjusted outcome in their 16 ICUs than all others (odds ratio = 1.21, confidence interval 1.06 to 1.38, p = .004). CONCLUSIONS: Teaching ICUs care for more complex patients in a substantially more complicated organizational setting. The best risk-adjusted survival rates occur at teaching ICUs, but production cost is higher in teaching units, secondary to increased testing and therapy. Teaching ICUs are also successfully transferring knowledge to trainees who, after their training, are achieving equivalent results at slightly lower cost in nonteaching ICUs.

Rapoport J, Teres D, Lemeshow S, Gehlbach S A method for assessing the clinical performance and cost-effectiveness of intensive care units: a multicenter inception cohort study. Crit Care Med 1994;22:1385-91

OBJECTIVES: To present an approach for assessing intensive care unit (ICU) performance which takes into account both economic and clinical performance while adjusting for severity of illness. To present a graphic display which permits comparisons among a group of hospitals. DESIGN: A multicenter, inception cohort study. SETTING: Twenty-five ICUs in U.S. hospitals that participated in the European and North American Study of Severity Systems for ICU Patients. PATIENTS: Consecutive patients (n = 3,397) admitted to ICUs in participating hospitals between September 30, 1991 and December 27, 1991. Excluded were coronary care patients, burn patients, cardiac surgery patients and patients aged 18 yrs. MEASUREMENTS AND MAIN RESULTS: The clinical performance index is the difference between observed hospital survival rate and survival rate predicted by the Mortality Probability Model measuring severity of illness at ICU admission. The economic performance (resource use) measure is a length of stay index, Weighted Hospital Days, which weights ICU days more heavily than non-ICU days. The economic performance index is the difference between actual mean resource use and the resource use predicted by a regression including severity of illness and percent of surgical patients. Both the clinical and economic performance indices are standardized to show how far a particular hospital is from the overall mean and are graphed together. Most of the 25 hospitals lie within 1 SD of the mean on both clinical and economic performance scales. The graph makes it easy to identify those hospitals that are outside this range. There is no evidence of a trade-off between high clinical performance and high economic performance; i.e, it is possible to achieve both. CONCLUSIONS: Cross-indexing of clinical and economic ICU performance is easy to calculate. It has potential as a research and evaluation tool used by physicians, hospital administrators, payers, and others.

Chalfin DB, Fein AM Critical care medicine in managed competition and a managed care environment. New Horiz 1994;2:275-82

The high cost of medical care in the United States and diminishing access to health care for many Americans has spurred healthcare reform efforts in this country. Several bills have been introduced into Congress. Many of these healthcare bills and other proposals embrace the concept of managed care and managed competition as their central feature. The steady growth of managed care organizations and the possible adoption of managed competition stands to significantly alter the way critical care medicine is practiced and delivered in the United States. The number of ICUs and ICU beds may be reduced, affecting both patient case mix and the overall mission of the ICU and critical care practice. Furthermore, fewer critical care practitioners may be available as a result of diminished educational funding and reduced training programs. In view of these and other impending changes in the American healthcare system, it is vital to investigate the impact of managed care on ICU practice and patient outcome and to study the incremental and value-added contributions of critical care medicine.

Bone RC, McElwee NE, Eubanks DH, Gluck EH Analysis of indications for early discharge from the intensive care unit. Clinical efficacy assessment project: American College of Physicians. Chest 1993;104:1812-7

OBJECTIVE: To formulate recommendations for the development of early intensive care unit (ICU) discharge criteria for low-risk monitor patients. DESIGN: Literature review of published reports over the period 1966 to 1991 pertaining to ICU discharge criteria. PATIENTS: Studies identifying patients admitted to ICUs who could be characterized as low risk. Patient populations of interest included adults ( or = 18 years of age) with low-risk medical or mixed medical/surgical conditions; cardiac care unit and burn patients were excluded. MEASUREMENTS AND MAIN RESULTS: Of 1,492 articles identified as being pertinent to ICU discharge, only 2 studies (by the same group of investigators) were found that distinguished low-risk populations among medical and mixed medical/surgical ICU patients. The physiologic component of the Acute Physiology and Chronic Health Evaluation (APACHE) was used in both of these studies to ascertain the degree of risk. No studies were found that compared outcomes of low-risk patients remaining in the ICU after 24 h with those transferred to other hospital locations. CONCLUSIONS: Objective methods (such as APACHE III) should be used to identify low-risk patients at 24 h post-ICU admission. A multicenter study should be conducted to compare outcomes on patients identified as low risk who are randomly assigned to alternative hospital locations for treatment versus those assigned to continued ICU treatment until routine ICU discharge. Mortality and quality of life data should be used as outcome measures (prior to ICU admission and 6 months post-ICU discharge).

Robinson R Cost-utility analysis [see comments] Comment in: BMJ 1993;307:BMJ 1993 N

Decisions have to be made about allocating health resources. Currently the best economic evaluation method for doing this is cost-utility analysis. This compares the costs of different procedures with their outcomes measured in "utility based" units--that is, units that relate to a person's level of wellbeing. The most commonly used unit is the quality adjusted life year (QALY). QALYs are calculated by estimating the total life years gained from a procedure and weighting each year to reflect the quality of life in that year. To compare outcomes of different programmes the Rosser index is one measure that is widely used to assign quality of life scores to patients. Combined with a measure of life years gained from a procedure, this enables QALYs to be calculated and procedures ranked according to cost per QALY gained. In this article Ray Robinson explains the measures used and discusses how QALY league tables can be used to guide decisions on resource allocation.

Quality of life: a tool for decision-making in the ICU. Spanish Group for the Epidemiological Analysis of Critical Patients (PAEEC) [editorial] Intensive Care Med 1994;20:251-2

Drummond M, O'Brien B Clinical importance, statistical significance and the assessment of economic and quality-of-life outcomes. Health Econ 1993;2:205-12

The assessment of economic and quality-of-life outcomes of health care interventions is moving into a new era, with such assessments increasingly being made within the context of controlled clinical trials. Traditionally the measurement of many variables in economic evaluations, particularly costs, has been deterministic. In the context of clinical trials the measurement of variables is stochastic, with the standard principles of statistical inference being applied to analyse differences between treatments in terms of effectiveness. Economists participating in clinical research are therefore being called upon to specify the sample size for the economic component of the evaluation and to undertake statistical tests for differences in cost or cost-effectiveness. This paper discusses the current methodological issues surrounding stochastic measurement in clinical trials, discusses the additional issues raised by the assessment of economic and quality-of-life outcomes and specifies the challenges facing economists if they are to answer the questions now being posed about economic analysis by statisticians and clinical researchers. It is concluded that application of the standard principles of statistical inference to economic data is not straightforward and will require value judgements to be made about statistical significance and economic importance, which may differ from those already made in purely clinical studies.

Hermanns K, Salomon F [Dying and death in a surgical intensive care unit from the viewpoint of close relatives--a questionnaire survey] [Sterben und Tod auf einer operativen Intensivstation aus de TT ;TT:TT - [Ste

No studies are available so far on the way dying and death in the ICU are perceived by relatives of the patients. It is also not clear in how far the current criticism of intensive care medicine stems from these relatives. These problems were investigated by sending a self-developed 48-item questionnaire to relatives of patients who had died in the ICU. The questions centred on the following subjects: Communication and information structures Perception of the ICU and emotional reaction Assessment of treatment Dying and death in the ICU. Of 181 questionnaires distributed, 145 (85.3%) were returned. We present the replies of the 109 persons who visited their relatives in the ICU. The majority regarded themselves as well informed. Initial impressions were a high technical and medical standard. Emotional reactions to ICU treatment of a relative alternated between anxiety and hope with the dominant impression that the patient received the best possible therapy. However, the treatment was not perceived as an artificial prolongation of life. Although death loses dignity in the ICU according to those questioned, dying in peace does seem possible in this situation. The high response rate, the positive general assessment and the critical view of death in the ICU are discussed in the following.

Scitovsky AA "The high cost of dying" revisited. Milbank Q 1994;72:561-91

This review of the literature of the past decade on medical care costs at the end of life finds that the data do not support the often-voiced hypothesis that the rise in medical care costs is due largely to the disproportionate use of high-technology medical care by persons who die. It also shows that although the intensity of care, as indicated by hospital expenditures, declines with age, any savings on hospital costs of very old decedents are offset by nursing-home costs. Studies of hospice care and advance directives are reviewed for their effectiveness in reducing end-of-life costs, but these strategies are not promising at this time, largely because of the difficulty of predicting when an individual patient will die. It is suggested that curbing the rise in medical care costs will require basic changes in the physician-patient relationship and in our attitude to death.

Drummond M, Torrance G, Mason J Cost-effectiveness league tables: more harm than good? Soc Sci Med 1993;37:33-40

In recent years it has become fashionable to make comparisons (in 'league tables' or rankings) between health care interventions in terms of their relative cost-effectiveness, in cost per life-year or cost per quality-adjusted life-year gained. However, concerns have been raised about the unthinking use of league tables and some authors have questioned the theoretical basis of their construction. In this paper a recently-reported league table is scrutinized and the important methodological features of the source studies identified. These include the choice of discount rate, the method of estimating utility values for health states, the range of costs and consequences considered and the choice of comparison programme. Several recommendations are made for improvements, both in the methodology of economic evaluation studies and in the construction and use of league tables. It is concluded that, for league tables to be useful, decision makers should be able to assess the relevance and reliability of the evidence in their own setting. Fuller reporting of methods and results by the authors of economic evaluation studies would greatly assist in the appropriate construction and use of league tables.

Gerard K, Mooney G QALY league tables: handle with care [see comments] Comment in: Health Econ 1994;3:Health Eco

This paper examines some of the difficulties in using QALY league tables in priority setting. Such tables sometimes are seen as being 'the' way to prioritise in health care and in particular, at present, with respect to priority setting among purchasers in the UK NHS. However the paper highlights the fact that the base on which such tables is built is small--relatively few studies in the English language using CUA have been conducted anywhere. Further, four issues which require handling with care are set out: (i) the relevant measure of cost in QALY league tables has to be restricted to health service resource use; (ii) the relevant measure of benefit in QALY league tables is clearly restricted to QALYs, thereby the utility of health gains and indeed the maximisation of the utility of health gains; (iii) in incorporating the results of CUA studies into QALY league tables there is a need for greater clarification on what the margin constitutes; and (iv) those who might use CUA results in QALY league tables need to ascertain whether the original context of the study will allow the results to be transferred to the local context of the decision maker. The paper suggests that there is a need to be quite clear what goal QALY league tables serve. The authors argue that the only legitimate (and clearly important) goal of QALY league tables is the maximization of the utility of health gains within a health service budget.(ABSTRACT TRUNCATED AT 250 WORDS).

Mason J, Drummond M, Torrance G Some guidelines on the use of cost effectiveness league tables [see comments] Comment in: BMJ 1993;306:BMJ 1993 A

Decisions to allocate resources in health care are increasingly influenced by relative cost effectiveness. To warn decision makers of some of the pitfalls currently found in cost effectiveness league tables and to suggest how meaningful comparisons may be made between health care technologies a published league table was scrutinised by examining its sources. This showed some of the methodological problems surrounding such tables and how such difficulties could be reduced in future. The source studies in the table featured different years of origin, discount rates, health state evaluations, settings, and types of comparison programmes; all of these differences may raise problems for meaningful comparison. Decision makers need to assess the relative value for money of competing health care interventions. In the absence of systematic comparisons such assessments are likely to take place informally. This will probably have a worse risk-benefit trade off than the formalized use of league tables.

Schapira DV, Studnicki J, Bradham DD, Wolff P, Jarrett A Intensive care, survival, and expense of treating critically ill cancer patients [see comments] Comment in: JAMA 1993;269:JAMA 1993

OBJECTIVE--To determine the survival and factors affecting the survival of patients with solid tumors and hematologic cancers who were admitted to the intensive care unit, the time these patients spent at home (meaningful survival) before they died, and the cost per year of life gained and per year of life gained at home. DESIGN--Survival and cost-effectiveness analysis. SETTING--A tertiary-care cancer center at a university medical center. PATIENTS--Every patient admitted to the intensive care unit between July 1, 1988, and June 30, 1990, was entered into the study. This group comprised 83 patients with solid tumors and 64 patients with hematologic cancers. MAIN OUTCOME MEASURES--Factors affecting survival, such as age, sex, malignancy, length of stay in the intensive care unit, and necessity for mechanical ventilator assistance, as well as cost per year of life gained and cost per year of life gained at home. RESULTS--The only factor that significantly affected survival was the requirement for mechanically assisted ventilation for patients with hematologic cancers. More than three fourths of the patients in either group spent less than 3 months at home before dying. The cost per year of life gained for patients with solid tumors was $82,845 and for patients with hematologic cancers was $189,339. The cost per year of life gained at home was $95,142 for patients with solid tumors and $449,544 for patients with hematologic cancers. CONCLUSION--The majority of patients with solid tumors and hematologic cancers admitted to the intensive care unit die before discharge, or, if they survive the hospital admission, they spend a minimal amount of time at home before dying. This limited survival is achieved at considerable cost. Physicians who treat patients with neoplastic disease should discuss potential outcomes and the possibility of withdrawing life-supportive therapy if appropriate with the patient and family, so that a reasonable strategy can be agreed on before the initiation

Atkinson S, Bihari D, Smithies M, Daly K, Mason R, McColl I Identification of futility in intensive care. Lancet 1994;344:1203-6

Rising costs of intensive care and the ability to prolong the life of critically ill patients creates a need to recognise early those patients who will die despite treatment. We used changes in a modified APACHE II score (organ failure score) to make daily predictions of individual outcome in 3600 patients. 137 patients were predicted to die and of these, 131 (95.6%) died within 90 days of discharge from hospital (sensitivity 23.4%, specificity 99.8%); a false-positive diagnosis rate of 4.4%. 2 of the 6 survivors have subsequently died but 4 are alive with good quality of life. Patients predicted to die stayed 1492 days in intensive care and incurred 16.7% of total intensive care expenditure and 46.4% of the cost of all patients that died. Median survival after a prediction to die was 2 days, accounting for 62% of intensive care patient days in this patient group, giving an effective intensive care cost per survivor of UK 129,651 pounds. If used prospectively, this algorithm has the potential to indicate the futility of continued intensive care but at the cost of 1 in 20 patients who would survive if intensive care were continued.

Predicting outcome in ICU patients. 2nd European Consensus Conference in Intensive Care Medicine. Intensive Care Med 1994;20:390-7

Robinson R Economic evaluation and health care. What does it mean? BMJ 1993;307:670-3

Ever since the concept of value for money in health care was introduced into the NHS, economic terms and jargon have become part of our everyday lives--but do we understand what the different types of economic evaluation all mean, particularly those that sound similar to the uninitiated? This article introduces readers to the purpose of economic evaluation, and briefly explains the differences between cost-minimisation analysis (used when the outcomes of the procedures being compared are the same); cost-effectiveness analysis (used when the outcomes may vary, but can be expressed in common natural units, such as mm Hg for treatments of hypertension); cost-utility analysis (used when outcomes do vary--for example, quality of life scales); and cost-benefit analysis (used when a monetary value is being placed on services received). Further articles will deal with each one in more detail.

Rustom R, Daly K Quality of life after intensive care. Br J Nurs 1993;2:316-20

Quality of life must be assessed after patients have received intensive care. Long-term survival of intensive care patients should be evaluated. TISS (Therapeutic Intervention Scoring System) is an extremely useful tool for estimating the cost of treatment given to an individual patient. APACHE II (Acute Physiology and Chronic Health Evaluation) is an effective index for measuring severity of illness. Age of patient and severity of illness dramatically affect the cost of treatment in intensive care.