International comparisons of outcomes in intensive care units

Validation of Pediatric Index of Mortality-2 scoring system in a pediatric intensive care unit, Barbados

This study evaluated the outcome of patients in a pediatric intensive care unit (ICU) of a developing country applying Pediatric Index of Mortality (PIM) version-2 scoring system. A total of 163 consecutive patients were prospectively studied. Data included demographics, diagnoses at admission, PIM-2 score, the duration of ICU stay and hospital outcome. Predicted mortality and standardized mortality ratio (SMR) were calculated. Respiratory and neurological illnesses were the main admission diagnoses. The mean length of stay was 5.4 [95% Confidence Intervals (CI): 4-6.9] days. The mean predicted mortality was 6.2% (95% CI: 4.3-8.1); the observed mortality rate was 5.5%, the SMR being 0.89. Hosmer-Lemeshow analysis calibrated PIM-2 for the case mix [χ(2) = 5.64 (df = 7), p = 0.58]. The area under the ROC curve was 0.82 (95% CI: 0.72-0.92) showing a good discriminant function. Performance of the pediatric ICU in Barbados is comparable to that of developed world by risk-adjusted outcome evaluation.

Critical care in difficult areas

Critical care in India has grown very rapidly in the past decade. The Indian Society of Critical Care Medicine has developed into a strong national body that has established its own journal, academic program, and Web site. Its annual national congresses are well organized and very well attended and have a high degree of academic content. International publications have started coming out of India despite limitations. International recognition of the standards of critical care in India has begun. Besides other common patients seen everywhere, those with tropical diseases form a significant group of patients in Indian ICUs. Development of guidelines, starting formal training through a certificate course, and formation of a resuscitation council have been some of the other achievements of Indian Society of Critical Care Medicine. A number of problems still exist in the field of critical care in India. Considering that India as a portal for medical tourism, growth of this field is expected in the next decade.

Prediction of mortality in an Indian intensive care unit. Comparison between APACHE II and artificial neural networks

OBJECTIVE

To compare hospital outcome prediction using an artificial neural network model, built on an Indian data set, with the APACHE II (Acute Physiology and Chronic Health Evaluation II) logistic regression model.

DESIGN

Analysis of a database containing prospectively collected data.

SETTING

Medical-neurological ICU of a university hospital in Mumbai, India.

SUBJECTS

Two thousand sixty-two consecutive admissions between 1996 and 1998.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

The 22 variables used to obtain day-1 APACHE II score and risk of death were recorded. Data from 1,962 patients were used to train the neural network using a back-propagation algorithm. Data from the remaining 1,000 patients were used for testing this model and comparing it with APACHE II. There were 337 deaths in these 1,000 patients; APACHE II predicted 246 deaths while the neural network predicted 336 deaths. Calibration, assessed by the Hosmer-Lemeshow statistic, was better with the neural network (H=22.4) than with APACHE II (H=123.5) and so was discrimination (area under receiver operating characteristic curve =0.87 versus 0.77, p=0.002). Analysis of information gain due to each of the 22 variables revealed that the neural network could predict outcome using only 15 variables. A new model using these 15 variables predicted 335 deaths, had calibration (H=27.7) and discrimination (area under receiver operating characteristic curve =0.88) which was comparable to the 22-variable model (p=0.87) and superior to the APACHE II equation (p<0.001).

CONCLUSION

Artificial neural networks, trained on Indian patient data, used fewer variables and yet outperformed the APACHE II system in predicting hospital outcome.

Outcome evaluation in a surgical intensive care unit in Barbados

The performance of the Acute Physiology and Chronic Health Evaluation II scoring system was prospectively assessed in the surgical intensive care unit at the Queen Elizabeth Hospital, Barbados. A total of 309 patients admitted consecutively during a 2-year period (1999-2001) were evaluated. Demographic data, diagnosis, Acute Physiology and Chronic Health Evaluation II score, duration of stay and hospital outcome were recorded. The predicted mortality for every patient and the costs incurred were also calculated. The overall observed mortality rate was 15.9% while the mean predicted mortality rate for our case-mix was 16.4%, which is comparable to results from developed countries. The cost incurred per patient was much lower at $13,636 (Barbados), compared to the patients' cost in North America ($60,000 Barbados).

Measuring the impact of new technology: an outcomes-based approach

In the current era of decreasing resources, many healthcare organizations are under increasing pressure to evaluate new technology. Advances and innovations in healthcare technology are instrumental in reshaping the healthcare system and in impacting the practice of medicine, including critical care. Healthcare organizations are faced with the following four questions related to adopting a new technology: 1) Should the organization invest in this technology? 2) What are the associated benefits and risks of the capital investment? 3) What is the impact on patient outcomes as a result of adopting the technology? 4) What is the return on investment to the organization? These issues represent challenging areas for the researcher, clinician, manager, and policy maker. New techniques from the business and outcomes research arenas allow for the development of quantitative and qualitative models to facilitate answering these questions. By integrating business and clinical considerations, these models can impact policy at two levels: 1) by identifying optimal capital expenditure decisions for individual healthcare organizations, it can provide a significant competitive advantage for an organization; and 2) by identifying optimal health policies related to technology at a national and international health level, it can impact the healthcare systems and patient outcomes in a favorable manner.

Intensive care--a cost effective option for developing countries?

The estimation of cost-effectiveness of pediatric critical care services is an extremely relevant issue for both developing and industrialized nations. Pediatric critical care is expensive and the long outcomes are still relatively unclear. From the perspective of patients who receive the benefits of these services, there may be little controversy regarding cost-effectiveness. However, the issue becomes very complex when attempts are made to identify which patients will benefit most. This also needs to be considered while developing public policy when decisions for allocation of limited resources need to be made within health care systems, and choices need to be made between the provision of health care and other public services. This article addresses the complex issue of economic evaluations and describes various type of cost analyses. The difference between charges and costs is defined, and a discussion of the measurement of costs and benefits, and their relationship to outcomes research is provided. Although there is not a unique answer to the issue of cost-effectiveness for pediatric critical care services, the available literature particularly from the United States is summarized, and the ethical implications explored.