Are aggressive treatment strategies less cost-effective for older patients? The case of ventilator support and aggressive care for patients with acute respiratory failure

Prognosis of frail older patients treated with intubation and artificial ventilation for respiratory failure

BACKGROUND

Older patients with severe respiratory failure have higher mortality rates and are more likely to experience impairments in activities of daily living (ADL).

METHODS

We retrospectively reviewed patients (??75 years) who received intubation and artificial ventilation for respiratory failure at Shimane University Hospital between November 2014 and December 2020. We compared the outcomes of frail patients with those of self-sufficient patients.

RESULTS

Thirty-two patients were included. ADL ability before respiratory failure was rated self-sufficient in 18 patients (self-sufficient group) and not self-sufficient in 14 patients (frail group). None of the patients in either group underwent advanced care planning prior to the onset of respiratory failure. In the self-sufficient and frail groups, the in-hospital mortality rates were 33% and 50%, and the incidence of bedridden patients at discharge was 6% and 43%, respectively. Most patients in the frail group (93%) died or were bedridden. The median hospitalization cost was JPY 2,984,000 for the self-sufficient group and JPY 3,008,000 for the frail group.

CONCLUSION

The overall prognosis of frail older patients who underwent intubation and artificial ventilation was poor. When providing intensive care to such patients, it is important to carefully consider their suitability for the treatment. J. Med. Invest. 70 : 494-498, August, 2023.

Recent trends of invasive mechanical ventilation in older adults: a nationwide population-based study

BACKGROUND

Critical care demand for older people is increasing. However, there is scarce population-based information about the use of life-support measures such as invasive mechanical ventilation (IMV) in this population segment.

OBJECTIVE

To examine the characteristics and recent trends of IMV for older adults.

METHODS

Retrospective cohort study on IMV in adults ≥65 years using the 2004-15 Spanish national hospital discharge database. Primary outcomes were incidence, inhospital mortality and resource utilization. Trends were assessed for average annual percentage change in rates using joinpoint regression models.

RESULTS

233,038 cases were identified representing 1.27% of all-cause hospitalizations and a crude incidence of 248 cases/100,000 older adult population. Mean age was 75 years, 62% were men and 70% had comorbidities. Inhospital mortality was 48%. Across all ages, about 80% of survivors were discharged home. Incidence rates of IMV remained roughly unchanged over time with an average annual change of -0.2% (95% confidence interval (CI): -0.9, 0.6). Inhospital mortality decreased an annual average of -0.7% (95% CI: -0.5, -1.0), a trend detected across age groups and most clinical strata. Further, there was a 3.4% (95% CI: 3.0, 3.8) annual increase in the proportion of adults aged ≥80 years, an age group that showed higher mortality risk, lower frequency of prolonged IMV, shorter hospital stays and lower costs.

CONCLUSIONS

Overall rates of IMV remained roughly stable among older adults, while inhospital mortality showed a decreasing trend. There was a notable increase in adults aged ≥80 years, a group with high mortality and lower associated hospital resource use.

Health-Related Quality-of-Life and Cost Utility Analyses in Critical Care: A Systematic Review

OBJECTIVES

Cost utility analyses compare the costs and health outcome of interventions, with a denominator of quality-adjusted life year, a generic health utility measure combining both quality and quantity of life. Cost utility analyses are difficult to compare when methods are not standardized. It is unclear how cost utility analyses are measured/reported in critical care and what methodologic challenges cost utility analyses pose in this setting. This may lead to differences precluding cost utility analyses comparisons. Therefore, we performed a systematic review of cost utility analyses conducted in critical care. Our objectives were to understand: 1) methodologic characteristics, 2) how health-related quality-of-life was measured/reported, and 3) what costs were reported/measured.

DESIGN

Systematic review.

DATA SOURCES

We systematically searched for cost utility analyses in critical care in MEDLINE, Embase, American College of Physicians Journal Club, CENTRAL, Evidence-Based Medicine Reviews' selected subset of archived versions of UK National Health Service Economic Evaluation Database, Database of Abstracts of Reviews of Effects, and American Economic Association electronic databases from inception to April 30, 2020.

SETTING

Adult ICUs.

PATIENTS

Adult critically ill patients.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 8,926 citations, 80 cost utility analyse studies were eligible. The time horizon most commonly reported was lifetime (59%). For health utility reporting, health-related quality-of-life was infrequently measured (29% reported), with only 5% of studies reporting baseline health-related quality-of-life. Indirect utility measures (generic, preference-based health utility measurement tools) were reported in 85% of studies (majority Euro-quality-of-life-5 Domains, 52%). Methods of estimating health-related quality-of-life were seldom used when the patient was incapacitated: imputation (19%), assigning fixed utilities for incapacitation (19%), and surrogates reporting on behalf of incapacitated patients (5%). For cost utility reporting transparency, separate incremental costs and quality-adjusted life years were both reported in only 76% of studies. Disaggregated quality-adjusted life years (reporting separate health utility and life years) were described in only 34% of studies.

CONCLUSIONS

We identified deficiencies which warrant recommendations (standardized measurement/reporting of resource use/unit costs/health-related quality-of-life/methodological preferences) for improved design, conduct, and reporting of future cost utility analyses in critical care.

Cost-Effectiveness Studies in the ICU: A Systematic Review

OBJECTIVES

Cost-effectiveness analyses are increasingly used to aid decisions about resource allocation in healthcare; this practice is slow to translate into critical care. We sought to identify and summarize original cost-effectiveness studies presenting cost per quality-adjusted life year, incremental cost-effectiveness ratios, or cost per life-year ratios for treatments used in ICUs.

DESIGN

We conducted a systematic search of the English-language literature for cost-effectiveness analyses published from 1993 to 2018 in critical care. Study quality was assessed using the Drummond checklist.

SETTING

Critical care units.

PATIENTS OR SUBJECTS

Critical care patients.

INTERVENTIONS

Identified studies with cost-effectiveness analyses.

MEASUREMENTS AND MAIN RESULTS

We identified 97 studies published through 2018 with 156 cost-effectiveness ratios. Reported incremental cost-effectiveness ratios ranged from -$119,635 (hypothetical cohort of patients requiring either intermittent or continuous renal replacement therapy) to $876,539 (data from an acute renal failure study in which continuous renal replacement therapy was the most expensive therapy). Many studies reported favorable cost-effectiveness profiles (i.e., below $50,000 per life year or quality-adjusted life year). However, several therapies have since been proven harmful. Over 2 decades, relatively few cost-effectiveness studies in critical care have been published (average 4.6 studies per year). There has been a more recent trend toward using hypothetical cohorts and modeling scenarios without proven clinical data (2014-2018: 19/33 [58%]).

CONCLUSIONS

Despite critical care being a significant healthcare cost burden there remains a paucity of studies in the literature evaluating its cost effectiveness.

Treatment intensity, age and outcome in medical ICU patients: results of a French administrative database

Background

Intensive care unit (ICU) patients are aging, and older age has been associated with higher mortality in ICU. As previous studies have reported that older age was also associated with less intensive treatment, we investigated the relationship between age, treatment intensity and mortality in medical ICU patients.

Methods

Data were extracted from the administrative database of 18 medical ICUs. Patients with a unique medical ICU stay and a Simplified Acute Physiology Score II (without age-related points) >15 were included. Treatment intensity was described with a novel indicator, which is a four-group classification based upon the most frequent ICU procedures. The relationship between age, treatment intensity and hospital mortality was analyzed with the estimation of standardized mortality ratio in the four groups of treatment intensity.

Results

A total of 23,578 patients, including 3203 patients aged ≥80 years, were analyzed. Hospital mortality increased from 13 % for the younger patients (age < 40 years) to 38 % for the older patients (age ≥ 80 years), while Simplified Acute Physiology Score II (without age-related points) increased only from 36 (age < 40 years) to 43 (age ≥ 80). Hospital mortality increased with age in the four groups of treatment intensity. Standardized mortality ratio increased with age among the patients with less intensive treatment but was not associated with age among the patients with the highest treatment intensity.

Conclusion

Our results support the fact that the increase in mortality with age among ICU patients is not related to an increase in severity. Using a new tool to estimate ICU treatment intensity, our study suggests that mortality of ICU patients increases with age whatever the treatment intensity is. Further investigations are required to determinate whether this increase in mortality among older ICU patients is related to undertreatment or to a lower efficiency of organ support treatment.

Trends in mechanical ventilation among patients hospitalized with acute exacerbations of COPD in the United States, 2001 to 2011

BACKGROUND

The use of noninvasive ventilation (NIV) in acute exacerbation of COPD has increased over time. However, little is known about patient factors influencing its use in routine clinical practice.

METHODS

This was a retrospective cohort study of 723,560 hospitalizations for exacerbation of COPD at 475 hospitals between 2001 and 2011. The primary study outcome was the initial form of ventilation (NIV or invasive mechanical ventilation [IMV]). Hierarchical generalized linear models were used to examine the trends in ventilation and patient characteristics associated with receipt of NIV.

RESULTS

After adjusting for patient and hospital characteristics, initial NIV increased by 15.1% yearly (from 5.9% to 14.8%), and initial IMV declined by 3.2% yearly (from 8.7% to 5.9%); annual exposure to any form of mechanical ventilation increased by 4.4% (from 14.1% to 20.3%). Among case subjects treated with ventilation, those aged ≥ 85 years had a 22% higher odds of receiving NIV compared with those aged < 65 years, while blacks (OR, 0.86) and Hispanics (OR, 0.91) were less likely to be treated with NIV than were whites. Cases with a high burden of comorbidities and those with concomitant pneumonia had high rates of NIV failure and were more likely to receive initial IMV. Use of NIV increased at a faster rate among the admissions of the oldest patients relative to the youngest.

CONCLUSIONS

The use of NIV for COPD exacerbations has increased steadily, whereas IMV use has declined. Several patient factors, including age, race, and comorbidities, influenced the receipt of NIV. Further research is needed to identify the factors driving these patterns.

Epidemiology and outcomes of acute respiratory failure in the United States, 2001 to 2009: a national survey

BACKGROUND

The objective of this study was to evaluate trends in hospitalization, cost, and short-term outcomes in acute respiratory failure (ARF) between 2001 and 2009 in the United States.

METHODS

Using the Nationwide Inpatient Sample we identified cases of ARF based on International Classification for Diseases, Ninth Revision, Clinical Modification codes. We calculated weighted frequencies of ARF hospitalizations by year and estimated population-adjusted incidence and mortality rates. We used logistic regression to examine hospital mortality rates over time while adjusting for changes in demographic characteristics and comorbidities of patients.

RESULTS

The number of hospitalizations with a diagnosis of ARF rose from 1,007,549 in 2001 to 1,917,910 in 2009, with an associated increase in total hospital costs from $30.1 billion to $54.3 billion. During the same period we observed a decrease in hospital mortality from 27.6% in 2001 to 20.6% in 2009, a slight decline in average length of stay from 7.8 days to 7.1 days, and no significant change in the mean cost per case ($15,900). Rates of mechanical ventilation (noninvasive [NIV] or invasive mechanical ventilation [IMV]) remained stable over the 9-year period, and the use of NIV increased from 4% in 2001 to 10% in 2009.

CONCLUSIONS

Over the period of 2001 to 2009, there was a steady increase in the number of hospitalizations with a discharge diagnosis of ARF, with a decrease in inpatient mortality. There was a significant shift during this time toward the use of NIV, with a decrease in the rates of IMVuse.

Economics of mechanical ventilation and respiratory failure

For patients with acute respiratory failure, mechanical ventilation provides the most definitive life-sustaining therapy. Because of the intense resources required to care for these patients, its use accounts for considerable costs. There is great societal need to ensure that use of mechanical ventilation maximizes societal benefits while minimizing costs, and that mechanical ventilation, and ventilator support in general, is delivered in the most efficient and cost-effective manner. This review summarizes the economic aspects of mechanical ventilation and summarizes the existing literature that examines its economic impact cost effectiveness.

ICU and critical care outreach for the elderly

Average life expectancy has increased over the past century resulting in a shift in world population demographics. There are more elderly people alive now than throughout all of human history. The burden of comorbid disease and dependency rises with age and has been shown to independently predict need for hospitalization, institutionalization and mortality. Accordingly, there are more elderly persons living longer in more tenuous states of health. The relative proportion of patients admitted to hospital and intensive care who are elderly is considerable and recent data have suggested an increasing trend. There is likely significant selection bias amongst elderly patients triaged for access to finite critical care services. In fact, data have shown that elderly patients often receive less intensive therapy and have greater support limitations when admitted to an intensive care environment. "Chronologic" age has been an inconsistent predictor of prognosis in elderly patients who present with critical illness. However, surrogate measures of "physiologic" age are likely more relevant, such as an assessment of frailty, to aid in prognostication and informed decision-making and that ultimately correlate not only with short-term survival but additional outcomes such as functional status, institutionalization and quality of life after an episode of critical illness. There is a paucity of literature on the specific interaction of rapid response systems (RRS) and hospitalized "at-risk" elderly patients; however, the RRS may have particular application for this cohort. In particular, data have emerged to suggest mature ICU-based RRS respond commonly to elderly patients and are increasingly participating in end-of-life care discussions. In addition, another aspect of the RRS, critical care outreach (CCO), may facilitate the identification of elderly patients for timely goal-oriented advanced care planning prior to clinical deterioration.

Very old patients admitted to intensive care in Australia and New Zealand: a multi-centre cohort analysis

Introduction

Older age is associated with higher prevalence of chronic illness and functional impairment, contributing to an increased rate of hospitalization and admission to intensive care. The primary objective was to evaluate the rate, characteristics and outcomes of very old (age ≥ 80 years) patients admitted to intensive care units (ICUs).

Methods

Retrospective analysis of prospectively collected data from the Australian New Zealand Intensive Care Society Adult Patient Database. Data were obtained for 120,123 adult admissions for ≥ 24 hours across 57 ICUs from 1 January 2000 to 31 December 2005.

Results

A total of 15,640 very old patients (13.0%) were admitted during the study. These patients were more likely to be from a chronic care facility, had greater co-morbid illness, greater illness severity, and were less likely to receive mechanical ventilation. Crude ICU and hospital mortalities were higher (ICU: 12% vs. 8.2%, P < 0.001; hospital: 24.0% vs. 13%, P < 0.001). By multivariable analysis, age ≥ 80 years was associated with higher ICU and hospital death compared with younger age strata (ICU: odds ratio (OR) = 2.7, 95% confidence interval (CI) = 2.4 to 3.0; hospital: OR = 5.4, 95% CI = 4.9 to 5.9). Factors associated with lower survival included admission from a chronic care facility, co-morbid illness, nonsurgical admission, greater illness severity, mechanical ventilation, and longer stay in the ICU. Those aged ≥ 80 years were more likely to be discharged to rehabilitation/long-term care (12.3% vs. 4.9%, OR = 2.7, 95% CI = 2.6 to 2.9). The admission rates of very old patients increased by 5.6% per year. This potentially translates to a 72.4% increase in demand for ICU bed-days by 2015.

Conclusions

The proportion of patients aged ≥ 80 years admitted to intensive care in Australia and New Zealand is rapidly increasing. Although these patients have more co-morbid illness, are less likely to be discharged home, and have a greater mortality than younger patients, approximately 80% survive to hospital discharge. These data also imply a potential major increase in demand for ICU bed-days for very old patients within a decade.

When is critical care medicine cost-effective? A systematic review of the cost-effectiveness literature

BACKGROUND

Receiving care in an intensive care unit can greatly influence patients' survival and quality of life. Such treatments can, however, be extremely resource intensive. Therefore, it is increasingly important to understand the costs and consequences associated with interventions aimed at reducing mortality and morbidity of critically ill patients. Cost-effectiveness analyses (CEAs) have become increasingly common to aid decisions about the allocation of scarce healthcare resources.

OBJECTIVES

To identify published original CEAs presenting cost/quality-adjusted life year or cost/life-year ratios for treatments used in intensive care units, to summarize the results in an accessible format, and to identify areas in critical care medicine that merit further economic evaluation.

METHODS

We conducted a systematic search of the English-language literature for original CEAs of critical care interventions published from 1993 through 2003. We collected data on the target population, therapy or program, study results, analytic methods employed, and the cost-effectiveness ratios presented.

RESULTS

We identified 19 CEAs published through 2003 with 48 cost-effectiveness ratios pertaining to treatment of severe sepsis, acute respiratory failure, and general critical care interventions. These ratios ranged from cost saving to 958,423 US dollars/quality-adjusted life year and from 1,150 to 575,054 US dollars/life year gained. Many studies reported favorable cost-effectiveness profiles (i.e., below 50,000 US dollars/life year or quality-adjusted life year).

CONCLUSIONS

Specific interventions such as activated protein C for patients with severe sepsis have been shown to provide good value for money. However, overall there is a paucity of CEA literature on the management of the critically ill, and further high-quality CEA is needed. In particular, research should focus on costly interventions such as 24-hr intensivist availability, early goal-directed therapy, and renal replacement therapy. Recent guidelines for the conduct of CEAs in critical care may increase the number and improve the quality of future CEAs.

Clinical characteristics and prognostic factors in patients with complicated acute coronary syndromes requiring prolonged mechanical ventilation

Patients with acute coronary syndromes (ACSs) may develop serious multiorgan complications and require prolonged intensive care. Our aim was to characterize and identify factors that are associated with outcomes in these patients. We retrospectively identified 267 consecutive patients admitted to the coronary care unit for an ACS who required >3 days of mechanical ventilation. Multiple clinical and laboratory variables were correlated with mortality. Patients' ages were 68.3 +/- 10.9 years (mean +/- SD) and 165 (62%) were men. Seventy-six patients (29%) died within 30 days of admission, and the 1 year mortality was 46%. Moderate or severe left ventricular systolic dysfunction was found in 72% of the patients. Eighty-nine patients (33.3%) required vasopressors, of whom 64 (72%) did not survive 30 days. Among 127 patients who required antibiotics (48.3%), 30-day mortality was 53% compared with 4% among patients who did not require antibiotics (p <0.001). The 30-day mortality among patients who received both antibiotics and vasopressors was 64 of 87 patients (74%), and the 1-year mortality in this subgroup was 86.2%. Parameters found to be independent predictors of 30-day mortality were (in descending order): vasopressor requirement, use of antibiotics, peripheral vascular disease, ST-elevation myocardial infarction, renal failure, obesity and Killip class on admission. In conclusion, mortality among patients who require prolonged mechanical ventilation after an ACS is substantial. The main independent predictors of with mortality are the severity of heart failure and the presence of co-morbidities.

Treatment intensity and outcome of patients aged 80 and older in intensive care units: a multicenter matched-cohort study

OBJECTIVES

To determine whether patients aged 80 and older have similar treatment intensity to that of younger patients in the intensive care unit (ICU).

DESIGN

Multicenter, matched-cohort study.

SETTING

Data were extracted from a multicenter database with 36 ICUs in the Paris area (France) during a 4-year period (1997-2000).

PARTICIPANTS

Three thousand one hundred seventy-five patients aged 80 and older (oldest-old) were retrospectively matched to 3,175 patients aged 65 to 79 (young-old).

MEASUREMENTS

The matching criteria were severity status on admission (+/-2) (assessed using a corrected Simplified Acute Physiology Score II leaving out age points), Charlson Comorbidity Index, type of admission (surgical vs medical), sex, admission to same ICU, and year of ICU admission. The underlying condition was classified using the McCabe classification. The functional status was assessed using the Knaus classification. The ICU workload was assessed using the OMEGA scoring system.

RESULTS

Total and daily workload were lower in the oldest-old than in matched young-old patients. Estimated mean direct medical cost per stay was approximately 1,280 dollars lower for oldest-old patients. Older patients received less mechanical ventilation (adjusted odds ratio (AOR)=0.69, 95% confidence interval (CI)=0.61-0.78), less tracheostomy (AOR=0.37, 95% CI=0.28-0.50), and less renal support (AOR=0.52, 95% CI=0.41-0.66) than matched young-old patients. Oldest-old patients had a shorter length of ICU stay than matched young-old patients and the same length of post-ICU stay.

CONCLUSION

Oldest-old patients receive less treatment in the ICU than young-old patients even after adjustment for severity of illness.

Increase in tracheostomy for prolonged mechanical ventilation in North Carolina, 1993–2002

OBJECTIVE

Patients who require tracheostomy for prolonged mechanical ventilation have poor outcomes and high costs of care. However, recent longitudinal trends relevant to these patients and their care have not been described. We aimed to describe trends in the annual incidence and timing of tracheostomy for prolonged mechanical ventilation, as well as prolonged mechanical ventilation patient resource utilization and overall in-hospital mortality.

DESIGN AND SETTING

Retrospective review of the North Carolina Hospital Discharge Database, a comprehensive record of all state nonfederal, nonpsychiatric hospital discharges between 1993 and 2002.

PATIENTS

Patients were 9,794 medical and surgical patients >/=18 yrs of age with International Classification of Diseases, Ninth Revision, Clinical Modification code 96.72 (mechanical ventilation for >96 hrs) and Diagnosis Related Group code 483 (tracheostomy except for face, neck, and mouth diagnoses).

INTERVENTIONS

None.

MEASUREMENTS

Incidence rates adjusted for annual population growth, mechanical ventilation days until tracheostomy placement, length of stay, and hospital charges and payments adjusted by the medical component of the Consumer Price Index.

MAIN RESULTS

Between 1993 and 2002, the incidence of tracheostomy for prolonged mechanical ventilation increased across all age groups from 8.3 of 100,000 to 24.2 of 100,000 (p < .001), although most significantly among patients <55 yrs of age. During this period, a decrease was seen in mortality (from 39% to 25%), median mechanical ventilation days to tracheostomy placement (from 12 to 10 days), and median length of stay (from 47 to 33 days). By 2002, patients were almost three times less likely to be discharged to home independently although twice as likely to be sent to a skilled nursing facility. Although prolonged mechanical ventilation patients with tracheostomies represented only 7% of all who required mechanical ventilation, their total charges during the study period were 1.74 billion dollars-22% of all mechanical ventilation patient charges.

CONCLUSION

The incidence of tracheostomy for prolonged mechanical ventilation increased by nearly 200% during the past decade in North Carolina, exceeding changes in the overall incidence of respiratory failure three-fold. Although in-hospital mortality, length of stay, and charges per patient fell over time, the overall resource utilization of prolonged mechanical ventilation patients increased dramatically.

Prognosis of patients aged 80 years and over admitted in medical intensive care unit

OBJECTIVE

To determine the prognostic indicators of long-term survival after admission to a medical intensive care unit (MICU) for patients aged 80 years and over. DESIGN. Prospective cohort study.

SETTING

A 14-bed MICU in a 970-bed, acute care, tertiary, university hospital in Paris, France.

PATIENTS

A total of 233 patients aged 80 years and over discharged from a MICU during a 2-year period.

MEASUREMENTS AND MAIN RESULTS

Severity at admission was estimated using the Simplified Acute Physiology Score. The underlying condition was classified using the MacCabe classification. The functional status was assessed using the Knaus classification. The outcome after MICU discharge was determined after a median 2-year follow-up. The functional outcome was assessed by telephone interviews, employing the Instrumental Activities of Daily Living (IADL). The in-MICU mortality was 19.5% including death occurring during the 2 days following discharge. The long-term survival rates for patients admitted to the MICU were 59% at 2 months, 33% at 2 years, and 29% at 3 years. The multivariate analysis identified two prognostic factors of death after discharge: presence of an underlying fatal disease (HR 1.7; 95% CI 1.1-2.6) and severe functional limitation (HR 1.7; 95% CI 1.2-2.6). The IADL was excellent or good for 56% of the surviving patients.

CONCLUSION

Long-term survival after MICU is mainly related to the underlying condition, whereas known factors for in-MICU survival do not influence long-term prognosis.

The epidemiology of critical illness in the elderly

A substantial proportion of patients admitted to intensive care units (ICUs) are elderly patients. Based upon population growth, patient preference, and current physician practice, the number of elderly patients who receive critical care services is likely to increase substantially over the next 10 to 20 years. Numerous studies have shown that survival from critical illness is lower in elderly patients; however, after adjusting for factors such as illness severity, comorbid diseases, and functional status, chronologic age accounts for very little explanatory power for survival from critical illness. Elderly survivors of critical illness often have significant functional limitations, but their perceived quality of life is usually better than that of younger survivors of critical illness. Elderly patients frequently receive less aggressive care in the ICU and probably consume a lower relative proportion of ICU resources than younger patients. However, this does not necessarily result in worse outcomes.

Improving Family Communications at the End of Life: Implications for Length of Stay in the Intensive Care Unit and Resource Use

• Background Inadequate communication persists between healthcare professionals and patients and patients’ families in intensive care units. Unwanted or ineffective treatments can occur when patients’ goals of care are unknown or not honored, increasing costs and care. Having the primary physician provide medical information and then having a physician and clinical nurse specialist team improve opportunities for patients and their families to process that information could improve the situation. This model has not been tested for its effect on patients’ outcomes and resource utilization.

• Objectives To evaluate the effect of a communication team that included a physician and a clinical nurse specialist on length of stay and costs for patients near the end of life in the intensive care unit.

• Methods During a 1-year period, patients judged to be at high risk for death (N = 151) were divided into 2 groups: 43 patients who were cared for by the medical director teamed with a clinical nurse specialist and 108 patients who received standard care, provided by an attending physician.

• Results Compared with the control group, patients in the intervention group had significantly shorter stays in both the intensive care unit (6.1 vs 9.5 days) and the hospital (11.3 vs 16.4 days) and had lower fixed ($15 559 vs $24 080) and variable ($5087 vs $8035) costs.

• Conclusions Use of a physician and a clinical nurse specialist focused on improving communication with patients and patients’ families reduced lengths of stay and resource utilization.

Respiratory failure in elderly patients

Elderly individuals comprise an increasing proportion of the population and represent a progressively expanding number of patients admitted to the ICU. Because of underlying pulmonary disease, loss of muscle mass, and other comorbid conditions, older persons are at increased risk of developing respiratory failure. Recognition of this vulnerability and the adoption of proactive measures to prevent decompensation requiring intrusive support are major priorities together with clear delineation of patients' wishes regarding the extent of support desired should clinical deterioration occur. Further, the development of coordinated approaches to identify patients at risk for respiratory failure and strategies to prevent the need for intubation, such as the use of NIV in appropriate patients, are crucial. As soon as endotracheal intubation and mechanical ventilation are implemented strategies that facilitate the liberation of elderly patients from the ventilator are especially important. The emphasis on a team approach, which characterizes geriatric medicine, is essential in coordinating the skills of multiple health care professionals in this setting. Respiratory failure can neither be effectively diagnosed nor managed in isolation. Integration with all other aspects of care is essential. Patient vulnerability to nosocomial complications and the "cascade effect" of these problems such as the effects of medications and invasive supportive procedures all impact on respiratory care of elderly patients. For example, prolonged mechanical ventilation may be required long after resolution of the underlying cause of respiratory failure because of unrecognized and untreated delirium or residual effects of small doses of sedative and/or analgesic agents or other medications in elderly patients with altered drug metabolism. The deleterious impact of the foreign and sometimes threatening ICU environment and/or sleep deprivation on the patient's course are too often overlooked because the physician focuses management on physiologic measurements, mechanical ventilator settings, and other technologic nuances of care [40]. Review of the literature suggests that the development of respiratory failure in patients with certain disease processes such as COPD, IPF, and ARDS in elderly patients may lead to worsened outcome but it appears that the disease process itself, rather than the age of the patient, is the major determinant of outcome. Additional studies suggest that other comorbid factors may be more important than age. Only when comorbid processes are taken into account should decisions be made about the efficacy of instituting mechanical ventilation. In addition, because outcome prediction appears to be more accurate for groups of patients rather than for individual patients a well-structured therapeutic trial of instituting mechanical ventilation, even if comorbidities are present, may be indicated in certain patients if appropriately informed patients wish to pursue this course. This approach requires careful and realistic definition of potential outcomes, focus on optimizing treatment of the reversible components of the illness, and continuous communication with the patient and family. Although many clinicians share a nihilistic view regarding the potential usefulness of mechanical ventilation in elderly patients few data warrant this negative prognostication and more outcome studies are needed to delineate the optimum application of this element of supportive care. As with other interventions individualization of the decision must take into account the patient's premorbid status, concomitant conditions, the nature of the precipitating illness and its prospects for improvement, and most important, patient preferences. In this determination pursuing the course most consistent with the patient's wishes is essential and it must be appreciated that caregivers' impressions regarding the vigor of support desired by the patient are often erroneous. The SUPPORT investigators observed that clinicians often underestimated the degree of intervention desired by older patients assuming that less care would be desired [13]. Thus, as in other circumstances, effective communication and elicitation of patients' preferences regarding management options is crucial in the management of respiratory failure. The frequent discordance between patient preferences and the wishes of family members or other surrogate decision makers impose major clinical challenges and also mandates further investigation.

Research design in end-of-life research: state of science

PURPOSE

The volume of research on end-of-life care, death, and dying has exploded during the past decade. This article reviews the conceptual and methodological adequacy of end-of-life research to date, focusing on limitations of research to date and ways of improving future research.

DESIGN AND METHODS

A systematic search was conducted to identify the base of end-of-life research. Approximately 400 empirical articles were identified and are the basis of this review.

RESULTS

Although much has been learned from research to date, limitations in the knowledge base are substantial. The most fundamental problems identified are conceptual and include failure to define dying; neglect of the distinctions among quality of life, quality of death, and quality of end-of-life care. Methodologically, the single greatest problem is the lack of longitudinal studies that cover more than the time period immediately before death.

IMPLICATIONS

Gaps in the research base include insufficient attention to psychological and spiritual issues, the prevalence of psychiatric disorder and the effectiveness of the treatment of such disorders among dying persons, provider and health system variables, social and cultural diversity, and the effects of comorbidity on trajectories of dying.

An update on cost-effectiveness analysis in critical care

Critical care providers are under increasing pressure to be attentive to cost concerns. The ICU consumes a significant amount of resources and, as such, is a frequently identified target of efforts to limit escalating healthcare costs. Attempts to reduce costs need not progress in a haphazard fashion. Rather, they can proceed in a logical, systematic manner with the assistance of formal economic studies. Cost-effectiveness analysis is one tool for these projects-it allows physicians to compare the financial consequences of different approaches to resource allocation. ICU physicians, therefore, must become familiar with the basic concepts that underlie cost-effectiveness analysis. Cost-effectiveness analyses that address many different aspects of critical care delivery are now commonly found in the critical care literature. With a framework for evaluating these studies, clinicians can better apply their findings to their own institutions.