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Byard RW, Tan L. Changing diagnostic patterns in cases of sudden and unexpected natural death in infants and young children: 1994-2018. Acta Paediatr 2023; 112:1236-1239. [PMID: 36635214 DOI: 10.1111/apa.16669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 12/26/2022] [Accepted: 01/10/2023] [Indexed: 01/14/2023]
Abstract
AIM To determine whether there has been a change in the incidence and type of conditions causing sudden and unexpected natural death in infants and young children in recent years. METHODS A search was undertaken of pathology records at Forensic Science SA in Adelaide, Australia for all cases of sudden and unexpected natural death in children aged less than 10 years at the time of death over two time periods: 1994-1998 and 2014-2018. RESULTS Overall, 136 cases were identified consisting of 81 boys and 55 girls (M:F = 16:11; age range 0-9 years). No difference was shown in the numbers of sudden unexplained deaths in infants and young children between the two time periods (80 vs. 56; p = 0.18). A trend was shown for a prominent decrease in SIDS cases (55 vs. 12) with an increase in undetermined cases, <1 year (5 vs. 18). However, when the two categories were combined there was no statistical difference between the two periods (60/80 vs. 30/56) (p = 0.26), although a decrease in numbers had occurred. CONCLUSION Analysis of numbers of fatalities reported from medicolegal institutes should be undertaken with an awareness of the potential effect of diagnostic shift.
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Affiliation(s)
- Roger W Byard
- School of Biomedicine, The University of Adelaide, Adelaide, South Australia, Australia.,Forensic Science South Australia, Adelaide, South Australia, Australia
| | - Luzern Tan
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
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Tan L, Byard RW. An analysis of the use of standard SIDS definitions in the English language literature over a three-year period (2019-2021). Acta Paediatr 2022; 111:1019-1022. [PMID: 35067982 DOI: 10.1111/apa.16266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 01/11/2022] [Accepted: 01/20/2022] [Indexed: 11/26/2022]
Abstract
AIM To evaluate the use of the three standard definitions of sudden infant death syndrome (SIDS) in the contemporary literature. METHODS A search was undertaken of the US National Library of Medicine 'PubMed' database for all research articles listed under 'sudden infant death syndrome' or 'SIDS', from 2019 to 2021 accessible through the University of Adelaide library. RESULTS 564 papers had keywords 'sudden infant death syndrome' or 'SIDS'. 300 papers were not included in the study as they were not written in English, SIDS was not the primary focus, publishing was in predatory journals, or they were Letters to the Editor, commentaries, technical reports, reviews or editorials. The remaining 264 papers consisted of 172 papers without a standard definition, including reports without definitions, with idiosyncratic or incorrectly quoted definitions or with incorrect referencing (65%), and 92 with one of the three standard definitions either quoted in full in the text or correctly referenced (35%). CONCLUSION Nearly two-thirds of peer-reviewed publications on SIDS listed on PubMed over the past three years have not quoted or referenced accepted definitions. Interpreting research conclusions and monitoring trends in SIDS mortality will be extremely difficult if different population subgroups are being targeted by different research groups.
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Affiliation(s)
- Luzern Tan
- Adelaide Medical School The University of Adelaide Adelaide SA Australia
| | - Roger W. Byard
- Adelaide Medical School The University of Adelaide Adelaide SA Australia
- Forensic Science South Australia Adelaide SA Australia
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Abstract
ABSTRACTIntroductionThis paper assesses the total medical costs associated with the US anthrax letter attacks of 2001. This information can be used to inform policies, which may help mitigate the potential economic impacts of similar bioterrorist attacks. METHODS Journal publications and news reports were reviewed to establish the number of people who were exposed, were potentially exposed, received prophylactics, and became ill. Where available, cost data from the anthrax letter attacks were used. Where data were unavailable, high, low, and best cost estimates were developed from the broader literature to create a cost model and establish economic impacts. RESULTS Medical spending totaled approximately $177 million. CONCLUSIONS The largest expenditures stemmed from self-initiated prophylaxis (worried well): people who sought prophylactic treatment without any indication that they had been exposed to anthrax letters. This highlights an area of focus for mitigating the economic impacts of future disasters. (Disaster Med Public Health Preparedness. 2019;13:539-546).
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Wheeler DS, Stalets EL. A day in the life. Transl Pediatr 2018; 7:242-245. [PMID: 30460174 PMCID: PMC6212388 DOI: 10.21037/tp.2018.09.07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Derek S Wheeler
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Erika L Stalets
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Wheeler DS, Dewan M, Maxwell A, Riley CL, Stalets EL. Staffing and workforce issues in the pediatric intensive care unit. Transl Pediatr 2018; 7:275-283. [PMID: 30460179 PMCID: PMC6212383 DOI: 10.21037/tp.2018.09.05] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
The health care industry is in the midst of incredible change, and unfortunately, change is not easy. The intensive care unit (ICU) plays a critical role in the overall delivery of care to patients in the hospital. Care in the ICU is expensive. One of the best ways of improving the value of care delivered in the ICU is to focus greater attention on the needs of the critical care workforce. Herein, we highlight three major areas of concern-the changing model of care delivery outside of the traditional four walls of the ICU, the need for greater diversity in the pediatric critical care workforce, and the widespread problem of professional burnout and its impact on patient care.
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Affiliation(s)
- Derek S Wheeler
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Maya Dewan
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Andrea Maxwell
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Carley L Riley
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Erika L Stalets
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Verburg IW, Holman R, Dongelmans D, de Jonge E, de Keizer NF. Is patient length of stay associated with intensive care unit characteristics? J Crit Care 2018; 43:114-121. [DOI: 10.1016/j.jcrc.2017.08.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 07/24/2017] [Accepted: 08/08/2017] [Indexed: 11/15/2022]
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Byard RW. Issues with suicide databases in forensic research. Forensic Sci Med Pathol 2017; 13:401-402. [DOI: 10.1007/s12024-017-9859-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2017] [Indexed: 10/20/2022]
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Critical Care Medicine Beds, Use, Occupancy, and Costs in the United States: A Methodological Review. Crit Care Med 2016; 43:2452-9. [PMID: 26308432 DOI: 10.1097/ccm.0000000000001227] [Citation(s) in RCA: 103] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This article is a methodological review to help the intensivist gain insights into the classic and sometimes arcane maze of national databases and methodologies used to determine and analyze the ICU bed supply, use, occupancy, and costs in the United States. Data for total ICU beds, use, and occupancy can be derived from two large national healthcare databases: the Healthcare Cost Report Information System maintained by the federal Centers for Medicare and Medicaid Services and the proprietary Hospital Statistics of the American Hospital Association. Two costing methodologies can be used to calculate U.S. ICU costs: the Russell equation and national projections. Both methods are based on cost and use data from the national hospital datasets or from defined groups of hospitals or patients. At the national level, an understanding of U.S. ICU bed supply, use, occupancy, and costs helps provide clarity to the width and scope of the critical care medicine enterprise within the U.S. healthcare system. This review will also help the intensivist better understand published studies on administrative topics related to critical care medicine and be better prepared to participate in their own local hospital organizations or regional critical care medicine programs.
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Sjoding MW, Valley TS, Prescott HC, Wunsch H, Iwashyna TJ, Cooke CR. Rising Billing for Intermediate Intensive Care among Hospitalized Medicare Beneficiaries between 1996 and 2010. Am J Respir Crit Care Med 2016; 193:163-70. [PMID: 26372779 PMCID: PMC4731714 DOI: 10.1164/rccm.201506-1252oc] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 09/15/2015] [Indexed: 12/31/2022] Open
Abstract
RATIONALE Intermediate care (i.e., step-down or progressive care) is an alternative to the intensive care unit (ICU) for patients with moderate severity of illness. The adoption and current use of intermediate care is unknown. OBJECTIVES To characterize trends in intermediate care use among U.S. hospitals. METHODS We examined 135 million acute care hospitalizations among elderly individuals (≥65 yr) enrolled in fee-for-service Medicare (U.S. federal health insurance program) from 1996 to 2010. We identified patients receiving intermediate care as those with intensive care or coronary care room and board charges labeled intermediate ICU. MEASUREMENTS AND MAIN RESULTS In 1996, a total of 960 of the 3,425 hospitals providing critical care billed for intermediate care (28%), and this increased to 1,643 of 2,783 hospitals (59%) in 2010 (P < 0.01). Only 8.2% of Medicare hospitalizations in 1996 were billed for intermediate care, but billing steadily increased to 22.8% by 2010 (P < 0.01), whereas the percentage billed for ICU care and ward-only care declined. Patients billed for intermediate care had more acute organ failures diagnoses codes compared with general ward patients (22.4% vs. 15.8%). When compared with patients billed for ICU care, those billed for intermediate care had fewer organ failures (22.4% vs. 43.4%), less mechanical ventilation (0.9% vs. 16.7%), lower mean Medicare spending ($8,514 vs. $18,150), and lower 30-day mortality (5.6% vs. 16.5%) (P < 0.01 for all comparisons). CONCLUSIONS Intermediate care billing increased markedly between 1996 and 2010. These findings highlight the need to better define the value, specific practices, and effective use of intermediate care for patients and hospitals.
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Affiliation(s)
- Michael W. Sjoding
- The Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, and
| | - Thomas S. Valley
- The Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, and
| | - Hallie C. Prescott
- The Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, and
- Institute for Healthcare Innovation and Policy, University of Michigan, Ann Arbor, Michigan
- VA Center for Clinical Management Research, Ann Arbor, Michigan
| | - Hannah Wunsch
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Anesthesia and Interdisciplinary Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Theodore J. Iwashyna
- The Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, and
- VA Center for Clinical Management Research, Ann Arbor, Michigan
- Institute for Social Research, Ann Arbor, Michigan; and
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Colin R. Cooke
- The Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, and
- Institute for Healthcare Innovation and Policy, University of Michigan, Ann Arbor, Michigan
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A Changing Workforce for the Changing Needs of Critically Ill Children in the United States and Canada. Pediatr Crit Care Med 2015; 16:791-2. [PMID: 26427817 DOI: 10.1097/pcc.0000000000000485] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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11
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Do you know how much it costs? Intensive Care Med 2015; 41:1454-6. [DOI: 10.1007/s00134-015-3911-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 06/03/2015] [Indexed: 10/23/2022]
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Wallace DJ, Angus DC, Seymour CW, Barnato AE, Kahn JM. Critical care bed growth in the United States. A comparison of regional and national trends. Am J Respir Crit Care Med 2015; 191:410-6. [PMID: 25522054 DOI: 10.1164/rccm.201409-1746oc] [Citation(s) in RCA: 121] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
RATIONALE Although the number of intensive care unit (ICU) beds in the United States is increasing, it is unknown whether this trend is consistent across all regions. OBJECTIVES We sought to better characterize regional variation in ICU bed changes over time and identify regional characteristics associated with these changes. METHODS We used data from the Centers for Medicare and Medicaid Services and the U.S. Census to summarize the numbers of hospitals, hospital beds, ICU beds, and ICU occupancy at the level of Dartmouth Atlas hospital referral region from 2000 to 2009. We categorized regions into quartiles of bed change over the study interval and examined the relationship between change categories, regional characteristics, and population characteristics over time. MEASUREMENTS AND MAIN RESULTS From 2000 to 2009 the national number of ICU beds increased 15%, from 67,579 to 77,809, mirroring population. However, there was substantial regional variation in absolute changes (median, +16 ICU beds; interquartile range, -3 to +51) and population-adjusted changes (median, +0.9 ICU beds per 100,000; interquartile range, -3.8 to +5.9), with 25.0% of regions accounting for 74.8% of overall growth. At baseline, regions with increasing numbers of ICU beds had larger populations, lower ICU beds per 100,000 capita, higher average ICU occupancy, and greater market competition as measured by the Herfindahl-Hirschman Index (P < 0.001 for all comparisons). CONCLUSIONS National trends in ICU bed growth are not uniformly reflected at the regional level, with most growth occurring in a small number of highly populated regions.
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Affiliation(s)
- David J Wallace
- 1 Clinical Research, Investigation and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine
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13
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Abstract
The past 50 years have witnessed the emergence and evolution of the modern pediatric ICU and the specialty of pediatric critical care medicine. ICUs have become key in the delivery of health care services. The patient population within pediatric ICUs is diverse. An assortment of providers, including intensivists, trainees, physician assistants, nurse practitioners, and hospitalists, perform a variety of roles. The evolution of critical care medicine also has seen the rise of critical care nursing and other critical care staff collaborating in multidisciplinary teams. Delivery of optimal critical care requires standardized, reliable, and evidence-based processes, such as bundles, checklists, and formalized communication processes.
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Abstract
OBJECTIVE Interhospital transfer of critically ill patients is a common part of their care. This article sought to review the data on the current patterns of use of interhospital transfer and identify systematic barriers to optimal integration of transfer as a mechanism for improving patient outcomes and value of care. DATA SOURCE Narrative review of medical and organizational literature. SUMMARY Interhospital transfer of patients is common, but not optimized to improve patient outcomes. Although there is a wide variability in quality among hospitals of nominally the same capability, patients are not consistently transferred to the highest quality nearby hospital. Instead, transfer destinations are selected by organizational routines or non-patient-centered organizational priorities. Accomplishing a transfer is often quite difficult for sending hospitals. But once a transfer destination is successfully found, the mechanics of interhospital transfer now appear quite safe. CONCLUSION Important technological advances now make it possible to identify nearby hospitals best able to help critically ill patients, and to successfully transfer patients to those hospitals. However, organizational structures have not yet developed to insure that patients are optimally routed, resulting in potentially significant excess mortality.
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Seymour CW, Iwashyna TJ, Ehlenbach WJ, Wunsch H, Cooke CR. Hospital-level variation in the use of intensive care. Health Serv Res 2012; 47:2060-80. [PMID: 22985033 PMCID: PMC3513618 DOI: 10.1111/j.1475-6773.2012.01402.x] [Citation(s) in RCA: 89] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To determine the extent to which hospitals vary in the use of intensive care, and the proportion of variation attributable to differences in hospital practice that is independent of known patient and hospital factors. DATA SOURCE Hospital discharge data in the State Inpatient Database for Maryland and Washington States in 2006. STUDY DESIGN Cross-sectional analysis of 90 short-term, acute care hospitals with critical care capabilities. DATA COLLECTION/METHODS: We quantified the proportion of variation in intensive care use attributable to hospitals using intraclass correlation coefficients derived from mixed-effects logistic regression models after successive adjustment for known patient and hospital factors. PRINCIPAL FINDINGS The proportion of hospitalized patients admitted to an intensive care unit (ICU) across hospitals ranged from 3 to 55 percent (median 12 percent; IQR: 9, 17 percent). After adjustment for patient factors, 19.7 percent (95 percent CI: 15.1, 24.4) of total variation in ICU use across hospitals was attributable to hospitals. When observed hospital characteristics were added, the proportion of total variation in intensive care use attributable to unmeasured hospital factors decreased by 26-14.6 percent (95 percent CI: 11, 18.3 percent). CONCLUSIONS Wide variability exists in the use of intensive care across hospitals, not attributable to known patient or hospital factors, and may be a target to improve efficiency and quality of critical care.
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Affiliation(s)
- Christopher W Seymour
- Departments of Critical Care and Emergency Medicine, University of Pittsburgh School of Medicine, Core Faculty, Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, 639 Scaife Hall 3550 Terrace Street, Pittsburgh, PA 15261, USA.
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Abstract
The main drivers of critical care medicine (CCM) costs are the numbers and use of intensive care unit (ICU) beds. The Russell equation, an indirect costing methodology, is most commonly used to estimate national CCM costs. Calculating national CCM costs in a standardized manner remains challenging because there is no universal approach to defining the types of hospitals, ICU beds, days, and billing codes to be included in the overall cost. Although numerous CCM cost-containment strategies have been proposed or implemented, CCM cost reduction remains elusive, and measuring cost remains challenging,given the complexities involved in assessing costs.
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Affiliation(s)
- Stephen M Pastores
- Department of Medicine and Anesthesiology, Weill Medical College of Cornell University, New York, NY 10065, USA.
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17
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Abstract
PURPOSE OF REVIEW Critical care medicine (CCM) is expensive. CCM costs have continued to rise since they were first calculated in the 1970s. By 2005, CCM costs in the US were estimated to be $81.7 billion accounting for 13.4% of hospital costs, 4.1% of the national health expenditures and 0.66% of the gross domestic product. RECENT FINDINGS This review first addresses the methodology and inherent limitations of calculating global CCM costs using the Russell equation and the challenges of defining critical care in the US when universal definitions of intensive care unit (ICU) bed types do not exist. Studies and concepts recently put forth to control CCM costs are then discussed. These include rationing ICU care, caring for patients in non-ICU locations, regionalizing care, changing the ICU workforce, imposing care protocols and bundles, and adjusting long-term ICU traditions. Many of these programs have benefits but may also have unintended expenses. Even documenting ICU costs themselves may be quite challenging as costs are frequently shifted between the ICU and its supporting clinical and hospital services. SUMMARY Cost containment is difficult to attain in critical care as the programs proposed to achieve cost control may be so pricey, that potential cost savings are offset. Some CCM cost saving methodologies may benefit patient care, whereas others may be detrimental to society. CCM cost containment may prove as illusory in the future as it has been in the past.
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Halpern NA, Pastores SM. Critical care medicine in the United States 2000-2005: an analysis of bed numbers, occupancy rates, payer mix, and costs. Crit Care Med 2010; 38:65-71. [PMID: 19730257 DOI: 10.1097/ccm.0b013e3181b090d0] [Citation(s) in RCA: 554] [Impact Index Per Article: 39.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To analyze the evolving role, patterns of use, and costs of critical care medicine in the United States from 2000 to 2005. DESIGN Retrospective study of data from the Hospital Cost Report Information System (Centers for Medicare and Medicaid Services, Baltimore, Maryland). SETTING Nonfederal, acute care hospitals with critical care medicine beds in the United States. SUBJECTS None. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We analyzed hospital and critical care medicine beds, bed types, days, occupancy rates, payer mix (Medicare and Medicaid), and costs. Critical care medicine costs were compared with national cost indexes. Between 2000 and 2005, the total number of U.S. hospitals with critical care medicine beds decreased by 12.2% (from 3,586 to 3,150). Although the number of hospital beds decreased by 4.2% (from 655,785 to 628,409), both hospital days and occupancy rates increased by 5.1% (from 145.1 to 152.5 million) and 13.7% (from 59% to 67%), respectively. Critical care medicine beds increased by 6.5% (from 88,252 to 93,955), days by 10.6% (from 21.0 to 23.2 million), and occupancy rates by 4.5% (from 65% to 68%). The majority (90%) of critical care medicine beds were classified as intensive care, premature/neonatal, and coronary care unit beds. The percentage of critical care medicine days used by Medicare decreased by 3.8% (from 37.9% to 36.5%) compared with an increase of 15.5% (from 14.5% to 16.8%) by Medicaid. From 2000 to 2005, critical care medicine costs per day increased by 30.4% (from $2698 to $3518). Although annual critical care medicine costs increased by 44.2% (from $56.6 to $81.7 billion), the proportion of hospital costs and national health expenditures allocated to critical care medicine decreased by 1.6% and 1.8%, respectively. However, the proportion of the gross domestic product used by critical care medicine increased by 13.7%. In 2005, critical care medicine costs represented 13.4% of hospital costs, 4.1% of national health expenditures, and 0.66% of the gross domestic product. CONCLUSIONS Critical care medicine continues to grow in a shrinking U.S. hospital system. The critical care medicine payer mix is evolving, with Medicaid increasing in its percentage of critical care medicine use. Critical care medicine is more cost controlled than other healthcare indexes, but is still using an increasing percentage of the gross domestic product. Our updated and comprehensive critical care medicine use and cost analysis provides a contemporary benchmark for the strategic planning of critical care medicine services within the U.S. healthcare system.
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Affiliation(s)
- Neil A Halpern
- Critical Care Medicine Service, Department of Anesthesiology and Critical Care Medicine, Memorial Sloan-Kettering Cancer Center, New York, USA.
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Wunsch H, Linde-Zwirble WT, Harrison DA, Barnato AE, Rowan KM, Angus DC. Use of Intensive Care Services during Terminal Hospitalizations in England and the United States. Am J Respir Crit Care Med 2009; 180:875-80. [DOI: 10.1164/rccm.200902-0201oc] [Citation(s) in RCA: 126] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Abstract
RATIONALE Moving patients from low-performing hospitals to high-performing hospitals may improve patient outcomes. These transfers may be particularly important in critical care, where small relative improvements can yield substantial absolute changes in survival. OBJECTIVE To characterize the existing critical care network in terms of the pattern of transfers. METHODS In a retrospective cohort study, the nationwide 2005 Medicare fee-for-service claims were used to identify the interhospital transfer of critically ill patients, defined as instances where patients used critical care services in 2 temporally adjacent hospitalizations. MEASUREMENTS We measured the characteristics of the interhospital transfer network and the extent to which intensive care unit patients are referred to each hospital in that network--a continuous quantitative measure at the hospital-level known as centrality. We evaluated associations between hospital centrality and organizational, medical, surgical, and radiologic capabilities. RESULTS There were 47,820 transfers of critically ill patients among 3308 hospitals. 4.5% of all critical care stays of any length involved an interhospital critical care transfer. Hospitals transferred out to a mean of 4.4 other hospitals. More central hospital positions were associated with multiple indicators of increased capability. Hospital characteristics explained 40.7% of the variance in hospitals' centrality. CONCLUSIONS Critical care transfers are common, and traverse an informal but structured network. The centrality of a hospital is associated with increased capability in delivery of services, suggesting that existing transfers generally direct patients toward better resourced hospitals. Studies of this network promise further improvements in patient outcomes and efficiency of care.
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Development and validation of an algorithm for identifying prolonged mechanical ventilation in administrative data. HEALTH SERVICES AND OUTCOMES RESEARCH METHODOLOGY 2009. [DOI: 10.1007/s10742-009-0050-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Iwashyna TJ, Christie JD, Kahn JM, Asch DA. Uncharted paths: hospital networks in critical care. Chest 2009; 135:827-833. [PMID: 19265091 PMCID: PMC2692049 DOI: 10.1378/chest.08-1052] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2008] [Accepted: 10/31/2008] [Indexed: 11/06/2022] Open
Abstract
Wide variation between hospitals in the quality of critical care lead to many potentially avoidable deaths. Regionalization of critical care is a possible solution; regionalization has been implemented for trauma and neonatal intensive care, and it is under active discussion for medical and cardiac critical care. However, regionalization is only one possible approach to reorganizing critical care services. This commentary introduces the technique of network analysis as a framework for the following: (1) understanding how critically ill patients move between hospitals, (2) defining the roles hospitals play in regional care delivery, and (3) suggesting systematic improvements that may benefit population health. We examined transfers of critically ill Medicare patients in Connecticut in 2005 as a model system. We found that patients are systematically transferred to more capable hospitals. However, we find the standard distinction of hospitals into either "secondary hospitals" or "tertiary hospitals" poorly explains observed transfer patterns; instead, hospitals show a continuum of roles. We further examine the implications of the network pattern in a simulation of quarantine of a hospital to incoming transfers, as occurred during the severe acute respiratory syndrome epidemic. Network perspectives offer new ways to study systems to care for critically ill patients and provide additional tools for addressing pragmatic problems in triage and bed management, regionalization, quality improvement, and disaster preparedness.
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Affiliation(s)
- Theodore J Iwashyna
- Division of Pulmonary and Critical Care, Department of Medicine, University of Michigan, Ann Arbor, MI.
| | - Jason D Christie
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania, Philadelphia, PA
| | - Jeremy M Kahn
- Department of Medicine and the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - David A Asch
- Department of Medicine and the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
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Fadlalla AMA, Golob JF, Claridge JA. The Surgical Intensive Care-infection Registry: a research registry with daily clinical support capabilities. Am J Med Qual 2009; 24:29-34. [PMID: 19139461 DOI: 10.1177/1062860608326633] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Infections in the surgical and trauma intensive care unit (STICU) are responsible for significant patient morbidity and mortality. Research into these infectious complications often uses administrative databases or clinical information systems designed for documenting and billing daily patient care. Neither of these sources is intended for research, and many investigators have questioned their accuracy. The Surgical Intensive Care-Infection Registry (SIC-IR) was developed as a research data repository to use to monitor STICU infections. SIC-IR is a relational database application designed to collect quality data and to integrate with daily patient care. SIC-IR prospectively collects and archives more than 100 clinical variables daily on each STICU patient to ensure completeness and correctness of the registry. Furthermore, SIC-IR aids in clinical activities by providing patient summaries and medical record documentation. SIC-IR provides accurate data for STICU infection research and enables the users to easily undertake quality-of-care improvement initiatives.
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Affiliation(s)
- Adam M A Fadlalla
- Department of Computer and Information Science, Cleveland State University, Cleveland, Ohio, USA
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Abstract
OBJECTIVE The past 10-15 yrs brought significant changes in the United States healthcare system. Effects on Medicare intensive care unit use and costs are unknown. Intensive care unit costs are estimated using the Russell equation with a ratio of intensive care unit to floor cost per day, or "R value," of 3, which may no longer be valid. We sought to determine contemporary Medicare intensive care unit resource use, costs, and R values; whether these vary by patient and hospital characteristics; and the impact of updated values on estimated intensive care unit costs. DESIGN Retrospective analysis of Medicare Inpatient Prospective Payment System hospitalizations from 1994 to 2004 using Medicare Provider Analysis and Review files. SETTING All nonfederal acute care US hospitals paid through the Inpatient Prospective Payment System. SUBJECTS Inpatient prospective payment system hospitalizations from 1994 to 2004 (n = 121,747, 260). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We examined resource use and costs (adjusted to y2004$), calculating intensive care unit and floor costs directly and using these to generate year-specific R values. By 2004, 33% of Medicare hospitalizations had intensive care unit or coronary care unit care, with more than half of the increase in total hospitalizations because of additional intensive care unit hospitalizations. Adjusted intensive care unit cost per day remained stable ($2,616 vs. $2,575; 1994 vs 2004), yet adjusted floor cost per day rose substantially ($1,027 vs. $1,488) driven by decreased floor length of stay. Annual adjusted Medicare intensive care unit costs increased 36% to $32.3B, largely because of increased utilization. R values decreased progressively from 2.55 to 1.73, were lower for surgical vs. medical admissions and survivors vs. nonsurvivors, but varied little by hospital characteristics. An R value of 3 overestimated Medicare intensive care unit costs by 17.6% ($5.7 billion) in 2004. CONCLUSIONS Medicare intensive care unit use is rising rapidly and will likely continue to do so. Despite significant healthcare system changes, adjusted daily critical care costs remained stable, yet care outside the intensive care unit became more expensive. To track intensive care unit cost over time, year-specific R values should be used.
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Golob JF, Fadlalla AM, Kan JA, Patel NP, Yowler CJ, Claridge JA. Validation of Surgical Intensive Care–Infection Registry: A Medical Informatics System for Intensive Care Unit Research, Quality of Care Improvement, and Daily Patient Care. J Am Coll Surg 2008; 207:164-73. [DOI: 10.1016/j.jamcollsurg.2008.04.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2008] [Accepted: 04/08/2008] [Indexed: 10/21/2022]
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Roberts RJ, Stockwell DC, Slonim AD. Discrepancies in administrative databases: implications for practice and research. Crit Care Med 2007; 35:949-50. [PMID: 17421084 DOI: 10.1097/01.ccm.0000257461.17112.89] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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