Potentially ineffective care. A new outcome to assess the limits of critical care
L. Esserman, J. Belkora and L. Lenert
Department of Surgery, Stanford University School of Medicine, CA 94143-1610, USA.
OBJECTIVE--To examine the limits of the effectiveness of critical care
through the study of patients for whom it was ineffective. DESIGN--We
studied the relationship between resource use and long-term outcome (2-year
follow-up) in 402 consecutively admitted critical care patients to develop
a benchmark for ineffective applications of critical care. We defined an
outcome called potentially ineffective care (PIC), developed and evaluated
a model with an independent data set to predict PIC from a patient's
response to treatment, and estimated the economic effects of limiting care
after a prediction of PIC. SETTING--The combined medical and surgical
intensive care unit at a 600-bed university teaching hospital.
PATIENTS--Two groups of 402 consecutively admitted critical care patients,
one from 1989, the other from 1991. MAIN OUTCOME MEASURES AND
RESULTS--Based on observations from a two-dimensional plot of resource use
vs benefit for 402 critical care patients, PIC was defined as resource use
in the upper 25th percentile and survival for less than 100 days after
discharge. Thirteen percent of the patients fell into the PIC category and
used 32% of the resources. A product of the APACHE risk estimates on days 1
and 5 of at least 0.35 predicted 37% of PIC outcomes with a specificity of
98%. In a second data set, PIC outcome prediction had a sensitivity of 43%
and a specificity of 94%, and a positive predictive value of 80%. For the
hospital studied, reduction of intensity of treatment after a prediction of
a PIC outcome would result in a reduction of hospital charges in the range
of $1.8 million to $5 million per year. CONCLUSION--Patients in the PIC
category consumed a large portion of the resources devoted to critical care
at an academic teaching hospital. We suggest a change in focus from
assessment of the quality of critical care and risk-adjusted mortality to
an assessment of ineffective care based on outcome and resource use and a
patient's response to treatment over time.
Factors influencing length of stay in the intensive care unit.
Gruenberg et al.
Am J Crit Care 2006;15:502-509.
ABSTRACT
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Identifying Potentially Ineffective Care in the Sickest Critically Ill Patients on the Third ICU Day
Afessa et al.
Chest 2004;126:1905-1909.
ABSTRACT
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Circumstances Surrounding End of Life in a Pediatric Intensive Care Unit
Garros et al.
Pediatrics 2003;112:e371-371.
ABSTRACT
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Effect of Ethics Consultations on Nonbeneficial Life-Sustaining Treatments in the Intensive Care Setting: A Randomized Controlled Trial
Schneiderman et al.
JAMA 2003;290:1166-1172.
ABSTRACT
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Outcomes of and Resource Consumption by High-Cost Patients in the Intensive Care Unit
Welton et al.
Am J Crit Care 2002;11:467-473.
ABSTRACT
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Can Health Care Costs Be Reduced by Limiting Intensive Care at the End of Life?
LUCE and RUBENFELD
Am. J. Respir. Crit. Care Med. 2002;165:750-754.
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Identifying futility in a paediatric critical care setting: a prospective observational study
Goh and Mok
Arch. Dis. Child. 2001;84:265-268.
ABSTRACT
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Patients Readmitted to ICUs* : A Systematic Review of Risk Factors and Outcomes
Rosenberg and Watts
Chest 2000;118:492-502.
ABSTRACT
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Potentially Ineffective Care in Intensive Care
Riley et al.
JAMA 1998;279:651-654.
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Fair Allocation of Intensive Care Unit Resources
Am. J. Respir. Crit. Care Med. 1997;156:1282-1301.
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