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Koraishy FM, Mallipattu SK. Dialysis resource allocation in critical care: the impact of the COVID-19 pandemic and the promise of big data analytics. FRONTIERS IN NEPHROLOGY 2023; 3:1266967. [PMID: 37965069 PMCID: PMC10641281 DOI: 10.3389/fneph.2023.1266967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 10/05/2023] [Indexed: 11/16/2023]
Abstract
The COVID-19 pandemic resulted in an unprecedented burden on intensive care units (ICUs). With increased demands and limited supply, critical care resources, including dialysis machines, became scarce, leading to the undertaking of value-based cost-effectiveness analyses and the rationing of resources to deliver patient care of the highest quality. A high proportion of COVID-19 patients admitted to the ICU required dialysis, resulting in a major burden on resources such as dialysis machines, nursing staff, technicians, and consumables such as dialysis filters and solutions and anticoagulation medications. Artificial intelligence (AI)-based big data analytics are now being utilized in multiple data-driven healthcare services, including the optimization of healthcare system utilization. Numerous factors can impact dialysis resource allocation to critically ill patients, especially during public health emergencies, but currently, resource allocation is determined using a small number of traditional factors. Smart analytics that take into account all the relevant healthcare information in the hospital system and patient outcomes can lead to improved resource allocation, cost-effectiveness, and quality of care. In this review, we discuss dialysis resource utilization in critical care, the impact of the COVID-19 pandemic, and how AI can improve resource utilization in future public health emergencies. Research in this area should be an important priority.
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Affiliation(s)
- Farrukh M. Koraishy
- Division of Nephrology, Department of Medicine, Stony Brook University Hospital, , Stony Brook, NY, United States
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2
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Oral care to reduce costs and increase clinical effectiveness in preventing nosocomial pneumonia: a systematic review. J Evid Based Dent Pract 2023; 23:101834. [DOI: 10.1016/j.jebdp.2023.101834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 12/27/2022] [Accepted: 01/19/2023] [Indexed: 01/30/2023]
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Rahimi H, Goudarzi R, Markazi-Moghaddam N, Nezami-Asl A, Zargar Balaye Jame S. Cost-benefit analysis of Intensive Care Unit with Activity-Based Costing approach in the era COVID-19 pandemic: A case study from Iran. PLoS One 2023; 18:e0285792. [PMID: 37192194 DOI: 10.1371/journal.pone.0285792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 04/29/2023] [Indexed: 05/18/2023] Open
Abstract
BACKGROUND Providing intensive care to acute patients is a vital part of health systems. However, the high cost of Intensive Care Units (ICU) has limited their development, especially in low-income countries. Due to the increasing need for intensive care and limited resources, ICU cost management is important. This study aimed to analyze the cost-benefit of ICU during COVID-19 in Tehran, Iran. METHODS This cross-sectional study is an economic evaluation of health interventions. The study was conducted in the COVID-19 dedicated ICU, from the provider's point of view and within one-year horizon. Costs were calculated using a top-down approach and the Activity-Based Costing technique. Benefits were extracted from the hospital's HIS system. Benefit Cost ratio (BCR) and Net Present Value (NPV) indexes were used for cost-benefit analysis (CBA). A sensitivity analysis was performed to evaluate the dependence of the CBA results on the uncertainties in the cost data. Analysis was performed with Excel and STATA software. RESULTS The studied ICU had 43 personnel, 14 active beds, a 77% bed occupancy rate, and 3959 occupied bed days. The total costs were $2,372,125.46 USD, of which 70.3% were direct costs. The highest direct cost was related to human resources. The total net income was $1,213,314.13 USD. NPV and BCR were obtained as $-1,158,811.32 USD and 0.511 respectively. CONCLUSION Despite operating with a relatively high capacity, ICU has had high losses during the COVID-19. Proper management and re-planning in the structure of human resources is recommended due to its importance in the hospital economy, provision of resources based on needs assessment, improvement of drugs management, reduction of insurance deductions in order to reduce costs and improve ICU productivity.
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Affiliation(s)
- Hamed Rahimi
- Department of Health Management and Economics, Faculty of Medicine, AJA University of Medical Sciences, Tehran, Iran
| | - Reza Goudarzi
- Health Services Management Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Nader Markazi-Moghaddam
- Department of Health Management and Economics, Faculty of Medicine, AJA University of Medical Sciences, Tehran, Iran
| | - Amir Nezami-Asl
- Faculty of Aerospace and Subaquatic Medicine, AJA University of Medical Sciences, Tehran, Iran
| | - Sanaz Zargar Balaye Jame
- Department of Health Management and Economics, Faculty of Medicine, AJA University of Medical Sciences, Tehran, Iran
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de Vos J, Visser LA, de Beer AA, Fornasa M, Thoral PJ, Elbers PWG, Cinà G. The Potential Cost-Effectiveness of a Machine Learning Tool That Can Prevent Untimely Intensive Care Unit Discharge. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:359-367. [PMID: 35227446 DOI: 10.1016/j.jval.2021.06.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 05/06/2021] [Accepted: 06/29/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVES The machine learning prediction model Pacmed Critical (PC), currently under development, may guide intensivists in their decision-making process on the most appropriate time to discharge a patient from the intensive care unit (ICU). Given the financial pressure on healthcare budgets, this study assessed whether PC has the potential to be cost-effective compared with standard care, without the use of PC, for Dutch patients in the ICU from a societal perspective. METHODS A 1-year, 7-state Markov model reflecting the ICU care pathway and incorporating the PC decision tool was developed. A hypothetical cohort of 1000 adult Dutch patients admitted in the ICU was entered in the model. We used the literature, expert opinion, and data from Amsterdam University Medical Center for model parameters. The uncertainty surrounding the incremental cost-effectiveness ratio was assessed using deterministic and probabilistic sensitivity analyses and scenario analyses. RESULTS PC was a cost-effective strategy with an incremental cost-effectiveness ratio of €18 507 per quality-adjusted life-year. PC remained cost-effective over standard care in multiple scenarios and sensitivity analyses. The likelihood that PC will be cost-effective was 71% at a willingness-to-pay threshold of €30 000 per quality-adjusted life-year. The key driver of the results was the parameter "reduction in ICU length of stay." CONCLUSIONS We showed that PC has the potential to be cost-effective for Dutch ICUs in a time horizon of 1 year. This study is one of the first cost-effectiveness analyses of a machine learning device. Further research is needed to validate the effectiveness of PC, thereby focusing on the key parameter "reduction in ICU length of stay" and potential spill-over effects.
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Affiliation(s)
- Juliette de Vos
- Pacmed B.V., Amsterdam, The Netherlands; Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands.
| | - Laurenske A Visser
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | | | | | - Patrick J Thoral
- Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Paul W G Elbers
- Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
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Wibrow B, Martinez FE, Myers E, Chapman A, Litton E, Ho KM, Regli A, Hawkins D, Ford A, van Haren FMP, Wyer S, McCaffrey J, Rashid A, Kelty E, Murray K, Anstey M. Prophylactic melatonin for delirium in intensive care (Pro-MEDIC): a randomized controlled trial. Intensive Care Med 2022; 48:414-425. [DOI: 10.1007/s00134-022-06638-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 01/28/2022] [Indexed: 12/16/2022]
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Ingraham NE, Vakayil V, Pendleton KM, Robbins AJ, Freese RL, Palzer EF, Charles A, Dudley RA, Tignanelli CJ. Recent Trends in Admission Diagnosis and Related Mortality in the Medically Critically Ill. J Intensive Care Med 2022; 37:185-194. [PMID: 33353475 DOI: 10.1177/0885066620982905] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE With decades of declining ICU mortality, we hypothesized that the outcomes and distribution of diseases cared for in the ICU have changed and we aimed to further characterize them. STUDY DESIGN AND METHODS A retrospective cohort analysis of 287,154 nonsurgical-critically ill adults, from 237 U.S. ICUs, using the manually abstracted Cerner APACHE Outcomes database from 2008 to 2016 was performed. Surgical patients, rare admission diagnoses (<100 occurrences), and low volume hospitals (<100 total admissions) were excluded. Diagnoses were distributed into mutually exclusive organ system/disease-based categories based on admission diagnosis. Multi-level mixed-effects negative binomial regression was used to assess temporal trends in admission, in-hospital mortality, and length of stay (LOS). RESULTS The number of ICU admissions remained unchanged (IRR 0.99, 0.98-1.003) while certain organ system/disease groups increased (toxicology [25%], hematologic/oncologic [55%] while others decreased (gastrointestinal [31%], pulmonary [24%]). Overall risk-adjusted in-hospital mortality was unchanged (IRR 0.98, 0.96-1.0004). Risk-adjusted ICU LOS (Estimate -0.06 days/year, -0.07 to -0.04) decreased. Risk-adjusted mortality varied significantly by disease. CONCLUSION Risk-adjusted ICU mortality rate did not change over the study period, but there was evidence of shifting disease burden across the critical care population. Our data provides useful information regarding future ICU personnel and resource needs.
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Affiliation(s)
- Nicholas E Ingraham
- Department of Medicine, 311816University of Minnesota Medical School, Minneapolis, MN, USA
- School of Public Health, 311816University of Minnesota, Minneapolis, MN, USA
| | - Victor Vakayil
- School of Public Health, 311816University of Minnesota, Minneapolis, MN, USA
- Department of Surgery, 311816University of Minnesota Medical School, Minneapolis, MN, USA
| | - Kathryn M Pendleton
- Department of Medicine, 311816University of Minnesota Medical School, Minneapolis, MN, USA
| | - Alexandria J Robbins
- Department of Surgery, 311816University of Minnesota Medical School, Minneapolis, MN, USA
| | - Rebecca L Freese
- Biostatistical Design and Analysis Center, Clinical and Translational Science Institute, 311816University of Minnesota, Minneapolis, MN, USA
| | - Elise F Palzer
- Biostatistical Design and Analysis Center, Clinical and Translational Science Institute, 311816University of Minnesota, Minneapolis, MN, USA
| | - Anthony Charles
- Department of Surgery, 2331University of North Carolina School of Medicine, Chapel Hill, NC, USA
- Gillings School of Global Public Health, 2331University of North Carolina, Chapel Hill, NC, USA
| | - R Adams Dudley
- Department of Medicine, 311816University of Minnesota Medical School, Minneapolis, MN, USA
- School of Public Health, 311816University of Minnesota, Minneapolis, MN, USA
- Institute for Health Informatics, 311816University of Minnesota Academic Health Center, Minneapolis, MN, USA
| | - Christopher J Tignanelli
- Department of Surgery, 311816University of Minnesota Medical School, Minneapolis, MN, USA
- Institute for Health Informatics, 311816University of Minnesota Academic Health Center, Minneapolis, MN, USA
- Department of Surgery, North Memorial Health Hospital, Robbinsdale, MN, USA
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7
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Padilla Fortunatti C, Munro CL. Factors associated with family satisfaction in the adult intensive care unit: A literature review. Aust Crit Care 2021; 35:604-611. [PMID: 34535370 DOI: 10.1016/j.aucc.2021.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 07/08/2021] [Accepted: 07/12/2021] [Indexed: 10/20/2022] Open
Abstract
OBJECTIVE The objective of this study was to identify and summarise factors associated with family satisfaction among family members of adult intensive care unit (ICU) patients. REVIEW METHODS/DATA SOURCES A search was conducted from inception to October 2020 in the following databases: PubMed, Scopus, EMBASE, CINAHL Plus, ProQuest Health Management, PsycINFO, LILACS, and SciELO. Studies reporting the questionnaire's items or dimensions as family satisfaction factors, studies dichotomising family satisfaction outcome, and those involving family members of neonatal, paediatric, palliative, and end-of-life patients were excluded. Quality of the studies was examined through a modified approach to the Consolidated Standards for Reporting Trials (CONSORT). Reported factors were classified as family member, patient, or provider/organisation related. RESULTS The search yielded 26 articles reporting factors associated with family satisfaction in the ICU. Regarding study quality, 19.2% were classified as high-quality studies. Family member-related variables such as educational level, gender, and kinship to the patient showed divergent associations with family satisfaction. Within patient-related variables, the severity of illness was positively associated with family satisfaction. Factors related to healthcare providers and organisations were reported only in 26.9% of the studies. CONCLUSIONS A broad number of factors associated with family satisfaction in the ICU were found in this review. However, few nonmodifiable factors related to the family members and the patient showed a significant and consistent association with family satisfaction. Evidence on factors related to healthcare providers was scarce. Gaps in knowledge regarding family satisfaction in the ICU, including methodological issues that impair the validity of the findings, were identified. Future studies should address these limitations to accurately identify factors that impact family satisfaction in the ICU.
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Affiliation(s)
- Cristóbal Padilla Fortunatti
- University of Miami, School of Nursing and Health Studies, Coral Gables, USA; Pontificia Universidad Católica de Chile, School of Nursing, Santiago, Chile.
| | - Cindy L Munro
- University of Miami, School of Nursing and Health Studies, Coral Gables, USA
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Critical Care Is a Bargain? An Intensive Look at Value for Money in the ICU. Crit Care Med 2021; 48:777-778. [PMID: 32301779 DOI: 10.1097/ccm.0000000000004299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Cognitive biases, environmental, patient and personal factors associated with critical care decision making: A scoping review. J Crit Care 2021; 64:144-153. [PMID: 33906103 DOI: 10.1016/j.jcrc.2021.04.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 03/31/2021] [Accepted: 04/15/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Cognitive biases and factors affecting decision making in critical care can potentially lead to life-threatening errors. We aimed to examine the existing evidence on the influence of cognitive biases and factors on decision making in critical care. MATERIALS AND METHODS We conducted a scoping review by searching MEDLINE for articles from 2004 to November 2020. We included studies conducted in physicians that described cognitive biases or factors associated with decision making. During the study process we decided on the method to summarize the evidence, and based on the obtained studies a descriptive summary of findings was the best fit. RESULTS Thirty heterogenous studies were included. Four main biases or factors were observed, e.g. cognitive biases, personal factors, environmental factors, and patient factors. Six (20%) studies reported biases associated with decision making comprising omission-, status quo-, implicit-, explicit-, outcome-, and overconfidence bias. Nineteen (63%) studies described personal factors, twenty-two (73%) studies described environmental factors, and sixteen (53%) studies described patient factors. CONCLUSIONS The current evidence on cognitive biases and factors is heterogenous, but shows they influence clinical decision. Future studies should investigate the prevalence of cognitive biases and factors in clinical practice and their impact on clinical outcomes.
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Rotar EP, Beller JP, Smolkin ME, Chancellor WZ, Ailawadi G, Yarboro LT, Hulse M, Ratcliffe SJ, Teman NR. Prediction of Prolonged Intensive Care Unit Length of Stay Following Cardiac Surgery. Semin Thorac Cardiovasc Surg 2021; 34:172-179. [PMID: 33689923 DOI: 10.1053/j.semtcvs.2021.02.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 02/01/2021] [Indexed: 11/11/2022]
Abstract
Intensive care unit (ICU) costs comprise a significant proportion of the total inpatient charges for cardiac surgery. No reliable method for predicting intensive care unit length of stay following cardiac surgery exists, making appropriate staffing and resource allocation challenging. We sought to develop a predictive model to anticipate prolonged ICU length of stay (LOS). All patients undergoing coronary artery bypass grafting (CABG) and/or valve surgery with a Society of Thoracic Surgeons (STS) predicted risk score were evaluated from an institutional STS database. Models were developed using 2014-2017 data; validation used 2018-2019 data. Prolonged ICU LOS was defined as requiring ICU care for at least three days postoperatively. Predictive models were created using lasso regression and relative utility compared. A total of 3283 patients were included with 1669 (50.8%) undergoing isolated CABG. Overall, 32% of patients had prolonged ICU LOS. Patients with comorbid conditions including severe COPD (53% vs 29%, P < 0.001), recent pneumonia (46% vs 31%, P < 0.001), dialysis-dependent renal failure (57% vs 31%, P < 0.001) or reoperative status (41% vs 31%, P < 0.001) were more likely to experience prolonged ICU stays. A prediction model utilizing preoperative and intraoperative variables correctly predicted prolonged ICU stay 76% of the time. A preoperative variable-only model exhibited 74% prediction accuracy. Excellent prediction of prolonged ICU stay can be achieved using STS data. Moreover, there is limited loss of predictive ability when restricting models to preoperative variables. This novel model can be applied to aid patient counseling, resource allocation, and staff utilization.
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Affiliation(s)
- Evan P Rotar
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Jared P Beller
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Mark E Smolkin
- Public Health Sciences, University of Virginia School of Medicine, Charlottesville, Virginia
| | - William Z Chancellor
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Gorav Ailawadi
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Leora T Yarboro
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Mathew Hulse
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
| | - Sarah J Ratcliffe
- Public Health Sciences, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Nicholas R Teman
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia.
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11
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Role of anabolic testosterone agents and structured exercise to promote recovery in ICU survivors. Curr Opin Crit Care 2021; 26:508-515. [PMID: 32773614 DOI: 10.1097/mcc.0000000000000757] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE OF REVIEW ICU survivors frequently suffer significant, prolonged physical disability. 'ICU Survivorship', or addressing quality-of-life impairments post-ICU care, is a defining challenge, and existing standards of care fail to successfully address these disabilities. We suggest addressing persistent catabolism by treatment with testosterone analogues combined with structured exercise is a promising novel intervention to improve 'ICU Survivorship'. RECENT FINDINGS One explanation for lack of success in addressing post-ICU physical disability is most ICU patients exhibit severe testosterone deficiencies early in ICU that drives persistent catabolism despite rehabilitation efforts. Oxandrolone is an FDA-approved testosterone analogue for treating muscle weakness in ICU patients. A growing number of trials with this agent combined with structured exercise show clinical benefit, including improved physical function and safety in burns and other catabolic states. However, no trials of oxandrolone/testosterone and exercise in nonburn ICU populations have been conducted. SUMMARY Critical illness leads to a catabolic state, including severe testosterone deficiency that persists throughout hospital stay, and results in persistent muscle weakness and physical dysfunction. The combination of an anabolic agent with adequate nutrition and structured exercise is likely essential to optimize muscle mass/strength and physical function in ICU survivors. Further research in ICU populations is needed.
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Abushanab D, Abounahia FF, Alsoukhni O, Abdelaal M, Al-Badriyeh D. Clinical and Economic Evaluation of the Impact of Midazolam on Morphine Therapy for Pain Relief in Critically Ill Ventilated Infants with Respiratory Distress Syndrome. Paediatr Drugs 2021; 23:143-157. [PMID: 33354750 PMCID: PMC7755454 DOI: 10.1007/s40272-020-00432-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/13/2020] [Indexed: 10/31/2022]
Abstract
BACKGROUND The impact of midazolam on the overall performance of morphine therapy for pain in ventilated neonates with respiratory distress syndrome (RDS) has never been investigated. OBJECTIVE This study is a clinical and economic analysis of morphine monotherapy versus morphine plus midazolam in ventilated infants with RDS. METHODS A decision-analytic model from the hospital perspective was developed to follow the consequences of the use of the study drugs. Clinical and resource utilization data were extracted based on a retrospective cohort study of 104 neonates with RDS receiving morphine alone versus in combination with midazolam at the main neonatal intensive care unit (NICU) in Qatar, from 2014 to 2019. Primary outcome measures were the analgesia success rate, via the Premature Infant Pain Profile scale, and overall costs of therapies. Multivariate statistical analyses confirmed no significant variations in baseline characteristics between study groups. RESULTS With 0.05 significance and 80% power, morphine had a higher rate of successful analgesia (65.4 vs. 34.6%; risk ratio 1.91; 95% confidence interval 1.11-3.28; p = 0.019). Overall costs were also in favor of morphine compared with its combination with midazolam, with cost savings of 40,959 Qatari Riyal ($US11,222), year 2019/20 values. The Monte Carlo analyses confirmed the economic advantage of morphine alone in 100% of cases and demonstrated that it is not sensitive to uncertainties in study model inputs. CONCLUSIONS Morphine monotherapy enabled enhanced pain relief over its combination with midazolam in the NICU, at a reduced overall cost. Morphine alone, therefore, seems to be a dominant analgesia strategy.
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Affiliation(s)
- Dina Abushanab
- grid.413548.f0000 0004 0571 546XDrug Information Department, Hamad Medical Corporation, Doha, Qatar
| | - Fouad F. Abounahia
- grid.413548.f0000 0004 0571 546XNeonatal Intensive Care Unit Department, Hamad Medical Corporation, Doha, Qatar
| | - Omar Alsoukhni
- Pharmacy Department, Al Jalila Children’s Specialty Hospital, Dubai, United Arab Emirates
| | - Mohammed Abdelaal
- grid.498619.bPharmacy and Drug Control, Ministry of Public Health, Doha, Qatar
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13
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Analyzing clinical and system drivers of satisfaction in the intensive care unit as a component of high quality care. Heart Lung 2020; 50:277-283. [PMID: 33383546 DOI: 10.1016/j.hrtlng.2020.12.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 12/06/2020] [Accepted: 12/22/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Quality improvement in the intensive care unit has transitioned from focusing on mortality to improving care and reducing morbidity. OBJECTIVE This study prospectively investigated clinical and system drivers of family satisfaction in a large quaternary hospital ICU. METHODS A validated tool was distributed to family members and a registry chart analysis was conducted. The aims were to assess associations with high or low family satisfaction to evaluate unit-level satisfaction. Candidate predictors were selected from univariate logistic regressions and finalized in a multivariate model by a stepwise selection approach. RESULTS Overall, 75% (n = 188) of respondents (n = 250) indicated high satisfaction. Respondents with higher satisfaction had a Plan of the Day posted (OR = 3.3, 95% CI: 1.63, 6.89, p = 0.001), and did not live with the patient (OR =0.5, 95% CI: 0.25, 0.96, p = 0.044). CONCLUSION This study indicates that communication and transparency of plans contributes to family satisfaction with ICU care.
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14
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Taylor C, Yang L, Finfer S, Machado FR, YouZhong A, Billot L, Bloos F, Bozza F, Cavalcanti AB, Correa M, Du B, Hjortrup PB, McIntyre L, Saxena M, Schortgen F, Watts NR, Myburgh J, Thompson K, Hammond NE. An international comparison of the cost of fluid resuscitation therapies. Aust Crit Care 2020; 34:23-32. [PMID: 32828672 DOI: 10.1016/j.aucc.2020.06.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 05/31/2020] [Accepted: 06/01/2020] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVE Fluid resuscitation is a ubiquitous intervention in the management of patients treated in the intensive care unit, which has implications for intensive care unit resourcing and budgets. Our objective was to calculate the relative cost of resuscitation fluids in several countries to inform future economic evaluations. METHODS We collected site-level data regarding the availability and cost of fluids as part of an international survey. We normalised costs to net present values using purchasing power parities and published inflation figures. Costs were also adjusted for equi-effective dosing based on intravascular volume expansion effectiveness and expressed as US dollars (USD) per 100 mL crystalloid equivalent. RESULTS A total of 187 sites had access to cost data. Between countries, there was an approximate six fold variation in the cost of crystalloids and colloids overall. The average cost for crystalloids overall was less than 1 USD per 100 mL. In contrast, colloid fluids had higher average costs (59 USD per 100 mL). After adjusting for equi-effective dosing, saline was ∼27 times less costly than albumin (saline: 0.6 USD per 100 mL crystalloid equivalent; albumin 4-5%: 16.4 USD; albumin 20-25%: 15.8 USD) and ∼4 times less costly than hydroxyethyl starch solution (saline: 0.6 USD; hydroxyethyl starch solution: 2.5 USD). Buffered salt solutions, such as compound sodium acetate solutions (e.g., Plasmalyte®), had the highest average cost of crystalloid fluids, costing between 3 and 4 USD per 100 mL. CONCLUSION The cost of fluid varies substantially between fluid types and between countries, although normal (0.9%) saline is consistently less costly than colloid preparations and some buffered salt solutions. These data can be used to inform future economic evaluations of fluid preparations.
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Affiliation(s)
- Colman Taylor
- Critical Care Division, The George Institute for Global Health, Sydney, Australia; Faculty of Medicine, University of New South Wales, Sydney, Australia.
| | - Li Yang
- Critical Care Division, The George Institute for Global Health, Sydney, Australia
| | - Simon Finfer
- Critical Care Division, The George Institute for Global Health, Sydney, Australia; Faculty of Medicine, University of New South Wales, Sydney, Australia; Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, Australia
| | - Flavia R Machado
- Anesthesiology, Pain and Intensive Care Department, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - An YouZhong
- Department of Critical Care Medicine, Peking University People's Hospital, Beijing, China
| | - Laurent Billot
- Faculty of Medicine, University of New South Wales, Sydney, Australia; Statistics Division, The George Institute for Global Health, Sydney, Australia
| | - Frank Bloos
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Fernando Bozza
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil
| | | | - Maryam Correa
- Critical Care Division, The George Institute for Global Health, Sydney, Australia; Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Bin Du
- Medical Intensive Care Unit, Peking Union Medical College Hospital, Beijing, China
| | - Peter B Hjortrup
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Lauralyn McIntyre
- Department of Medicine (Critical Care), The Ottawa Hospital Research Institute, Ottawa, Canada
| | - Manoj Saxena
- Critical Care Division, The George Institute for Global Health, Sydney, Australia; Faculty of Medicine, University of New South Wales, Sydney, Australia; Department of Intensive Care, Bankstown Hospital, Bankstown, Australia
| | - Frédérique Schortgen
- Assistance Publique-Hôpitaux de Paris, Réanimation Médicale Groupe Hospitalier Henri Mondor, Créteil, France
| | - Nicola R Watts
- Critical Care Division, The George Institute for Global Health, Sydney, Australia; Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - John Myburgh
- Critical Care Division, The George Institute for Global Health, Sydney, Australia; Faculty of Medicine, University of New South Wales, Sydney, Australia; Department of Intensive Care Medicine, St. George Hospital, Kograh, Australia
| | - Kelly Thompson
- Critical Care Division, The George Institute for Global Health, Sydney, Australia; Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Naomi E Hammond
- Critical Care Division, The George Institute for Global Health, Sydney, Australia; Faculty of Medicine, University of New South Wales, Sydney, Australia.
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15
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Sekulić A, Likić R, Matas M. How to allocate intensive care resources during the COVID-19 pandemic: medical triage or a priori selection? Croat Med J 2020; 61:276-278. [PMID: 32643345 PMCID: PMC7358688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2024] Open
Affiliation(s)
| | - Robert Likić
- Robert Likić, University of Zagreb School of Medicine, Zagreb, Croatia,
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16
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van Wagenberg L, Beurskens CJP, Stegeman I, Müller MCA. Program on high value cost-conscious education in intensive care: Educational program on prediction of outcome and cost awareness on Intensive Care admission. BMC MEDICAL EDUCATION 2020; 20:186. [PMID: 32513162 PMCID: PMC7282117 DOI: 10.1186/s12909-020-02100-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Accepted: 05/29/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Intensive Care (ICU) involves extended and long lasting support of vital functions and organs. However, current training programs of ICU residents mainly focus on extended support of vital functions and barely involve training on cost-awareness and outcome. We incorporated an educational program on high-value cost-conscious care for residents and fellows on our ICU and measured the effect of education. METHODS A cohort study with factorial survey design, in which ICU residents and fellows were asked to evaluate clinical vignettes, was performed on the mixed surgical-medical ICU of the Amsterdam University Medical Centre. Residents were offered an educational program focusing on outcome and costs of ICU care. Before and after the program they filled out a questionnaire, which consisted of 23 vignettes, in which known predictors of outcome of community acquired pneumonia (CAP), pancreatitis, acute respiratory distress syndrome (ARDS) and cardiac arrest were presented, together with varying patient factors (age, body mass index (BMI), acute kidney failure (AKI) and haemato-oncological malignancy). Participants were asked to either admit the patient or estimate mortality. RESULTS BMI, haemato-oncological malignancy and severity of pancreatitis were discriminative for admission to ICU in clinical vignettes on pancreatitis and CAP. After education, only severity of pancreatitis was judged as discriminative. Before the intervention only location of cardiac arrest (in- vs out of hospital) was distinctive for mortality, afterwards this changed to presence of haemato-oncological malignancy. CONCLUSION We incorporated an educational program on high-value cost-conscious care in the training of ICU physicians. Based on our vignette study, we conclude that the improvement of knowledge of costs and prognosis after this program was limited.
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Affiliation(s)
- L van Wagenberg
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.
- Department of Paediatrics, Paediatric Intensive Care, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Lundlaan 6, 3584 EC, Utrecht, the Netherlands.
| | - C J P Beurskens
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - I Stegeman
- Department of Otorhinolaryngology and Head & Neck Surgery, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
- Brain Centre Rudolf Magnus, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - M C A Müller
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
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Abstract
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.
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18
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Rongali S, Rose AJ, McManus DD, Bajracharya AS, Kapoor A, Granillo E, Yu H. Learning Latent Space Representations to Predict Patient Outcomes: Model Development and Validation. J Med Internet Res 2020; 22:e16374. [PMID: 32202503 PMCID: PMC7136840 DOI: 10.2196/16374] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 01/27/2020] [Accepted: 02/14/2020] [Indexed: 12/13/2022] Open
Abstract
Background Scalable and accurate health outcome prediction using electronic health record (EHR) data has gained much attention in research recently. Previous machine learning models mostly ignore relations between different types of clinical data (ie, laboratory components, International Classification of Diseases codes, and medications). Objective This study aimed to model such relations and build predictive models using the EHR data from intensive care units. We developed innovative neural network models and compared them with the widely used logistic regression model and other state-of-the-art neural network models to predict the patient’s mortality using their longitudinal EHR data. Methods We built a set of neural network models that we collectively called as long short-term memory (LSTM) outcome prediction using comprehensive feature relations or in short, CLOUT. Our CLOUT models use a correlational neural network model to identify a latent space representation between different types of discrete clinical features during a patient’s encounter and integrate the latent representation into an LSTM-based predictive model framework. In addition, we designed an ablation experiment to identify risk factors from our CLOUT models. Using physicians’ input as the gold standard, we compared the risk factors identified by both CLOUT and logistic regression models. Results Experiments on the Medical Information Mart for Intensive Care-III dataset (selected patient population: 7537) show that CLOUT (area under the receiver operating characteristic curve=0.89) has surpassed logistic regression (0.82) and other baseline NN models (<0.86). In addition, physicians’ agreement with the CLOUT-derived risk factor rankings was statistically significantly higher than the agreement with the logistic regression model. Conclusions Our results support the applicability of CLOUT for real-world clinical use in identifying patients at high risk of mortality.
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Affiliation(s)
- Subendhu Rongali
- College of Information and Computer Sciences, University of Massachusetts Amherst, Amherst, MA, United States
| | - Adam J Rose
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, United States
| | - David D McManus
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, United States
| | - Adarsha S Bajracharya
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, United States
| | - Alok Kapoor
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, United States.,Meyers Primary Care Institute, Worcester, MA, United States
| | - Edgard Granillo
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States
| | - Hong Yu
- College of Information and Computer Sciences, University of Massachusetts Amherst, Amherst, MA, United States.,Department of Medicine, University of Massachusetts Medical School, Worcester, MA, United States.,Department of Computer Science, University of Massachusetts Lowell, Lowell, MA, United States.,Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs Medical Center, Bedford, MA, United States
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19
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Angiotensin II for the treatment of distributive shock in the intensive care unit: A US cost-effectiveness analysis. Int J Technol Assess Health Care 2020; 36:145-151. [PMID: 32114996 DOI: 10.1017/s0266462320000082] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Patients with distributive shock who are unresponsive to traditional vasopressors are commonly considered to have severe distributive shock and are at high mortality risk. Here, we assess the cost-effectiveness of adding angiotensin II to the standard of care (SOC) for severe distributive shock in the US critical care setting from a US payer perspective. METHODS Short-term mortality outcomes were based on 28-day survival rates from the ATHOS-3 study. Long-term outcomes were extrapolated to lifetime survival using individually estimated life expectancies for survivors. Resource use and adverse event costs were drawn from the published literature. Health outcomes evaluated were lives saved, life-years gained, and quality-adjusted life-years (QALYs) gained using utility estimates for the US adult population weighted for sepsis mortality. Deterministic and probabilistic sensitivity analyses assessed uncertainty around results. We analyzed patients with severe distributive shock from the ATHOS-3 clinical trial. RESULTS The addition of angiotensin II to the SOC saved .08 lives at Day 28 compared to SOC alone. The cost per life saved was estimated to be $108,884. The addition of angiotensin II to the SOC was projected to result in a gain of .96 life-years and .66 QALYs. This resulted in an incremental cost-effectiveness ratio of $12,843 per QALY. The probability of angiotensin II being cost-effective at a threshold of $50,000 per QALY was 86 percent. CONCLUSIONS For treatment of severe distributive shock, angiotensin II is cost-effective at acceptable thresholds.
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20
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Higgins AM, Brooker JE, Mackie M, Cooper DJ, Harris AH. Health economic evaluations of sepsis interventions in critically ill adult patients: a systematic review. J Intensive Care 2020; 8:5. [PMID: 31934338 PMCID: PMC6950865 DOI: 10.1186/s40560-019-0412-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 10/31/2019] [Indexed: 12/12/2022] Open
Abstract
Background Sepsis is a global health priority. Interventions to reduce the burden of sepsis need to be both effective and cost-effective. We performed a systematic review of the literature on health economic evaluations of sepsis treatments in critically ill adult patients and summarised the evidence for cost-effectiveness. Methods We systematically searched MEDLINE, Embase, and the Cochrane Library using thesaurus (e.g. MeSH) and free-text terms related to sepsis and economic evaluations. We included all articles that reported, in any language, an economic evaluation of an intervention for the management of sepsis in critically ill adult patients. Data extracted included study details, intervention details, economic evaluation methodology, and outcomes. Included studies were appraised for reporting quality using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. Results We identified 50 records representing 46 economic evaluations for a variety of interventions including antibiotics (n = 5), fluid therapy (n = 2), early goal-directed therapy and other resuscitation protocols (n = 8), immunoglobulins (n = 2), and interventions no longer in clinical use such as monoclonal antibodies (n = 7) and drotrecogin alfa (n = 13). Twelve (26%) evaluations were of excellent reporting quality. Incremental cost-effectiveness ratios (ICERs) ranged from dominant (lower costs and higher effectiveness) for early goal-directed therapy, albumin, and a multifaceted sepsis education program to dominated (higher costs and lower effectiveness) for polymerase chain reaction assays (LightCycler SeptiFast testing MGRADE®, SepsiTest™, and IRIDICA BAC BSI assay). ICERs varied widely across evaluations, particularly in subgroup analyses. Conclusions There is wide variation in the cost-effectiveness of sepsis interventions. There remain important gaps in the literature, with no economic evaluations identified for several interventions routinely used in sepsis. Given the high economic and social burden of sepsis, high-quality economic evaluations are needed to increase our understanding of the cost-effectiveness of these interventions in routine clinical practice and to inform decision makers. Trial registration PROSPERO CRD42018095980
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Affiliation(s)
- Alisa M Higgins
- 1Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, Victoria 3004 Australia
| | - Joanne E Brooker
- 1Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, Victoria 3004 Australia
| | - Michael Mackie
- 1Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, Victoria 3004 Australia
| | - D Jamie Cooper
- 1Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, Victoria 3004 Australia.,2Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, Victoria Australia
| | - Anthony H Harris
- 3Centre for Health Economics, Monash University, Melbourne, Victoria Australia
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21
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Peine A, Hallawa A, Schöffski O, Dartmann G, Fazlic LB, Schmeink A, Marx G, Martin L. A Deep Learning Approach for Managing Medical Consumable Materials in Intensive Care Units via Convolutional Neural Networks: Technical Proof-of-Concept Study. JMIR Med Inform 2019; 7:e14806. [PMID: 31603430 PMCID: PMC6819012 DOI: 10.2196/14806] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Revised: 07/18/2019] [Accepted: 08/13/2019] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND High numbers of consumable medical materials (eg, sterile needles and swabs) are used during the daily routine of intensive care units (ICUs) worldwide. Although medical consumables largely contribute to total ICU hospital expenditure, many hospitals do not track the individual use of materials. Current tracking solutions meeting the specific requirements of the medical environment, like barcodes or radio frequency identification, require specialized material preparation and high infrastructure investment. This impedes the accurate prediction of consumption, leads to high storage maintenance costs caused by large inventories, and hinders scientific work due to inaccurate documentation. Thus, new cost-effective and contactless methods for object detection are urgently needed. OBJECTIVE The goal of this work was to develop and evaluate a contactless visual recognition system for tracking medical consumable materials in ICUs using a deep learning approach on a distributed client-server architecture. METHODS We developed Consumabot, a novel client-server optical recognition system for medical consumables, based on the convolutional neural network model MobileNet implemented in Tensorflow. The software was designed to run on single-board computer platforms as a detection unit. The system was trained to recognize 20 different materials in the ICU, while 100 sample images of each consumable material were provided. We assessed the top-1 recognition rates in the context of different real-world ICU settings: materials presented to the system without visual obstruction, 50% covered materials, and scenarios of multiple items. We further performed an analysis of variance with repeated measures to quantify the effect of adverse real-world circumstances. RESULTS Consumabot reached a >99% reliability of recognition after about 60 steps of training and 150 steps of validation. A desirable low cross entropy of <0.03 was reached for the training set after about 100 iteration steps and after 170 steps for the validation set. The system showed a high top-1 mean recognition accuracy in a real-world scenario of 0.85 (SD 0.11) for objects presented to the system without visual obstruction. Recognition accuracy was lower, but still acceptable, in scenarios where the objects were 50% covered (P<.001; mean recognition accuracy 0.71; SD 0.13) or multiple objects of the target group were present (P=.01; mean recognition accuracy 0.78; SD 0.11), compared to a nonobstructed view. The approach met the criteria of absence of explicit labeling (eg, barcodes, radio frequency labeling) while maintaining a high standard for quality and hygiene with minimal consumption of resources (eg, cost, time, training, and computational power). CONCLUSIONS Using a convolutional neural network architecture, Consumabot consistently achieved good results in the classification of consumables and thus is a feasible way to recognize and register medical consumables directly to a hospital's electronic health record. The system shows limitations when the materials are partially covered, therefore identifying characteristics of the consumables are not presented to the system. Further development of the assessment in different medical circumstances is needed.
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Affiliation(s)
- Arne Peine
- Department of Intensive Care Medicine and Intermediate Care, University Hospital Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany.,Clinomic GmbH, Aachen, Germany
| | - Ahmed Hallawa
- Department of Intensive Care Medicine and Intermediate Care, University Hospital Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany.,Chair for Integrated Signal Processing Systems, Rheinisch-Westfälische Technische Hochschule Aachen University, Aachen, Germany
| | - Oliver Schöffski
- Chair of Health Management, School of Business, Economics and Society, Friedrich-Alexander-University Erlangen-Nürnberg, Nürnberg, Germany
| | - Guido Dartmann
- Clinomic GmbH, Aachen, Germany.,Research Area Distributed Systems, Trier University of Applied Sciences, Trier, Germany
| | - Lejla Begic Fazlic
- Research Area Distributed Systems, Trier University of Applied Sciences, Trier, Germany
| | - Anke Schmeink
- Clinomic GmbH, Aachen, Germany.,Research Area Information Theory and Systematic Design of Communication Systems, Rheinisch-Westfälische Technische Hochschule Aachen University, Aachen, Germany
| | - Gernot Marx
- Department of Intensive Care Medicine and Intermediate Care, University Hospital Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany.,Clinomic GmbH, Aachen, Germany
| | - Lukas Martin
- Department of Intensive Care Medicine and Intermediate Care, University Hospital Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany.,Clinomic GmbH, Aachen, Germany
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Lalova V, Petrova G, Merdzhanova E. Assessment of various aspects of using protocols in intensive care units in Plovdiv, Bulgaria. MEDICAL SCIENCE PULSE 2019. [DOI: 10.5604/01.3001.0013.1586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Since 1950 intensive care has become a separate and independent specialty. Significant technological
advances have allowed the Intensive Care Unit (ICU)s to be monitored through the centralized work of a
multidisciplinary team of specialists. ICUs provide cares at different levels of support. To provide patient access
to this highly specialized cares, the “Critical care without walls” or “Intensive Care without Borders” theories
have emerged, involving reanimation nurses offering highly specialized care and support. Protocols for nurses
have been developed, with the aim of facilitating their day-to-day activities, improving outcomes and safety of
patients and all staff. Utilizing this concept, the role of intensive care has rapidly expanded over the past 20 years.
Aim of the study: To understand the effectiveness and benefits derived from organisation of the working process.
Material and methods: We used documentary and survey methods and analysed the data using the software
package SPSS v. 21.0. Graphics were prepared using Microsoft Excel 2013. Numbers from 1 to 5 refer to the
answers “no”, “not really”, “cannot judge”, “closer to yes” and “yes”, respectively.
Results: Nurses’ performance, as an integral part of multidisciplinary ICU teams, is evidence that mortality
and morbidity can be improved thanks to the early recognition of patient deterioration and rapid resuscitation.
The better healing process is accomplished by optimising the content and evaluation of the desired results, in
association with good doctor practices. Respondents’ opinions about outcomes of protocol use differed significantly
between professions in regard to making their job easier, improving patient outcomes, providing consistency
in care, and preventing patient harm.
Conclusions: A more flexible and standard framework for nurses should be developed to improve quality of
care. The rapidly growing lack of ICU nurses in Bulgaria is concerning.
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Affiliation(s)
- Valentina Lalova
- Department of Nursing, Faculty of Public Health, Medical University of Plovdiv, Bulgaria
| | - Gergana Petrova
- Department of Nursing, Faculty of Public Health, Medical University of Plovdiv, Bulgaria
| | - Elena Merdzhanova
- Department of Nursing, Faculty of Public Health, Medical University of Plovdiv, Bulgaria
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Abushanab D, Alsoukhni O, AbouNahia F, Al-Badriyeh D. Clinical and Economic Analysis of Morphine Versus Fentanyl in Managing Ventilated Neonates With Respiratory Distress Syndrome in the Intensive Care Setting. Clin Ther 2019; 41:714-727.e8. [PMID: 30846286 DOI: 10.1016/j.clinthera.2019.02.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 02/01/2019] [Accepted: 02/11/2019] [Indexed: 11/20/2022]
Abstract
PURPOSE Morphine and fentanyl opioids are common analgesic agents for consideration in the neonatal intensive care unit (NICU) for neonates with respiratory distress syndrome (RDS) and undergoing mechanical ventilation (MV). The aim of this study was to evaluate the clinical and economic impact of morphine versus fentanyl in neonates with RDS undergoing MV. METHODS Retrospective cost-effectiveness analysis of critically ill neonates with RDS receiving standard doses of morphine versus fentanyl at Women's Wellness and Research Center, Qatar. Clinical data of neonates were extracted from medical records of patients from 2014 to 2016. A decision analytic model based on the hospital's perspective was constructed to follow possible consequences of the initial dosing of analgesia, before potential titration. Primary end points were successful pain relief rate based on the Premature Infant Pain Profile scale and overall direct medical cost of therapy. Study population of 126 neonates was used to achieve results with 80% power and 0.05 significance. Sensitivity analysis was conducted to enhance robustness of conclusions against input uncertainties and to increase generalizability of results. FINDINGS Morphine achieved a success of 68% versus 43% with fentanyl (risk ratio = 1.72; 95% CI, 1.16-2.56; P = 0.0075). Morphine was associated with a minimal incremental cost-effectiveness ratio of USD 135 per additional case of successful pain relief over fentanyl. Higher morphine cost was reported in 2% of cases. Sensitivity analysis found model insensitivity to input uncertainties except NICU stay and cost of MV. IMPLICATIONS This is the first cost-effectiveness evaluation of morphine versus fentanyl in the NICU. Morphine significantly improved the relieve of pain over fentanyl. It had 98% probability of dominance over fentanyl. Results in this study support the use of morphine over fentanyl as first-line monotherapy with MV in NICU settings.
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Affiliation(s)
- Dina Abushanab
- Pharmacy Department, Hamad Medical Corporation, Doha, Qatar
| | - Omar Alsoukhni
- Pharmacy Department, Hamad Medical Corporation, Doha, Qatar
| | - Fouad AbouNahia
- Neonatal Intensive Care Unit Department, Hamad Medical Corporation, Doha, Qatar
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Tran DT, Thanh NX, Opgenorth D, Wang X, Zuege D, Zygun DA, Stelfox HT, Bagshaw SM. Association between strained ICU capacity and healthcare costs in Canada: A population-based cohort study. J Crit Care 2019; 51:175-183. [PMID: 30852346 DOI: 10.1016/j.jcrc.2019.02.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 02/11/2019] [Accepted: 02/25/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Intensive care is resource intensive, with costs representing a substantial quantity of total hospitalization costs. Strained ICU capacity compromises care quality and adversely impacts outcomes; however, the association between strain and healthcare costs has not been explored. MATERIALS AND METHODS Population-based cohort study performed in 17 adult ICUs in Alberta, Canada. Data were captured on hospitalizations, ambulatory care, physician services and drug dispenses occurring 1-year before and 1-year after index ICU admission. Strain was defined as occupancy ≥90%; with 21 additional definitions evaluated. Patients were categorized as strain and non-strain admissions. Costs attributable to strain, were calculated as difference-in-difference costs using propensity-score matching. RESULTS 30,557 patients were included (strain: 11,830 [38.7%]; non-strain: 18,727 [61.3%]). At 1-year, strain admissions had adjusted-incremental per-patient cost of CA$9406 (95%CI, $5654-13,157) compared to non-strain admissions, due to hospitalization costs (CA$7930; 95%CI, $4553-11,307) and physician claims (CA$844; 95%CI, $430-1259). This equated to CA$111.3 million (95%CI, $66.9-155.6 million) in excess attributable costs. Strain portended longer hospitalization (3.3 days; 95%CI, 1.1-5.5); and more ambulatory visits (1.0; 95%CI, 0.1-2.0) and physician claims (9.5; 95%CI, 6.2-12.7). Incremental costs were robust across strain definitions. CONCLUSIONS Admissions to ICUs experiencing strain incur incremental costs, attributed to longer hospitalization and physician services.
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Affiliation(s)
- Dat T Tran
- Institute of Health Economics, Edmonton, Alberta, Canada
| | - Nguyen X Thanh
- Institute of Health Economics, Edmonton, Alberta, Canada; School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Dawn Opgenorth
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada; Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada
| | - Xiaoming Wang
- Research Facilitation, Analytics (DIMR), Alberta Health Services, Edmonton, Canada
| | - Danny Zuege
- Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada; Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - David A Zygun
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Henry T Stelfox
- Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada; Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sean M Bagshaw
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada; Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada; Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada.
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Litton E, McCann M, van Haren F. Predicting Intensive Care Unit Length of Stay After Cardiac Surgery. J Cardiothorac Vasc Anesth 2018; 32:2683-2684. [PMID: 29752055 DOI: 10.1053/j.jvca.2018.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Edward Litton
- Fiona Stanley Hospital, Perth, WA, Australia; St John of God Hospital, Subiaco, Perth, WA, Australia
| | | | - Frank van Haren
- Canberra Hospital, Canberra, Australia; Australian National University, Medical School, Canberra, Australia
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26
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Fuchs G, Thevathasan T, Chretien YR, Mario J, Piriyapatsom A, Schmidt U, Eikermann M, Fintelmann FJ. Lumbar skeletal muscle index derived from routine computed tomography exams predict adverse post-extubation outcomes in critically ill patients. J Crit Care 2018; 44:117-123. [DOI: 10.1016/j.jcrc.2017.10.033] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 10/15/2017] [Accepted: 10/22/2017] [Indexed: 12/25/2022]
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Power N, Plummer NR, Baldwin J, James FR, Laha S. Intensive care decision-making: Identifying the challenges and generating solutions to improve inter-specialty referrals to critical care. J Intensive Care Soc 2018; 19:287-298. [PMID: 30515238 DOI: 10.1177/1751143718758933] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction Decision-making regarding admission to UK intensive care units is challenging. Demand for beds exceeds capacity, yet the need to provide emergency cover creates pressure to build redundancy into the system. Guidelines to aid clinical decision-making are outdated, resulting in an over-reliance on professional judgement. Although clinicians are highly skilled, there is variability in intensive care unit decision-making, especially at the inter-specialty level wherein cognitive biases contribute to disagreement. Method This research is the first to explore intensive care unit referral and admission decision-making using the Critical Decision Method interviewing technique. We interviewed intensive care unit (n = 9) and non-intensive care unit (n = 6) consultants about a challenging referral they had dealt with in the past where there was disagreement about the patient's suitability for intensive care unit. Results We present: (i) a description of the referral pathway; (ii) challenges that appear to derail referrals (i.e. process issues, decision biases, inherent stressors, post-decision consequences) and (iii) potential solutions to improve this process. Discussion This research provides a foundation upon which interventions to improve inter-specialty decision-making can be based.
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Affiliation(s)
- Nicola Power
- Department of Psychology, Lancaster University, UK
| | - Nicholas R Plummer
- Critical Care Unit, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK.,Health Education East Midlands, Leicester, UK
| | - Jacqueline Baldwin
- Critical Care Unit, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Fiona R James
- Critical Care Unit, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Shondipon Laha
- Critical Care Unit, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
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James FR, Power N, Laha S. Decision-making in intensive care medicine - A review. J Intensive Care Soc 2017; 19:247-258. [PMID: 30159017 DOI: 10.1177/1751143717746566] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Decision-making by intensivists around accepting patients to intensive care units is a complex area, with often high-stakes, difficult, emotive decisions being made with limited patient information, high uncertainty about outcomes and extreme pressure to make these decisions quickly. This is exacerbated by a lack of clear guidelines to help guide this difficult decision-making process, with the onus largely relying on clinical experience and judgement. In addition to uncertainty compounding decision-making at the individual clinical level, it is further complicated at the multi-speciality level for the senior doctors and surgeons referring to intensive care units. This is a systematic review of the existing literature about this decision-making process and the factors that help guide these decisions on both sides of the intensive care unit admission dilemma. We found many studies exist assessing the patient factors correlated with intensive care unit admission decisions. Analysing these together suggests that factors consistently found to be correlated with a decision to admit or refuse a patient from intensive care unit are bed availability, severity of illness, initial ward or team referred from, patient choice, do not resuscitate status, age and functional baseline. Less research has been done on the decision-making process itself and the factors that are important to the accepting intensivists; however, similar themes are seen. Even less research exists on referral decision and demonstrates that in addition to the factors correlated with intensive care unit admission decisions, other wider variables are considered by the referring non-intensivists. No studies are available that investigate the decision-making process in referring non-intensivists or the mismatch of processes and pressure between the two sides of the intensive care unit referral dilemma.
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Affiliation(s)
- Fiona R James
- Critical Care Unit, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Nicola Power
- Department of Psychology, Lancaster University, UK
| | - Shondipon Laha
- Critical Care Unit, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
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Abu Al-Saad N, Skedgel C, Nortje J. Principles of resource allocation in critical care. BJA Educ 2017. [DOI: 10.1093/bjaed/mkx029] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
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Geense W, Zegers M, Vermeulen H, van den Boogaard M, van der Hoeven J. MONITOR-IC study, a mixed methods prospective multicentre controlled cohort study assessing 5-year outcomes of ICU survivors and related healthcare costs: a study protocol. BMJ Open 2017; 7:e018006. [PMID: 29138206 PMCID: PMC5695418 DOI: 10.1136/bmjopen-2017-018006] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Due to advances in critical care medicine, more patients survive their critical illness. However, intensive care unit (ICU) survivors often experience long-term physical, cognitive and mental problems, summarised as post-intensive care syndrome (PICS), impacting their health-related quality of life (HRQoL). In what frequency PICS occurs, and to what extent this influences ICU survivors' HRQoL, is mostly unknown. The aims of this study are therefore to study the: (1) 5-year patient outcomes, (2) predictors for PICS, (3) ratio between HRQoL of ICU survivors and healthcare-related costs, and (4) care and support needs. METHODS The MONITOR-IC study is a multicentre prospective controlled cohort study, carried out in ICUs in four Dutch hospitals. Patients will be included between July 2016 and July 2021 and followed for 5 years. We estimated to include 12000 ICU patients. Outcomes are the HRQoL, physical, cognitive and mental symptoms, ICU survivors' care and support needs, healthcare use and related costs. A control cohort of otherwise seriously ill patients will be assembled to compare long-term patient-reported outcomes. We will use a mixed methods design, including questionnaires, medical data from patient records, cost data from health insurance companies and interviews with patients and family members. ETHICS AND DISSEMINATION Insights from this study will be used to inform ICU patients and their family members about long-term consequences of ICU care, and to develop prediction and screening instruments to detect patients at risk for PICS. Subsequently, tailored interventions can be developed and implemented to prevent and mitigate long-term consequences. Additionally, insights into the ratio between HRQoL of ICU patients and related healthcare costs during 5 years after ICU admission can be used to discuss the added value of ICU care from a community perspective. The study has been approved by the research ethics committee of the Radboud University Medical Center (2016-2724). CLINICAL TRIAL REGISTRATION NCT03246334.
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Affiliation(s)
- Wytske Geense
- Department of Intensive Care Medicine, Radboud Institute for Health Science, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marieke Zegers
- Department of Intensive Care Medicine, Radboud Institute for Health Science, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Hester Vermeulen
- Department of IQ Healthcare, Radboud Institute for Health Science, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Mark van den Boogaard
- Department of Intensive Care Medicine, Radboud Institute for Health Science, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Johannes van der Hoeven
- Department of Intensive Care Medicine, Radboud Institute for Health Science, Radboud University Medical Center, Nijmegen, The Netherlands
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Thompson K, Taylor C, Forde K, Hammond N. The evolution of Australian intensive care and its related costs: A narrative review. Aust Crit Care 2017; 31:325-330. [PMID: 28967466 DOI: 10.1016/j.aucc.2017.08.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 08/01/2017] [Accepted: 08/11/2017] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE To conduct a narrative review on the evolution of intensive care and the cost of intensive care services in Australia. REVIEW METHOD A narrative review using a search of online medical databases and grey literature with keyword verification via Delphi-technique. DATA SOURCES Using Medical Subject Headings and keywords (intensive care, critical care, mechanical ventilation, renal replacement therapy, extracorporeal membrane oxygenation, monitoring, staffing, cost, cost analysis) we searched MEDLINE, PubMed, CINAHL, Embase, Google and Google Scholar. RESULTS The search yielded 30 articles from which we provide a narrative synthesis on the evolving intensive care practice in relation to key service elements and therapies. For the review of costs, we found five relevant publications and noted significant variation in methods used to cost ICU. Notwithstanding the limitations of the methods used to cost all publications reported staffing as the primary cost driver, representing up to 71% of costs. CONCLUSION Intensive care is a highly specialised medical field, which has developed rapidly and plays an increasingly important role in the provision of hospital care. Despite the increasing importance of the specialty and the known resource intensity there is a paucity of data on the cost of providing this service. In Australia, staffing costs consistently represent the majority of costs associated with operating an ICU. This finding should be interpreted cautiously given the variation of methods used to cost ICU services and the limited number of available studies. Developing standardised methods to consistently estimate ICU costs which can be incorporated in research into the cost-effectiveness of alternate practice is an important step to ensuring cost-effective care.
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Affiliation(s)
- Kelly Thompson
- Critical Care & Trauma Division, The George Institute for Global Health, Sydney, Australia; School of Public Health and Community Medicine, UNSW, Australia.
| | - Colman Taylor
- Critical Care & Trauma Division, The George Institute for Global Health, Sydney, Australia
| | - Kevin Forde
- School of Public Health and Community Medicine, UNSW, Australia
| | - Naomi Hammond
- Critical Care & Trauma Division, The George Institute for Global Health, Sydney, Australia; Sydney Medical School, University of Sydney, Sydney, Australia; Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, Australia; St. George Clinical School, University of New South Wales, Sydney, Australia
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Lindemark F, Haaland ØA, Kvåle R, Flaatten H, Norheim OF, Johansson KA. Costs and expected gain in lifetime health from intensive care versus general ward care of 30,712 individual patients: a distribution-weighted cost-effectiveness analysis. Crit Care 2017; 21:220. [PMID: 28830479 PMCID: PMC5567919 DOI: 10.1186/s13054-017-1792-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 07/07/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clinicians, hospital managers, policy makers, and researchers are concerned about high costs, increased demand, and variation in priorities in the intensive care unit (ICU). The objectives of this modelling study are to describe the extra costs and expected health gains associated with admission to the ICU versus the general ward for 30,712 patients and the variation in cost-effectiveness estimates among subgroups and individuals, and to perform a distribution-weighted economic evaluation incorporating extra weighting to patients with high severity of disease. METHODS We used a decision-analytic model that estimates the incremental cost per quality-adjusted life year (QALY) gained (ICER) from ICU admission compared with general ward care using Norwegian registry data from 2008 to 2010. We assigned increasing weights to health gains for those with higher severity of disease, defined as less expected lifetime health if not admitted. The study has inherent uncertainty of findings because a randomized clinical trial comparing patients admitted or rejected to the ICU has never been performed. Uncertainty is explored in probabilistic sensitivity analysis. RESULTS The mean cost-effectiveness of ICU admission versus ward care was €11,600/QALY, with 1.6 QALYs gained and an incremental cost of €18,700 per patient. The probability (p) of cost-effectiveness was 95% at a threshold of €22,000/QALY. The mean ICER for medical admissions was €10,700/QALY (p = 97%), €12,300/QALY (p = 93%) for admissions after acute surgery, and €14,700/QALY (p = 84%) after planned surgery. For individualized ICERs, there was a 50% probability that ICU admission was cost-effective for 85% of the patients at a threshold of €64,000/QALY, leaving 15% of the admissions not cost-effective. In the distributional evaluation, 8% of all patients had distribution-weighted ICERs (higher weights to gains for more severe conditions) above €64,000/QALY. High-severity admissions gained the most, and were more cost-effective. CONCLUSIONS On average, ICU admission versus general ward care was cost-effective at a threshold of €22,000/QALY (p = 95%). According to the individualized cost-effectiveness information, one in six ICU admissions was not cost-effective at a threshold of €64,000/QALY. Almost half of these admissions that were not cost-effective can be regarded as acceptable when weighted by severity of disease in terms of expected lifetime health. Overall, existing ICU services represent reasonable resource use, but considerable uncertainty becomes evident when disaggregating into individualized results.
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Affiliation(s)
- Frode Lindemark
- Department of Research and Development, Haukeland University Hospital, Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Øystein A. Haaland
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Reidar Kvåle
- Norwegian Intensive Care Registry, Helse Bergen HF, Bergen, Norway
- Department of Anesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | - Hans Flaatten
- Norwegian Intensive Care Registry, Helse Bergen HF, Bergen, Norway
- Department of Anesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Ole F. Norheim
- Department of Research and Development, Haukeland University Hospital, Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Kjell A. Johansson
- Department of Research and Development, Haukeland University Hospital, Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
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[Cost analysis as a tool for assessing the efficacy of intensive care units]. Med Klin Intensivmed Notfmed 2017. [PMID: 28623434 DOI: 10.1007/s00063-017-0315-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND The German "Hospital Structure Act" intends to align the state hospital planning on quality criteria. Within this process cost-utility analyses (CUAs) shall be used to assess the efficacy of medical care. To be objective, CUAs of intensive care units (ICUs) require standardization (adjustment) of costs. The present study analyzed the extent to which treatment costs are related to patient-specific baseline variables (such as type and severity of the primary disease). METHODS From 2000-2004, a bottom-up procedure was used to quantify total costs on 14 ICUs in nine German university hospitals. Results were combined with demographic data, and data indicating type (ICD-10 codes) and severity (ICU scoring systems) of the primary disease at ICU admission. Various statistical models were tested to identify that which best described the associations between baseline variables and costs. RESULTS In all, 3803 critically ill patients could be examined. The median of treatment costs per patient was 3199 € (IQR 1768-6659 €). No model allowed an acceptably precise adjustment of costs; the estimated mean absolute prognostic error was at least 3860 € (mean relative prognostic error 66%), when we tested an Extreme Gradient Boosting Model. CONCLUSION Instruments which are currently available (cost adjustment based on patient-specific baseline variables) do not allow a standardization of costs, and an objective CUA of ICUs. Factors unknown at baseline may cause a large portion of treatment costs.
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Continuous Mandatory Onsite Consultant Intensivists in the ICU: Impacts on Patient Outcomes. J Patient Saf 2017; 12:108-13. [PMID: 24618645 DOI: 10.1097/pts.0000000000000097] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to compare the impacts on patient outcomes of continuous versus on-demand access to certified consultant intensivists in the intensive care unit (ICU). METHODS Two general adult ICUs within the same health-care organization were compared in terms of patient outcomes. One unit featured continuous mandatory presence of a consultant intensivist (unit A), whereas the other had continuous access to a consultant intensivist during daytime hours but only on-demand access during the night-time hours (unit B). The data collected from these 2 units over the same 12-month period included sex, age, APACHE II score, disease category (medical, surgical, or traumatic), ICU mortality, and length of stay. A subgroup analysis was undertaken to assess the impact of disease severity, age, sex, and disease category on mortality. RESULTS When adjusted for disease severity, mortality was significantly lower in unit A with continuous mandatory 24-hour presence of a consultant intensivist compared with unit B with on-demand access to a consultant intensivist after working hours. Old age, female sex, and a higher APACHE II score were associated with poorer outcomes at both sites. The subgroup analysis revealed that the difference in mortality was only significant among medical patients but not among surgical or trauma patients. CONCLUSIONS An improved survival rate was observed only among medical patients admitted to the ICU with mandatory continuous access to a consultant intensivist, despite the presence of greater disease severity in the population admitted to this unit.
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Can Sarcopenia Quantified by Ultrasound of the Rectus Femoris Muscle Predict Adverse Outcome of Surgical Intensive Care Unit Patients as well as Frailty? A Prospective, Observational Cohort Study. Ann Surg 2017; 264:1116-1124. [PMID: 26655919 DOI: 10.1097/sla.0000000000001546] [Citation(s) in RCA: 143] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To compare sarcopenia and frailty for outcome prediction in surgical intensive care unit (SICU) patients. BACKGROUND Frailty has been associated with adverse outcomes and describes a status of muscle weakness and decreased physiological reserve leading to increased vulnerability to stressors. However, frailty assessment depends on patient cooperation. Sarcopenia can be quantified by ultrasound and the predictive value of sarcopenia at SICU admission for adverse outcome has not been defined. METHODS We conducted a prospective, observational study of SICU patients. Sarcopenia was diagnosed by ultrasound measurement of rectus femoris cross-sectional area. Frailty was diagnosed by the Frailty Index Questionnaire based on 50 variables. Relationship between variables and outcomes was assessed by multivariable regression analysis NCT02270502. RESULTS Sarcopenia and frailty were quantified in 102 patients and observed in 43.1% and 38.2%, respectively. Sarcopenia predicted adverse discharge disposition (discharge to nursing facility or in-hospital mortality, odds ratio 7.49; 95% confidence interval 1.47-38.24; P = 0.015) independent of important clinical covariates, as did frailty (odds ratio 8.01; 95% confidence interval 1.82-35.27; P = 0.006); predictive ability did not differ between sarcopenia and frailty prediction model, reflected by χ values of 21.74 versus 23.44, respectively, and a net reclassification improvement (NRI) of -0.02 (P = 0.87). Sarcopenia and frailty predicted hospital length of stay and the frailty model had a moderately better predictive accuracy for this outcome. CONCLUSIONS Bedside diagnosis of sarcopenia by ultrasound predicts adverse discharge disposition in SICU patients equally well as frailty. Sarcopenia assessed by ultrasound may be utilized as rapid beside modality for risk stratification of critically ill patients.
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Jiang C, Esquinas A, Mina B. Evaluation of cough peak expiratory flow as a predictor of successful mechanical ventilation discontinuation: a narrative review of the literature. J Intensive Care 2017; 5:33. [PMID: 28588895 PMCID: PMC5457577 DOI: 10.1186/s40560-017-0229-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 05/23/2017] [Indexed: 11/19/2022] Open
Abstract
A crucial step in the transition from mechanical ventilation to extubation is the successful performance of a spontaneous breathing trial (SBT). The American College of Chest Physicians (ACCP) Guidelines recommend removal of the endotracheal tube upon successful completion of a SBT. However, this does not guarantee successful extubation as there remains a risk of re-intubation. Guidelines have outlined ventilator liberation protocols, selected use of non-invasive ventilation on extubation, early mobilization, and dynamic ventilator metrics to prevent and better predict extubation failure. However, a significant percentage of patients still fail mechanical ventilation discontinuation. A common reason for re-intubation is having a weak cough strength, which reflects the inability to protect the airway. Evaluation of cough strength via objective measures using peak expiratory flow rate is a non-invasive and easily reproducible assessment which can predict extubation failure. We conducted a narrative review of the literature regarding use of cough strength as a predictive index for extubation failure risk. Results of our review show that cough strength, quantified objectively with a cough peak expiratory flow measurement (CPEF), is strongly associated with extubation success. Furthermore, various cutoff thresholds have been identified and can provide reasonable diagnostic accuracy and predictive power for extubation failure. These results demonstrate that measurement of the CPEF can be a useful tool to predict extubation failure in patients on MV who have passed a SBT. In addition, the data suggest that this diagnostic modality may reduce ICU length of stay, ICU expenditures, and morbidity and mortality.
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Affiliation(s)
- Chuan Jiang
- Department of Medicine, Northwell Health, Lenox Hill Hospital, New York, NY USA
| | - Antonio Esquinas
- Intensive Care and Non-Invasive Ventilatory Unit, Hospital Morales Meseguer, Murcia, Spain
| | - Bushra Mina
- Department of Medicine, Pulmonary and Critical Care Medicine, Northwell Health, Lenox Hill Hospital, New York, NY USA
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Lee FA, Hervey AM, Berg GM, Acuna DL, Harrison PB. Association of Injury Factors, Not Body Mass Index, With Hospital Resource Usage in Trauma Patients. Am J Crit Care 2016; 25:327-34. [PMID: 27369031 DOI: 10.4037/ajcc2016665] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Allocating resources appropriately requires knowing whether obese patients use more resources during a hospital stay than nonobese patients. OBJECTIVES To determine if trauma patients with different body mass indexes differed in use of resources measured as a multifaceted outcome variable. METHODS A trauma registry was used for a retrospective study of adult patients admitted to a midwestern level I trauma center. Patients were stratified into 3 groups: nonobese (normal weight, overweight), obese, and morbidly obese. Three canonical correlation analyses were used to determine the relationship between patient/injury characteristics and hospital resource usage. RESULTS In a sample of 9771 patients, 71.2% were non-obese, 23.8% obese, and 5.0% morbidly obese. For patient/injury characteristics, Injury Severity Score and physiological complications were significant variables for all 3 groups. Scores on the Glasgow Coma Scale were significant for nonobese patients only. For resource usage, intensive care unit length of stay and procedures were significant variables for all 3 groups. CONCLUSIONS Associations between body mass index and outcomes have been noted when assessed as independent variables. However, when resource usage was assessed as a multifaceted outcome variable, injury factors (higher Injury Severity Score, lower scores on the Glasgow Coma Scale, more physiological complications) were associated with resource usage (increased length of stay in the intensive care unit and increased number of procedures). These findings provide clinicians a new perspective for evaluating the complex relationship between patient/injury characteristics and hospital resource usage.
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Affiliation(s)
- Felecia A. Lee
- Felecia A. Lee is a research assistant professor and Ashley M. Hervey is a teaching associate, Department of Family and Community Medicine, University of Kansas School of Medicine–Wichita, Wichita, Kansas. Gina M. Berg is director of trauma research, David L. Acuna is the trauma medical director, and Paul B. Harrison is assistant medical director, Wesley Medical Center, Trauma Services, Wichita, Kansas
| | - Ashley M. Hervey
- Felecia A. Lee is a research assistant professor and Ashley M. Hervey is a teaching associate, Department of Family and Community Medicine, University of Kansas School of Medicine–Wichita, Wichita, Kansas. Gina M. Berg is director of trauma research, David L. Acuna is the trauma medical director, and Paul B. Harrison is assistant medical director, Wesley Medical Center, Trauma Services, Wichita, Kansas
| | - Gina M. Berg
- Felecia A. Lee is a research assistant professor and Ashley M. Hervey is a teaching associate, Department of Family and Community Medicine, University of Kansas School of Medicine–Wichita, Wichita, Kansas. Gina M. Berg is director of trauma research, David L. Acuna is the trauma medical director, and Paul B. Harrison is assistant medical director, Wesley Medical Center, Trauma Services, Wichita, Kansas
| | - David L. Acuna
- Felecia A. Lee is a research assistant professor and Ashley M. Hervey is a teaching associate, Department of Family and Community Medicine, University of Kansas School of Medicine–Wichita, Wichita, Kansas. Gina M. Berg is director of trauma research, David L. Acuna is the trauma medical director, and Paul B. Harrison is assistant medical director, Wesley Medical Center, Trauma Services, Wichita, Kansas
| | - Paul B. Harrison
- Felecia A. Lee is a research assistant professor and Ashley M. Hervey is a teaching associate, Department of Family and Community Medicine, University of Kansas School of Medicine–Wichita, Wichita, Kansas. Gina M. Berg is director of trauma research, David L. Acuna is the trauma medical director, and Paul B. Harrison is assistant medical director, Wesley Medical Center, Trauma Services, Wichita, Kansas
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Biskup T, Phan P, Grunauer M. Lessons from the Design and Implementation of a Pediatric Critical Care and Emergency Medicine Training Program in a Low Resource Country-The South American Experience. J Pediatr Intensive Care 2016; 6:60-65. [PMID: 31073426 DOI: 10.1055/s-0036-1584678] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 02/15/2016] [Indexed: 10/21/2022] Open
Abstract
For more than 60 years, the world has recognized the need for pediatric critical care (PCC). Today, most low- and middle-income countries (LMICs) still lack access to pediatric intensive care units (PICUs) and specialists, resulting in high rates of morbidity and mortality. These disparities result from several infrastructure and socioeconomic factors, chief among them being the lack of trained PCC and emergency medicine (PCCEM) frontline providers. In this article, we describe a continuing medical education model to increase frontline PCC capacity in Ecuador. The Laude in PCCEM is a program created by a team of Ecuadorian physicians at the University San Francisco de Quito School of Medicine. The program is aimed at providers with no formal training in PCC and who, nonetheless, care for critically ill children. The program resulted in stronger, more cohesive PICU teams with improved resuscitation times and coordination during simulation rounds. In hospitals that implemented the program, we saw decreased PICU mortality rates. Our aim is to identify the opportunities and challenges learned and to offer lessons for other countries that use similar models to cope with the lack of local resource availability.
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Affiliation(s)
- Toni Biskup
- Department of Pediatrics, Universidad San Francisco de Quito Medical School, Cumbayá, Ecuador.,Hospital de los Valles, Ecuador
| | - Phillip Phan
- The Johns Hopkins Carey Business School, Baltimore, Maryland, United States.,Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, United States
| | - Michelle Grunauer
- Department of Pediatrics, Universidad San Francisco de Quito Medical School, Cumbayá, Ecuador.,Hospital de los Valles, Ecuador.,The Johns Hopkins Carey Business School, Baltimore, Maryland, United States
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Faulhaber-Walter R, Scholz S, Haller H, Kielstein JT, Hafer C. Health status, renal function, and quality of life after multiorgan failure and acute kidney injury requiring renal replacement therapy. Int J Nephrol Renovasc Dis 2016; 9:119-28. [PMID: 27284261 PMCID: PMC4883815 DOI: 10.2147/ijnrd.s89128] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Critically ill patients with acute kidney injury (AKI) in need of renal replacement therapy (RRT) may have a protracted and often incomplete rehabilitation. Their long-term outcome has rarely been investigated. Study design Survivors of the HANnover Dialysis OUTcome (HANDOUT) study were evaluated after 5 years for survival, health status, renal function, and quality of life (QoL). The HANDOUT study had examinded mortality and renal recovery of patients with AKI receiving either standard extendend or intensified dialysis after multi organ failure. Results One hundred fifty-six former HANDOUT participants were analyzed. In-hospital mortality was 56.4%. Five-year survival after AKI/RRT was 40.1% (86.5% if discharged from hospital). Main causes of death were cardiovascular complications and sepsis. A total of 19 survivors presented to the outpatient department of our clinic and had good renal recovery (mean estimated glomerular filtration rate 72.5±30 mL/min/1.73 m2; mean proteinuria 89±84 mg/d). One person required maintenance dialysis. Seventy-nine percent of the patients had a pathological kidney sonomorphology. The Charlson comorbidity score was 2.2±1.4 and adjusted for age 3.3±2.1 years. Numbers of comorbid conditions averaged 2.38±1.72 per patient (heart failure [52%] > chronic kidney disease/myocardial infarction [each 29%]). Median 36-item short form health survey (SF-36™) index was 0.657 (0.69 physical health/0.66 mental health). Quality-adjusted life-years after 5 years were 3.365. Conclusion Mortality after severe AKI is higher than short-term prospective studies show, and morbidity is significant. Kidney recovery as well as general health remains incomplete. Reduction of QoL is minor, and social rehabilitation is very good. Affectivity is heterogeneous, but most patients experience emotional well-being. In summary, AKI in critically ill patients leads to incomplete rehabilitation but acceptable QoL after 5 years.
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Affiliation(s)
- Robert Faulhaber-Walter
- Department of Renal and Hypertensive Disease, Medical School Hannover, Hannover, Germany; Facharztzentrum Aarberg, Waldshut-Tiengen, Germany
| | - Sebastian Scholz
- Department of Renal and Hypertensive Disease, Medical School Hannover, Hannover, Germany; Sanitaetsversorgungszentrum Wunstorf, Wunstorf, Germany
| | - Herrmann Haller
- Department of Renal and Hypertensive Disease, Medical School Hannover, Hannover, Germany
| | - Jan T Kielstein
- Department of Renal and Hypertensive Disease, Medical School Hannover, Hannover, Germany
| | - Carsten Hafer
- Department of Renal and Hypertensive Disease, Medical School Hannover, Hannover, Germany; HELIOS Klinikum Erfurt, Erfurt, Germany
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Persad GC. Expanding Deliberation in Critical-Care Policy Design. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2016; 16:60-63. [PMID: 26734753 DOI: 10.1080/15265161.2015.1115566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Cost awareness of physicians in intensive care units: a multicentric national study. Intensive Care Med 2015; 41:1402-10. [PMID: 26077058 DOI: 10.1007/s00134-015-3859-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 05/01/2015] [Indexed: 01/02/2023]
Abstract
PURPOSE Physicians play an important role in strategies to control health care spending. Being aware of the cost of prescriptions is surely the first step to incorporating cost-consciousness into medical practice. The aim of this study was to evaluate current intensivists' knowledge of the costs of common prescriptions and to identify factors influencing the accuracy of cost estimations. METHODS Junior and senior physicians in 99 French intensive care units were asked, by questionnaire, to estimate the true hospital costs of 46 selected prescriptions commonly used in critical care practice. RESULTS With an 83% response rate, 1092 questionnaires were examined, completed by 575 (53%) and 517 (47%) junior and senior intensivists, respectively. Only 315 (29%) of the overall estimates were within 50% of the true cost. Response errors included a 14,756 ± 301 € underestimation, i.e., -58 ± 1% of the total sum (25,595 €). High-cost drugs (>1000 €) were significantly (p < 0.001) the most underestimated prescriptions (-67 ± 1%). Junior grade physicians underestimated more costs than senior physicians (p < 0.001). Using multivariate analysis, junior physicians [odds ratio (OR), 2.1; 95% confidence interval (95% CI), 1.43-3.08; p = 0.0002] and female gender (OR, 1.4; 95% CI, 1.04-1.89; p = 0.02) were both independently associated with incorrect cost estimations. CONCLUSIONS ICU physicians have a poor awareness of prescriptions costs, especially with regards to high-cost drugs. Considerable emphasis and effort are still required to integrate the cost-containment problem into the daily prescriptions in ICUs.
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Abstract
BACKGROUND Focused cardiac ultrasound (FoCUS) is a simplified, clinician-performed application of echocardiography that is rapidly expanding in use, especially in emergency and critical care medicine. Performed by appropriately trained clinicians, typically not cardiologists, FoCUS ascertains the essential information needed in critical scenarios for time-sensitive clinical decision making. A need exists for quality evidence-based review and clinical recommendations on its use. METHODS The World Interactive Network Focused on Critical UltraSound conducted an international, multispecialty, evidence-based, methodologically rigorous consensus process on FoCUS. Thirty-three experts from 16 countries were involved. A systematic multiple-database, double-track literature search (January 1980 to September 2013) was performed. The Grading of Recommendation, Assessment, Development and Evaluation method was used to determine the quality of available evidence and subsequent development of the recommendations. Evidence-based panel judgment and consensus was collected and analyzed by means of the RAND appropriateness method. RESULTS During four conferences (in New Delhi, Milan, Boston, and Barcelona), 108 statements were elaborated and discussed. Face-to-face debates were held in two rounds using the modified Delphi technique. Disagreement occurred for 10 statements. Weak or conditional recommendations were made for two statements and strong or very strong recommendations for 96. These recommendations delineate the nature, applications, technique, potential benefits, clinical integration, education, and certification principles for FoCUS, both for adults and pediatric patients. CONCLUSIONS This document presents the results of the first International Conference on FoCUS. For the first time, evidence-based clinical recommendations comprehensively address this branch of point-of-care ultrasound, providing a framework for FoCUS to standardize its application in different clinical settings around the world.
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Lee J, Geyer B, Naraghi L, Kaafarani HMA, Eikermann M, Yeh DD, Bajwa EK, Cobb JP, Raja AS. Advanced imaging use in intensive care units has decreased, resulting in lower charges without negative effects on patient outcomes. J Crit Care 2014; 30:460-4. [PMID: 25596998 DOI: 10.1016/j.jcrc.2014.12.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Revised: 12/15/2014] [Accepted: 12/18/2014] [Indexed: 12/22/2022]
Abstract
PURPOSE There has been both greater recognition and scrutiny of the increased use of advanced imaging. Our aim was to determine whether there has been a change over time in the use of computed tomography (CT), magnetic resonance imaging (MRI), ultrasound (US) modalities in the intensive care units (ICUs). MATERIALS AND METHODS A retrospective review of 75657 admissions to 20 ICUs was conducted. Results were analyzed with multivariate linear, negative binomial, and Poisson regressions. Primary outcomes were rates of use of CT, MRI, and US per 1000 ICU admissions every 6 months. Secondary outcomes were changes in radiology use associated with impacts on mortality, hospital length of stay (LOS), ICU LOS, and hospital charges. RESULTS The rate of imaging use decreased by 13.5% between 2007 and 2011 (incidence rate ratio [IRR], 0.982; P < .001). Most of this decrease was by CTs (21.0%; IRR, 0.973; P < .001). Use of MRI decreased by 6.0% (IRR, 0.991; P = .04), whereas US increased by 18.9% (IRR, 1.012; P < .001). The charges associated with imaging decreased by $74 per ICU admission, which would save an estimated $1.2 million in charges during 2011. Decreased imaging was not associated with changes in mortality, hospital, and ICU LOS. CONCLUSION Advanced imaging use decreased for 5 years in the ICUs, resulting in decreased charges without negative effects on patient outcomes.
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Affiliation(s)
- Jarone Lee
- Departments of Surgery and Emergency Medicine, Massachusetts General Hospital & Harvard Medical School, Boston, MA.
| | - Brian Geyer
- Department of Emergency Medicine, Brigham and Women's Hospital and Massachusetts General Hospital, Boston, MA.
| | - Leily Naraghi
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital & Harvard Medical School, Boston, MA.
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital & Harvard Medical School, Boston, MA.
| | - Matthias Eikermann
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital & Harvard Medical School, Boston, MA.
| | - D Dante Yeh
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital & Harvard Medical School, Boston, MA.
| | - Ednan K Bajwa
- Department of Pulmonary and Critical Care Medicine, Massachusetts General Hospital & Harvard Medical School, Boston, MA.
| | - J Perren Cobb
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital & Harvard Medical School, Boston, MA.
| | - Ali S Raja
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA.
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Hutter MF, Rodríguez-Ibeas R, Antonanzas F. Methodological reviews of economic evaluations in health care: what do they target? THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2014; 15:829-840. [PMID: 23974963 DOI: 10.1007/s10198-013-0527-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Accepted: 08/06/2013] [Indexed: 06/02/2023]
Abstract
INTRODUCTION AND OBJECTIVES An increasing number of published studies of economic evaluations of health technologies have been reviewed and summarized with different purposes, among them to facilitate decision-making processes. These reviews have covered different aspects of economic evaluations, using a variety of methodological approaches. The aim of this study is to analyze the methodological characteristics of the reviews of economic evaluations in health care, published during the period 1990-2010, to identify their main features and the potential missing elements. This may help to develop a common procedure for elaborating these kinds of reviews. METHODS We performed systematic searches in electronic databases (Scopus, Medline and PubMed) of methodological reviews published in English, period 1990-2010. We selected the articles whose main purpose was to review and assess the methodology applied in the economic evaluation studies. We classified the data according to the study objectives, period of the review, number of reviewed studies, methodological and non-methodological items assessed, medical specialty, type of disease and technology, databases used for the review and their main conclusions. We performed a descriptive statistical analysis and checked how generalizability issues were considered in the reviews. RESULTS We identified 76 methodological reviews, 42 published in the period 1990-2001 and 34 during 2002-2010. The items assessed most frequently (by 70% of the reviews) were perspective, type of economic study, uncertainty and discounting. The reviews also described the type of intervention and disease, funding sources, country in which the evaluation took place, type of journal and author's characteristics. Regarding the intertemporal comparison, higher frequencies were found in the second period for two key methodological items: the source of effectiveness data and the models used in the studies. However, the generalizability issues that apparently are creating a growing interest in the economic evaluation literature did not receive as much attention in the reviews of the second period. The remaining items showed similar frequencies in both periods. CONCLUSIONS Increasingly more reviews of economic evaluation studies aim to analyze the application of methodological principles, and offer summaries of papers classified by either diseases or health technologies. These reviews are useful for finding literature trends, aims of studies and possible deficiencies in the implementation of methods of specific health interventions. As no significant methodological improvement was clearly detected in the two periods analyzed, it would be convenient to pay more attention to the methodological aspects of the reviews.
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Maron BJ, Friedman RA, Kligfield P, Levine BD, Viskin S, Chaitman BR, Okin PM, Saul JP, Salberg L, Van Hare GF, Soliman EZ, Chen J, Matherne GP, Bolling SF, Mitten MJ, Caplan A, Balady GJ, Thompson PD. Assessment of the 12-Lead ECG as a Screening Test for Detection of Cardiovascular Disease in Healthy General Populations of Young People (12–25 Years of Age). Circulation 2014; 130:1303-34. [DOI: 10.1161/cir.0000000000000025] [Citation(s) in RCA: 158] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Maron BJ, Friedman RA, Kligfield P, Levine BD, Viskin S, Chaitman BR, Okin PM, Saul JP, Salberg L, Van Hare GF, Soliman EZ, Chen J, Matherne GP, Bolling SF, Mitten MJ, Caplan A, Balady GJ, Thompson PD. Assessment of the 12-lead electrocardiogram as a screening test for detection of cardiovascular disease in healthy general populations of young people (12-25 years of age): a scientific statement from the American Heart Association and the American College of Cardiology. J Am Coll Cardiol 2014; 64:1479-514. [PMID: 25234655 DOI: 10.1016/j.jacc.2014.05.006] [Citation(s) in RCA: 140] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Greenberg D, Neumann PJ. Does adjusting for health-related quality of life matter in economic evaluations of cancer-related interventions? Expert Rev Pharmacoecon Outcomes Res 2014; 11:113-9. [DOI: 10.1586/erp.11.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Chandra S, Chong DH. New cost-effective treatment strategies for acute emergency situations. Annu Rev Med 2013; 65:459-69. [PMID: 24160941 DOI: 10.1146/annurev-med-060112-095857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
In an era of ever-increasing healthcare costs, new treatments must not only improve outcomes and quality of care but also be cost-effective. This is most challenging for emergency and critical care. Bigger and better has been the mantra of Western medical care for decades, leading to costlier but not necessarily better care. Recent advances focused on new implementation processes for evidence-based best practices such as checklists and bundles have transformed medical care. We outline recent advances in medical practice that have positively affected both the quality of care and its cost-effectiveness. Future medical care must be smarter and more effective if we are to meet the increasing demands of an aging patient population in the context of ever more limited resources.
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Affiliation(s)
- Subani Chandra
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care, Columbia University College of Physicians and Surgeons, New York, New York 10032; ,
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Healthcare resource utilization and costs after critical illness: current knowledge and a plan for moving forward*. Crit Care Med 2013; 41:2030-1. [PMID: 23863233 DOI: 10.1097/ccm.0b013e31828e8edc] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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