160 research outputs found
Definitions and methods of cost assessment: an intensivist's guide - ESICM Section on Health Services Research and Outcome Working Group on Cost Effectiveness
No full textObjective: To define the different types of costs incurred in the care of critically ill patients and to describe some of the most commonly used methods for measuring and allocating these costs. Design: Literature review. Definitions for opportunity, direct and indirect. fixed, variable, marginal, and total costs are described and interpreted in the context of the critical care setting. Two main methods of costing are described: the 'top-down' and 'bottom-up' methods together with a number of cost proxies, such as the use of weighted hospital days, diagnosis-related groups, severity and activity scores, and effective costs per survivor. Conclusions: The assessment and allocation of costs to critically ill patients is complex and as a result of the different definitions and methods used, meaningful comparisons between studies are plagued with difficulty. When undertaking a study looking to measure costs, it is important to state: (a) the aim of the cost assessment study; (b) the perspective (point of view); ( C) the type of costs that need to be measured and (d) the time span of assessment. By being explicit about the rationale of the study and the methods used, it is hoped that the results of economic evaluations will he better understood, and hence implemented within the critical care setting
Optimal productive size of hospital’s intensive care units
No full textHospital, Intensive Care Units, Returns to Scale, Optimal Size
SAPS 3—From evaluation of the patient to evaluation of the intensive care unit. Part 1: Objectives, methods and cohort description
No full textOBJECTIVE: Risk adjustment systems now in use were developed more than a decade ago and lack prognostic performance. Objective of the SAPS 3 study was to collect data about risk factors and outcomes in a heterogeneous cohort of intensive care unit (ICU) patients, in order to develop a new, improved model for risk adjustment. DESIGN: Prospective multicentre, multinational cohort study. PATIENTS AND SETTING: A total of 19,577 patients consecutively admitted to 307 ICUs from 14 October to 15 December 2002. MEASUREMENTS AND RESULTS: Data were collected at ICU admission, on days 1, 2 and 3, and the last day of the ICU stay. Data included sociodemographics, chronic conditions, diagnostic information, physiological derangement at ICU admission, number and severity of organ dysfunctions, length of ICU and hospital stay, and vital status at ICU and hospital discharge. Data reliability was tested with use of kappa statistics and intraclass-correlation coefficients, which were >0.85 for the majority of variables. Completeness of the data was also satisfactory, with 1 [0-3] SAPS II parameter missing per patient. Prognostic performance of the SAPS II was poor, with significant differences between observed and expected mortality rates for the overall cohort and four (of seven) defined regions, and poor calibration for most tested subgroups. CONCLUSIONS: The SAPS 3 study was able to provide a high-quality multinational database, reflecting heterogeneity of current ICU case-mix and typology. The poor performance of SAPS II in this cohort underscores the need for development of a new risk adjustment system for critically ill patient
SAPS 3--From evaluation of the patient to evaluation of the intensive care unit. Part 2 : Development of a prognostic model for hospital mortality at ICU admission
No full textOBJECTIVE: To develop a model to assess severity of illness and predict vital status at hospital discharge based on ICU admission data. DESIGN: Prospective multicentre, multinational cohort study. PATIENTS AND SETTING: A total of 16,784 patients consecutively admitted to 303 intensive care units from 14 October to 15 December 2002. MEASUREMENTS AND RESULTS: ICU admission data (recorded within +/-1 h) were used, describing: prior chronic conditions and diseases; circumstances related to and physiologic derangement at ICU admission. Selection of variables for inclusion into the model used different complementary strategies. For cross-validation, the model-building procedure was run five times, using randomly selected four fifths of the sample as a development- and the remaining fifth as validation-set. Logistic regression methods were then used to reduce complexity of the model. Final estimates of regression coefficients were determined by use of multilevel logistic regression. Variables selection and weighting were further checked by bootstraping (at patient level and at ICU level). Twenty variables were selected for the final model, which exhibited good discrimination (aROC curve 0.848), without major differences across patient typologies. Calibration was also satisfactory (Hosmer-Lemeshow goodness-of-fit test H=10.56, p=0.39, C=14.29, p=0.16). Customized equations for major areas of the world were computed and demonstrate a good overall goodness-of-fit. CONCLUSIONS: The SAPS 3 admission score is able to predict vital status at hospital discharge with use of data recorded at ICU admission. Furthermore, SAPS 3 conceptually dissociates evaluation of the individual patient from evaluation of the ICU and thus allows them to be assessed at their respective reference levels
Triage admission and rejection variations in European intensive care units
No full textINTRODUCTION. Triage decisions are made daily by physicians in ICUs throughout the world without
strict guidelines. Evaluation and comparisons of triage practices in different ICUs have not been
reported.
METHODS. A prospective, observational study of triage decisions was performed in 11 ICUs in 7
European countries from September 2003 until March 1, 2005. All patients > 18 years whose health
care professional explicitly requested admission to the ICU were included. Data collected for consecutive
patients included whether the patient was accepted or rejected and SAPS II scores at the time of
triage.
RESULTS. Of the 8472 triages there were 7737 patients (pt); 6390 pts were accepted to ICU,
1347 (18%) rejected. Numbers of accepted, rejected (%), total pts and mean SAPS II scores of
the 7737 pts per center were respectively, Isala, NE- 1231, 66(5%), 1297, 27.8; Univ Med Ctr,
NE- 839, 127(13%),28.8; Hadassah, IL- 725, 160 (18%), 885, 35.0; Royal Hallamshire, UK- 664,
142(18%),806,25.5; Herlev, DE- 498, 187(27%),685,46.9; San Paolo, IT- 483, 187(28%),670,36.1;
Parc Tauli, ES- 298, 272(48%),570,32.3; Soroka, IL- 491,10 (2%),501,35.4; San Gerardo,
IT- 442, 52(11%),494,33.0; Lariboisiere, FR- 426, 47(10%),473,29.7; Whittington, UK- 292,
97(25%),389,37.1; Total- 6390, 1347(18%),7737,32.7.
CONCLUSION. Marked variations in percentages of accepted and rejected patients were present in
the studied European ICUs that could not be explained by patient severity of illness
Triage decisions and bias against the elderly in European intensive care units
No full textINTRODUCTION. Life and death triage decisions are made daily by physicians in ICUs. Many hospitals
do not have adequate ICU resources and patients who might benefit from ICU are not always
admitted, especially the elderly.
METHODS. A prospective, observational study of triage decisions was performed in 11 ICUs in 7
European countries from September 2003 until March 1, 2005. All patients > 18 years whose health
care professional explicitly requested admission to the ICU were included. Data collected for consecutive
patients included age, SAPS II scores, whether the patient was accepted or rejected and 28-day
mortality.
RESULTS. Of the 8472 triages there were 7737 patients (pt). Of the 8472 triages, 6981 were accepted
to ICU, 1491 (18%) rejected. 3795 (49%) pts were 65 or older. As the pt’s age increased, the
refusal rate also increased (18-44- 191/1614- 12%; 45-64- 347/2328- 15%; 65-74- 337/1905- 18%;
75-84- 360/1576- 23%; >84- 112/314- 36%). Mortality was greater for older pts (18-44- 171/1566-
11%; 45-64- 497/2328- 21%; 65-74- 531/1905- 28%; 75-84- 580/1576- 37%; >84- 150/314- 48%;
total 1929/7737- 25%). Differences between mortalities of accepted vs. rejected pts, however, were
greatest for older pts (18-44- 148/1423- 10% vs 23/191- 12%; 45-64- 411/1981- 21% vs 86/347- 25%;
65-74- 413/1568- 26% vs 118/337- 35%; 75-84- 429/1216- 35% vs 151/360- 42%; >84- 86/202- 43%
vs 64/112- 57%. Logistic regression showed less mortality for accepted vs rejected pts corrected for
SAPS only for pts > 65 [OR- 0.56-0.77 (95%CI 0.35-0.98)] (p< 0.05).
CONCLUSION. Despite the fact that elderly pts are rejected from ICUs more often than younger pts
and have a higher mortality when admitted, the benefit of ICU survival appears greater for the elderly.
Physicians should consider changing their triage practices considering the elderly
The Eldicus prospective, observational study of triage decision making in European intensive care units : part II: Intensive care benefit for the elderly
No full textRationale: Life and death triage decisions are made daily by intensive care unit physicians. Admission to an intensive care unit is denied when intensive care unit resources are constrained, especially for the elderly.
Objective: To determine the effect of intensive care unit triage decisions on mortality and intensive care unit benefit, specifically for elderly patients.
Design: Prospective, observational study of triage decisions from September 2003 until March 2005.
Setting: Eleven intensive care units in seven European countries.
Patients: All patients >18 yrs with an explicit request for intensive care unit admission.
Interventions: Admission or rejection to intensive care unit.
Measurements and Main Results: Demographic, clinical, hospital, physiologic variables, and 28-day mortality were obtained on consecutive patients. There were 8,472 triages in 6,796 patients, 5,602 (82%) were accepted to the intensive care unit, 1,194 (18%) rejected; 3,795 (49%) were >65 yrs. Refusal rate increased with increasing patient age (18-44: 11%; 45-64: 15%; 65-74: 18%; 75-84: 23%; >84: 36%). Mortality was higher for older patients (18-44: 11%; 45-64: 21%; 65-74: 29%; 75-84: 37%; >84: 48%). Differences between mortalities of accepted vs. rejected patients, however, were greatest for older patients (18-44: 10.2% vs. 12.5%; 45-64: 21.2% vs. 22.3%; 65-74: 27.9% vs. 34.6%; 75-84: 35.5% vs. 40.4%; >84: 41.5% vs. 58.5%). Logistic regression showed a greater mortality reduction for accepted vs. rejected patients corrected for disease severity for elderly patients (age >65 [odds ratio 0.65, 95% confidence interval 0.550.78, p <.0001]) than younger patients (age <65 [odds ratio 0.74, 95% confidence interval 0.57-0.97, p = .01]).
Conclusions: Despite the fact that elderly patients have more intensive care unit rejections than younger patients and have a higher mortality when admitted, the mortality benefit appears greater for the elderly. Physicians should consider changing their intensive care unit triage practices for the elderly
Identification of cis-acting sequences responsible for phorbol ester induction of human serum amyloid A gene expression via a nuclear factor kappaB-like transcription factor
No full textWe have analyzed the 5'-flanking region of one of the genes coding for the human acute-phase protein, serum amyloid A (SAA). We found that SAA mRNA could be increased fivefold in transfected cells by treatment with phorbol 12-myristate 13-acetate (PMA). To analyze this observation further, we placed a 265-base-pair 5' SAA fragment upstream of the reporter chloramphenicol acetyltransferase (CAT) gene and transfected this construct into HeLa cells. PMA treatment of these transient transfectants resulted in increased CAT expression. Nuclear proteins from PMA-treated HeLa cells bound to this DNA fragment, and methylation interference analysis showed that the binding was specific to the sequence GGGACTTTCC (between -82 and -91), a sequence previously described by R. Sen and D. Baltimore (Cell 46:705-716, 1986) as the binding site for the nuclear factor NF kappa B. In a cotransfection competition experiment, we could abolish PMA-induced CAT activity by using cloned human immunodeficiency virus long-terminal-repeat DNA containing the NF kappa B-binding sequence. The same long-terminal-repeat DNA containing mutant NF kappa B-binding sequences (G. Nabel and D. Baltimore, Nature [London] 326:711-713, 1987) did not affect CAT expression, which suggested that binding by an NF kappa B-like factor is required for increased SAA transcription
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