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Piers RD, Banner-Goodspeed V, Åkerman E, Kieslichova E, Meyfroidt G, Gerritsen RT, Uyttersprot E, Benoit DD. Outcomes in Patients Perceived as Receiving Excessive Care by ICU Physicians and Nurses: Differences Between Patients < 75 and ≥ 75 Years of Age? Chest 2023; 164:656-666. [PMID: 37062350 DOI: 10.1016/j.chest.2023.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 03/24/2023] [Accepted: 04/04/2023] [Indexed: 04/18/2023] Open
Abstract
BACKGROUND The benefit of the ICU for older patients is often debated. There is little knowledge on subjective impressions of excessive care in ICU nurses and physicians combined with objective patient data in real-life cases. RESEARCH QUESTION Is there a difference in treatment limitation decisions and 1-year outcomes in patients < 75 and ≥ 75 years of age, with and without concordant perceptions of excessive care by two or more ICU nurses and physicians? STUDY DESIGN AND METHODS This was a reanalysis of the prospective observational DISPROPRICUS study, performed in 56 ICUs. Nurses and physicians completed a daily questionnaire about the appropriateness of care for each of their patients during a 28-day period in 2014. We compared the cumulative incidence of patients with concordant perceptions of excessive care, treatment limitation decisions, and the proportion of patients attaining the combined end point (death, poor quality of life, or not being at home) at 1 year across age groups via Cox regression with propensity score weighting and Fisher exact tests. RESULTS Of 1,641 patients, 405 (25%) were ≥ 75 years of age. The cumulative incidence of concordant perceptions of excessive care was higher in older patients (13.6% vs 8.5%; P < .001). In patients with concordant perceptions of excessive care, we found no difference between age groups in risk of death (1-year mortality, 83% in both groups; P > .99; hazard ratio [HR] after weighting, 1.11; 95% CI, 0.74-1.65), treatment limitation decisions (33% vs 31%; HR after weighting, 1.11; 95% CI, 0.69-2.17), and reaching the combined end point at 1 year (90% vs 93%; P = .546). In patients without concordant perceptions of excessive care, we found a difference in risk of death (1-year mortality, 41% vs 30%; P < .001; HR after weighting, 1.38; 95% CI, 1.11-1.73) and treatment limitation decisions (11% vs 5%; P < .001; HR, 2.11; 95% CI, 1.37-3.27); however, treatment limitation decisions were mostly documented prior to ICU admission. The risk of reaching the combined end point was higher in the older adults (61.6% vs 52.8%; P < .001). INTERPRETATION Although the incidence of perceptions of excessive care is slightly higher in older patients, there is no difference in treatment limitation decisions and 1-year outcomes between older and younger patients once patients are identified by concordant perceptions of excessive care. Additionally, in patients without concordant perceptions, the outcomes are worse in the older adults, pleading against ageism in ICU nurses and physicians.
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Affiliation(s)
- Ruth D Piers
- Department of Geriatrics, Ghent University Hospital, Ghent, Belgium.
| | - Valerie Banner-Goodspeed
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Eva Åkerman
- Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden; General Intensive Care Unit, Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Eva Kieslichova
- Department of Anesthesiology, Resuscitation and Intensive Care, Institute for Clinical and Experimental Medicine, Prague, Czech Republic; First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Geert Meyfroidt
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | | | - Emma Uyttersprot
- Department of Applied Mathematics and Computer Sciences, Ghent University, Ghent, Belgium
| | - Dominique D Benoit
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
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Bruno RR, Wernly B, Bagshaw SM, van den Boogaard M, Darvall JN, De Geer L, de Gopegui Miguelena PR, Heyland DK, Hewitt D, Hope AA, Langlais E, Le Maguet P, Montgomery CL, Papageorgiou D, Seguin P, Geense WW, Silva-Obregón JA, Wolff G, Polzin A, Dannenberg L, Kelm M, Flaatten H, Beil M, Franz M, Sviri S, Leaver S, Guidet B, Boumendil A, Jung C. The Clinical Frailty Scale for mortality prediction of old acutely admitted intensive care patients: a meta-analysis of individual patient-level data. Ann Intensive Care 2023; 13:37. [PMID: 37133796 PMCID: PMC10155148 DOI: 10.1186/s13613-023-01132-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 04/20/2023] [Indexed: 05/04/2023] Open
Abstract
BACKGROUND This large-scale analysis pools individual data about the Clinical Frailty Scale (CFS) to predict outcome in the intensive care unit (ICU). METHODS A systematic search identified all clinical trials that used the CFS in the ICU (PubMed searched until 24th June 2020). All patients who were electively admitted were excluded. The primary outcome was ICU mortality. Regression models were estimated on the complete data set, and for missing data, multiple imputations were utilised. Cox models were adjusted for age, sex, and illness acuity score (SOFA, SAPS II or APACHE II). RESULTS 12 studies from 30 countries with anonymised individualised patient data were included (n = 23,989 patients). In the univariate analysis for all patients, being frail (CFS ≥ 5) was associated with an increased risk of ICU mortality, but not after adjustment. In older patients (≥ 65 years) there was an independent association with ICU mortality both in the complete case analysis (HR 1.34 (95% CI 1.25-1.44), p < 0.0001) and in the multiple imputation analysis (HR 1.35 (95% CI 1.26-1.45), p < 0.0001, adjusted for SOFA). In older patients, being vulnerable (CFS 4) alone did not significantly differ from being frail. After adjustment, a CFS of 4-5, 6, and ≥ 7 was associated with a significantly worse outcome compared to CFS of 1-3. CONCLUSIONS Being frail is associated with a significantly increased risk for ICU mortality in older patients, while being vulnerable alone did not significantly differ. New Frailty categories might reflect its "continuum" better and predict ICU outcome more accurately. TRIAL REGISTRATION Open Science Framework (OSF: https://osf.io/8buwk/ ).
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Affiliation(s)
- Raphael Romano Bruno
- Medical Faculty, Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Duesseldorf, Moorenstraße 5, 40225, Duesseldorf, Germany
| | - Bernhard Wernly
- Department of Internal Medicine, General Hospital Oberndorf, Teaching Hospital of the Paracelsus Medical Private University, Paracelsusstraße 37, 5110, Oberndorf, Austria
- Institute of General Practice, Family Medicine and Preventive Medicine, Paracelsus Medical University, Strubergasse 21, 5020, Salzburg, Austria
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, 2-124 Clinical Sciences Building, 8440 112Th ST, Edmonton, AB, T6G 2B7, Canada
| | - Mark van den Boogaard
- Department of Intensive Care Medicine, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jai N Darvall
- Intensive Care Unit and Department of Anaesthesia & Pain Management, The Royal Melbourne Hospital, Grattan Street, Parkville, VIC, 3050, Australia
| | - Lina De Geer
- Department of Anaesthesiology and Intensive Care, Linköping University Hospital, Linköping, Sweden
| | | | - Daren K Heyland
- Clinical Evaluation Research Unit, and Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | - David Hewitt
- Glasgow Royal Infirmary Intensive Care Unit, Glasgow, Scotland
| | - Aluko A Hope
- Division of Pulmonary, Allergy, and Critical Care Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Emilie Langlais
- Réanimation Chirurgicale, CHU Rennes, Université Rennes 1, Rennes, France
| | - Pascale Le Maguet
- Département d'Anesthésie Réanimation, CHU Rennes, Rennes, France
- Service d'Anesthésie, CH Quimper, Quimper, France
| | - Carmel L Montgomery
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, 2-124 Clinical Sciences Building, 8440 112Th ST, Edmonton, AB, T6G 2B7, Canada
- Faculty of Nursing, University of Alberta, Edmonton Clinic Health Academy, 3-171, Edmonton, AB, T6G 1C9, Canada
| | - Dimitrios Papageorgiou
- Faculty of Health and Caring Sciences Department of Nursing, University of West Attica (UWA) Athens, Egaleo, Greece
| | - Philippe Seguin
- Réanimation Chirurgicale, CHU Rennes, Université Rennes 1, Rennes, France
| | - Wytske W Geense
- Department of Intensive Care Medicine, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J Alberto Silva-Obregón
- Department of Intensive Care Medicine, Hospital Universitario de Guadalajara, Guadalajara, Spain
| | - Georg Wolff
- Medical Faculty, Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Duesseldorf, Moorenstraße 5, 40225, Duesseldorf, Germany
| | - Amin Polzin
- Medical Faculty, Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Duesseldorf, Moorenstraße 5, 40225, Duesseldorf, Germany
| | - Lisa Dannenberg
- Medical Faculty, Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Duesseldorf, Moorenstraße 5, 40225, Duesseldorf, Germany
| | - Malte Kelm
- Medical Faculty, Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Duesseldorf, Moorenstraße 5, 40225, Duesseldorf, Germany
- CARID (Cardiovascular Research Institute Düsseldorf), University Hospital of Düsseldorf, Germany, Düsseldorf, Germany
| | - Hans Flaatten
- Department of Clinical Medicine, Department of Anaesthesia and Intensive Care, University of Bergen, Haukeland University Hospital, Bergen, Norway
| | - Michael Beil
- Dept. of Medical Intensive Care, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Marcus Franz
- Clinic of Internal Medicine I, Department of Cardiology, Friedrich Schiller University, 07737, Jena, Germany
| | - Sigal Sviri
- Department of Medical Intensive Care, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Susannah Leaver
- General Intensive Care, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Bertrand Guidet
- Equipe: Épidémiologie Hospitalière Qualité Et Organisation Des Soins, Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMR_S 1136, Institut Pierre Louis d'Epidémiologie Et de Santé Publique, 75012, Paris, France
- Service de Réanimation Médicale, Hôpitaux de Paris, Hôpital Saint-Antoine, 75012, Paris, France
| | - Ariane Boumendil
- Equipe: Épidémiologie Hospitalière Qualité Et Organisation Des Soins, Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMR_S 1136, Institut Pierre Louis d'Epidémiologie Et de Santé Publique, 75012, Paris, France
- Service de Réanimation Médicale, Hôpitaux de Paris, Hôpital Saint-Antoine, 75012, Paris, France
| | - Christian Jung
- Medical Faculty, Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Duesseldorf, Moorenstraße 5, 40225, Duesseldorf, Germany.
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Lee JY, Park H, Kim MK, Kim IK. Evaluating the effect of age on postoperative and clinical outcomes in patients admitted to the intensive care unit after gastrointestinal cancer surgery. Surgery 2022; 172:1270-1277. [DOI: 10.1016/j.surg.2022.04.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 03/24/2022] [Accepted: 04/29/2022] [Indexed: 11/25/2022]
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Bentin F, Van Den Noortgate N, Piers R. In-hospital end-of-life care in the old: a retrospective study of intensive care unit use and do-not-resuscitate forms in patients deceased in a Belgian university hospital. Acta Clin Belg 2022; 78:185-191. [PMID: 35816019 DOI: 10.1080/17843286.2022.2097408] [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: 10/17/2022]
Abstract
OBJECTIVES To explore the quality of in-hospital end-of-life care in adult patients with special attention to those 75 years and older and to make a comparison with the situation 10 years ago. METHODS Data were retrospectively collected on adult patients who deceased at Ghent University Hospital between September 2018 and December 2019. The main outcome measures were 'ICU use' and 'presence of DNR forms on non-ICU units' in the final hospitalization. In order to identify possible risk factors for ICU use, logistic regression was performed. RESULTS In total, 762 people died, of whom 35% were 75 or older. Just as 10 years ago, one-third (31%) died in the ICU versus 49% of those younger than 75 years (p < 0.001). Of people ≥75 years, 38%, compared to 42% 10 years ago, received an ICU treatment during their final hospitalization. The median length of an ICU stay was 4 versus 3 days 10 years ago. After adjusting for gender, comorbidities and the Charlson Comorbidity Index, factors associated with less ICU use were higher age, active malignancy and dementia (OR 0.838, 0.116 and 0.098 respectively). Seventy-nine percent of older patients on non-ICU wards died with a DNR form (versus 87% 10 years ago). CONCLUSION Although there was an increase in the presence of DNR forms in the final hospitalization, no significant differences were seen in actual ICU use compared to 10 years ago. Factors associated with less ICU use were higher age, active malignancy and dementia.
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Affiliation(s)
- Felicia Bentin
- Department of Geriatrics, University Hospital Ghent, Ghent, Belgium
| | | | - Ruth Piers
- Department of Geriatrics, University Hospital Ghent, Ghent, Belgium
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[Predicting prolonged length of intensive care unit stay via machine learning]. BEIJING DA XUE XUE BAO. YI XUE BAN = JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2021; 53. [PMID: 34916699 PMCID: PMC8695140 DOI: 10.19723/j.issn.1671-167x.2021.06.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To construct length of intensive care unit (ICU) stay (LOS-ICU) prediction models for ICU patients, based on three machine learning models support vector machine (SVM), classification and regression tree (CART), and random forest (RF), and to compare the prediction perfor-mance of the three machine learning models with the customized simplified acute physiology score Ⅱ(SAPS-Ⅱ) model. METHODS We used medical information mart for intensive care (MIMIC)-Ⅲ database for model development and validation. The primary outcome was prolonged LOS-ICU(pLOS-ICU), defined as longer than the third quartile of patients' LOS-ICU in the studied dataset. The recursive feature elimination method was used to do feature selection for three machine learning models. We utilized 5-fold cross validation to evaluate model prediction performance. The Brier value, area under the receiver operation characteristic curve (AUROC), and estimated calibration index (ECI) were used as perfor-mance measures. Performances of the four models were compared, and performance differences between the models were assessed using two-sided t test. The model with the best prediction performance was employed to generate variable importance ranking, and the identified top five important predictors were pre-sented. RESULTS The final cohort in our study consisted of 40 200 eligible ICU patients, of whom 23.7% were with pLOS-ICU. The proportion of the male patients was 57.6%, and the age of all the ICU patients was (61.9±16.5) years.Results showed that the three machine learning models outperformed the customized SAPS-Ⅱ model in terms of all the performance measures with statistical significance (P < 0.01). Among the three machine learning models, the RF model achieved the best overall performance (Brier value, 0.145), discrimination (AUROC, 0.770) and calibration (ECI, 7.259). The calibration curve showed that the RF model slightly overestimated the risk of pLOS-ICU in high-risk ICU patients, but underestimated the risk of pLOS-ICU in low-risk ICU patients. Top five important predictors for pLOS-ICU identified by the RF model included age, heart rate, systolic blood pressure, body tempe-rature, and ratio of arterial oxygen tension to the fraction of inspired oxygen(PaO2/FiO2). CONCLUSION The RF algorithm-based pLOS-ICU prediction model had a best prediction performance in this study. It lays a foundation for future application of the RF-based pLOS-ICU prediction model in ICU clinical practice.
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Bouza C, Martínez-Alés G, López-Cuadrado T. Recent trends of invasive mechanical ventilation in older adults: a nationwide population-based study. Age Ageing 2021; 50:1607-1615. [PMID: 33710265 DOI: 10.1093/ageing/afab023] [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: 07/09/2020] [Revised: 01/20/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Critical care demand for older people is increasing. However, there is scarce population-based information about the use of life-support measures such as invasive mechanical ventilation (IMV) in this population segment. OBJECTIVE To examine the characteristics and recent trends of IMV for older adults. METHODS Retrospective cohort study on IMV in adults ≥65 years using the 2004-15 Spanish national hospital discharge database. Primary outcomes were incidence, inhospital mortality and resource utilization. Trends were assessed for average annual percentage change in rates using joinpoint regression models. RESULTS 233,038 cases were identified representing 1.27% of all-cause hospitalizations and a crude incidence of 248 cases/100,000 older adult population. Mean age was 75 years, 62% were men and 70% had comorbidities. Inhospital mortality was 48%. Across all ages, about 80% of survivors were discharged home. Incidence rates of IMV remained roughly unchanged over time with an average annual change of -0.2% (95% confidence interval (CI): -0.9, 0.6). Inhospital mortality decreased an annual average of -0.7% (95% CI: -0.5, -1.0), a trend detected across age groups and most clinical strata. Further, there was a 3.4% (95% CI: 3.0, 3.8) annual increase in the proportion of adults aged ≥80 years, an age group that showed higher mortality risk, lower frequency of prolonged IMV, shorter hospital stays and lower costs. CONCLUSIONS Overall rates of IMV remained roughly stable among older adults, while inhospital mortality showed a decreasing trend. There was a notable increase in adults aged ≥80 years, a group with high mortality and lower associated hospital resource use.
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Affiliation(s)
- Carmen Bouza
- Health Technology Assessment Agency, Carlos III Health Institute, Madrid, Spain
| | - Gonzalo Martínez-Alés
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
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Sale JEM, Yang A, Elliot-Gibson V, Jain R, Sujic R, Linton D, Weldon J, Frankel L, Bogoch E. Patients 80 + have similar medication initiation rates to those aged 50-79 in Ontario FLS. Osteoporos Int 2021; 32:1405-1411. [PMID: 33471148 DOI: 10.1007/s00198-020-05796-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 12/10/2020] [Indexed: 10/22/2022]
Abstract
UNLABELLED Among individuals presenting to an Ontario FLS, we compared bone active medication initiation rates of patients 80 years and older with those 50-79 years old. After accounting for fracture risk status, there was no statistically significant difference in medication initiation rates between the two age groups INTRODUCTION: A Fracture Liaison Service (FLS) offers post-fracture services to individuals over the age of 50 years and could potentially address age inequities in pharmacotherapy often observed for older adults. Among individuals presenting to an Ontario FLS and classified as being at high risk for future fracture, our objective was to compare bone active medication initiation rates of patients 80 years and older with those 50-79 years old. METHODS In 39 FLS fracture clinics across Ontario, Canada, fracture prevention coordinators identified, assessed, and facilitated the referral of eligible patients for bone densitometry, fracture risk assessment, and implementation of pharmacotherapy in patients classified as high risk for future fracture. Variables assessed at baseline included age, sex, marital status, living location, fracture location, history of previous fracture, parent's history of hip fracture, history of falls, and fracture risk status. At 6 months, bone active medication initiation was assessed in patients classified as high risk for future fracture. The Chi-square test of independence was used to compare medication initiation rates between patients 80 + and those 50-79 years old. RESULTS Our sample size consisted of 808 patients aged 50-79 years and 346 aged 80 + years. After accounting for fracture risk status, there was no statistically significant difference in medication initiation rates of patients 50-79 and 80 + years old (76.9% versus 73.7%, p = 0.251). CONCLUSION A systematic approach to identifying patients at high risk for future fracture and tailoring treatment recommendations to these patients appeared to eliminate differences in treatment initiation rates based on older age.
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Affiliation(s)
- J E M Sale
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, 30 Bond Street, Toronto, Ontario, M5B 1W8, Canada.
- Institute of Health Policy, Management & Evaluation, University of Toronto, 4th Floor, 155 College Street, Toronto, Ontario, M5T 3M6, Canada.
| | - A Yang
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, 30 Bond Street, Toronto, Ontario, M5B 1W8, Canada
| | - V Elliot-Gibson
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, 30 Bond Street, Toronto, Ontario, M5B 1W8, Canada
| | - R Jain
- Osteoporosis Canada, Suite 201 - 250 Ferrand Drive, Toronto, Ontario, M3C 3G8, Canada
| | - R Sujic
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, 30 Bond Street, Toronto, Ontario, M5B 1W8, Canada
| | - D Linton
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, 30 Bond Street, Toronto, Ontario, M5B 1W8, Canada
| | - J Weldon
- Osteoporosis Canada, Suite 201 - 250 Ferrand Drive, Toronto, Ontario, M3C 3G8, Canada
| | - L Frankel
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, 30 Bond Street, Toronto, Ontario, M5B 1W8, Canada
| | - E Bogoch
- Department of Surgery, University of Toronto, St. Michael's Hospital, Unity Health Toronto, 30 Bond Street, Toronto, Ontario, M5B 1W8, Canada
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Kalseth J, Halvorsen T. Health and care service utilisation and cost over the life-span: a descriptive analysis of population data. BMC Health Serv Res 2020; 20:435. [PMID: 32429985 PMCID: PMC7236310 DOI: 10.1186/s12913-020-05295-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 05/05/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Current demographic changes affect both the level and composition of health and care needs in the population. The aim of this study was to estimate utilisation and cost for a comprehensive range of health and care services by age and gender to provide an in-depth picture of the life-span pattern of service needs and related costs. METHODS Data on service use in 2010 for the entire population in Norway were collected from four high-quality national registers. Cost for different services were calculated combining data on service utilisation from the registries and estimates of unit cost. Data on cost and users were aggregated within four healthcare services and seven long-term care services subtypes. Per capita cost by age and gender was decomposed into user rates and cost per user for each of the eleven services. RESULTS Half of the population is under 40 years of age, but only a quarter of the health and care cost is used on this age group. The age-group of 65 or older, on the other hand, represent only 15% of the population, but is responsible for almost half of the total cost. Healthcare cost dominates in ages under 80 and mental health services dominates in adolescents and young adults. Use of other healthcare services are high in middle aged and elderly but decreases for the oldest old. Use of care services and in particular institutional care increases in old age. Healthcare cost per user follows roughly the same age pattern as user rates, whereas user cost for care services typically are either relatively stable or decrease with age among adults. Gender differences in the age pattern of health and care costs are also revealed and discussed. CONCLUSION The type of services used, and the related cost, show a clear life-span as well as gender pattern. Hence, population aging and narrowing gender-gap in longivety calls for high policy awarness on changing health and care needs. Our study also underscores the need for an attentive and pro-active stance towards the high service prevalence and high cost of mental health care in our upcoming generations.
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Affiliation(s)
- Jorid Kalseth
- Department of Health Research, SINTEF Digital, P.O. Box 4760, Sluppen, NO-7465 Trondheim, Norway
| | - Thomas Halvorsen
- Department of Health Research, SINTEF Digital, P.O. Box 4760, Sluppen, NO-7465 Trondheim, Norway
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Silva DDJN, Casimiro LGG, Oliveira MISD, Ferreira LBDC, Abelha FJPA. [The very elderly surgical population in a critically ill scenario: clinical characteristics and outcomes]. Rev Bras Anestesiol 2020; 70:3-8. [PMID: 32164996 DOI: 10.1016/j.bjan.2019.10.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 10/15/2019] [Accepted: 10/26/2019] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND The elderly population is an especially heterogeneous group of patients with a rising number of surgical interventions being performed in the very elderly patient. The aim of this study was to evaluate the correlation between different age strata and functional status with the surgical outcome of the elderly patient. METHODS Retrospective cohort study conducted in a Surgical Intensive Care Unit (SICU), between 2006 and 2013. A total of 2331 surgical patients ≥ 65 years old were included. Patients were grouped according to age: Older Elderly Group (OEG: 65-85 years old); Very Elderly Group (VEG > 85 years old). Demographic and perioperative data were recorded. Revised Cardiac Risk Index, APACHE II and SAPS II scores were calculated and postoperative complications were documented. Variables were compared on univariate analysis. RESULTS The incidence of the VEG was 5.4%. This group had a higher proportion of non-elective surgery (22.4% vs. 11.2%, p < 0.001), higher APACHE II (12.0 vs. 10.0, p < 0.001) and SAPS II (26.6 vs. 22.2, p < 0.001) scores, higher incidence of organ failure (24.6% vs. 17.6%, p = 0.048) and a higher mortality rate during SICU (14.0% vs. 5.2%, p = 0.026) and hospital stay (9.3% vs. 5.0%, p = 0.012). CONCLUSION We found that very elderly patients represented a significant proportion of patients admitted to the SICU. They had higher severity scores with a higher prevalence of organ failure and were more likely to undergo non-elective surgery. They had worse outcomes in regarding mortality during SICU and hospital stay.
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Affiliation(s)
| | | | | | | | - Fernando José Pereira Alves Abelha
- Centro Hospitalar Universitário São João, Serviço de Anestesiologia, Porto, Portugal; Universidade do Porto, Faculdade de Medicina, Departamento de Cirurgia e Fisiologia, Porto, Portugal.
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Silva DDJN, Casimiro LGG, Oliveira MISD, Ferreira LBDC, Abelha FJPA. The very elderly surgical population in a critically ill scenario: clinical characteristics and outcomes. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2020. [PMID: 32164996 PMCID: PMC9373388 DOI: 10.1016/j.bjane.2020.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background The elderly population is an especially heterogeneous group of patients with a rising number of surgical interventions being performed in the very elderly patient. The aim of this study was to evaluate the correlation between different age strata and functional status with the surgical outcome of the elderly patient. Methods Retrospective cohort study conducted in a Surgical Intensive Care Unit (SICU), between 2006 and 2013. A total of 2331 surgical patients’ ≥ 65 years old were included. Patients were grouped according to age: Older Elderly Group (OEG: 65‒85 years old); Very Elderly Group (VEG > 85 years old). Demographic and perioperative data were recorded. Revised Cardiac Risk Index, APACHE II and SAPS II scores were calculated and postoperative complications were documented. Variables were compared on univariate analysis. Results The incidence of the VEG was 5.4%. This group had a higher proportion of non-elective surgery (22.4% vs. 11.2%, p < 0.001), higher APACHE II (12.0 vs. 10.0, p < 0.001) and SAPS II (26.6 vs. 22.2, p < 0.001) scores, higher incidence of organ failure (24.6% vs. 17.6%, p = 0.048) and a higher mortality rate during SICU (14.0% vs. 5.2%, p = 0.026) and hospital stay (9.3% vs. 5.0%, p = 0.012). Conclusion We found that very elderly patients represented a significant proportion of patients admitted to the SICU. They had higher severity scores with a higher prevalence of organ failure and were more likely to undergo non-elective surgery. They had worse outcomes in regarding mortality during SICU and hospital stay.
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Affiliation(s)
| | | | | | | | - Fernando José Pereira Alves Abelha
- Centro Hospitalar Universitário São João, Serviço de Anestesiologia, Porto, Portugal; Universidade do Porto, Faculdade de Medicina, Departamento de Cirurgia e Fisiologia, Porto, Portugal.
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11
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Monteiro NF, Simões I, Gaspar I, Carmo E. Do-not-resuscitate and treatment limitation decisions - Six years of experience from a Portuguese General Intensive Care Unit. Rev Assoc Med Bras (1992) 2019; 65:1168-1173. [PMID: 31618332 DOI: 10.1590/1806-9282.65.9.1168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 03/31/2019] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE Treatment limitation, as well as do-not-resuscitate (DNR) directives, are difficult but important to improve patients' quality of life and minimize dysthanasia. We aimed to study the approach to withholding, withdrawal, and DNR decisions, patients' characteristics, and process documentation in a general Intensive Care Unit (ICU) in Portugal. METHODS A retrospective analysis of data regarding the limitation of treatment decisions collected from previously-designed forms and complemented by medical record consultation. RESULTS A total of 1602 patients were admitted to the ICU between 2011 and 2016. DNR decisions were documented in 127 cases (7.9%). Patients with treatment limitations were older and had higher Simplified Acute Physiology Score II. The most frequent diagnosis preceding these decisions was sepsis (52.0%, n = 66); the most common main reason for limiting treatment was a poor prognosis of acute illness. Of the patients to whom a DNR was implemented, 117 (92.1%) died in the ICU (40.1% of the total number of ICU deaths), and hospital mortality was 100%. Participants in these decisions, as well as types of treatment withdrawn and their respective timings, were not registered in medical records. CONCLUSION Treatment limitation and DNR decisions were relatively common, in line with other Southern European studies, but behind Northern European and North American centers. Patients with these limitations were older and more severely ill than patients without such decisions. Documentation of these processes should be clear and detailed, either in specific forms or computerized clinical records; there is room for improvement in this area.
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Affiliation(s)
- Nuno Ferreira Monteiro
- . Service of Internal Medicine, Hospital de Egas Moniz, Centro Hospitalar de Lisboa, Lisboa, Portugal
| | - Isabel Simões
- . General Intensive Care Unit, Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal
| | - Isabel Gaspar
- . General Intensive Care Unit, Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal
| | - Eduarda Carmo
- . General Intensive Care Unit, Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal
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12
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Carlson KA, Dhillon NK, Patel KA, Huang R, Ng P, Margulies DR, Ley EJ, Barmparas G. Utilization of tracheostomy among geriatric trauma patients and association with mortality. Eur J Trauma Emerg Surg 2019; 46:1375-1383. [PMID: 31396650 DOI: 10.1007/s00068-019-01199-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 07/28/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND The purpose of this study was to investigate trends in tracheostomy (TR) utilization among trauma patients over the last decade and explore its impact on mortality among elderly trauma patients. METHODS Patients 18 years or older with at least 72 h on the ventilator were selected from the National Trauma Databank research datasets 2007 to 2015. Patients were divided into three groups based on age: 18-60, 61-80, and > 80 years and proportions of patients undergoing a TR were depicted. Elderly (> 80 years) were divided into two groups, based on whether they underwent a TR. The primary outcome was mortality. A Cox regression model with a time-dependent variable was utilized to account for survival bias. RESULTS Over the 9-year study period 284,774 patients met inclusion criteria. Of those, 21,465 (7.5%) were older than 80 years. Elderly patients were significantly less likely to undergo a TR (13.1% vs. 21.5% in the 18-60 years and 20.4% in the 61-80 years group, p < 0.01) and this trend continued throughout the study period. Among the elderly patients, those who underwent TR were more likely to have a severe (AIS ≥ 3) thoracic, abdominal, and/or spinal injury, but not head injury and were less likely to have a history of cerebrovascular accident (5.9% vs. 7.7%, p < 0.01). The overall mortality was significantly higher in elderly patients who did not undergo a TR (46.9% vs. 17.6%, p < 0.01). The adjusted hazard ratio for elderly patients undergoing a TR was 0.36 (adjusted p < 0.01). CONCLUSION In ventilated trauma patients, tracheostomy is less likely to be utilized in the elderly population compared to younger age groups. Amongst the elderly patients, performance of tracheostomy was associated with a significantly higher overall survival. Delaying or avoiding this procedure in the elderly trauma patient predominantly based on age might not be justified. STUDY TYPE Prognostic/epidemiological. LEVEL OF EVIDENCE III or IV.
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Affiliation(s)
- Kjirsten Ayn Carlson
- Division of Acute Care Surgery and Surgical Critical Care, Department of Surgery, Cedars-Sinai Medical Center, 8635 W. 3rd Street, Suite 650W, Los Angeles, CA, 90048, USA
| | - Navpreet Kaur Dhillon
- Division of Acute Care Surgery and Surgical Critical Care, Department of Surgery, Cedars-Sinai Medical Center, 8635 W. 3rd Street, Suite 650W, Los Angeles, CA, 90048, USA
| | - Kavita Anil Patel
- Division of Acute Care Surgery and Surgical Critical Care, Department of Surgery, Cedars-Sinai Medical Center, 8635 W. 3rd Street, Suite 650W, Los Angeles, CA, 90048, USA
| | - Raymond Huang
- Division of Acute Care Surgery and Surgical Critical Care, Department of Surgery, Cedars-Sinai Medical Center, 8635 W. 3rd Street, Suite 650W, Los Angeles, CA, 90048, USA
| | - Phillip Ng
- Division of General Internal Medicine, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Daniel Reed Margulies
- Division of Acute Care Surgery and Surgical Critical Care, Department of Surgery, Cedars-Sinai Medical Center, 8635 W. 3rd Street, Suite 650W, Los Angeles, CA, 90048, USA
| | - Eric Jude Ley
- Division of Acute Care Surgery and Surgical Critical Care, Department of Surgery, Cedars-Sinai Medical Center, 8635 W. 3rd Street, Suite 650W, Los Angeles, CA, 90048, USA
| | - Galinos Barmparas
- Division of Acute Care Surgery and Surgical Critical Care, Department of Surgery, Cedars-Sinai Medical Center, 8635 W. 3rd Street, Suite 650W, Los Angeles, CA, 90048, USA.
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Beier D, Weiß C, Hagmann M, Balaban Ü, Thiel M, Schneider-Lindner V. Is antibacterial treatment intensity lower in elderly patients? A retrospective cohort study in a German surgical intensive care unit. BMC Health Serv Res 2019; 19:367. [PMID: 31182082 PMCID: PMC6558678 DOI: 10.1186/s12913-019-4204-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Accepted: 05/30/2019] [Indexed: 11/13/2022] Open
Abstract
Background Demographic change concurrent with medical progress leads to an increasing number of elderly patients in intensive care units (ICUs). Antibacterial treatment is an important, often life-saving, aspect of intensive care but burdened by the associated antimicrobial resistance risk. Elderly patients are simultaneously at greater risk of infections and may be more restrictively treated because, generally, treatment intensity declines with age. We therefore described utilization of antibacterials in ICU patients older and younger than 80 years and examined differences in the intensity of antibacterial therapy between both groups. Methods We analysed 17,464 valid admissions from the electronic patient data management system of our surgical ICU from April 2006 – October 2013. Antibacterial treatment rates were defined as days of treatment (exposed patient days) relative to patient days of ICU stay and calculated for old and young patients. Rates were compared in zero-inflated Poisson regression models adjusted for patients’ sex, mean SAPS II- and TISS-scores, and calendar years yielding adjusted rate ratios (aRRs). Rate ratios exceeding 1 represent higher rates in old patients reflecting greater treatment intensity in old compared to younger patients. Results Observed antibacterial treatment rates were lower in patients 80 years and older compared to younger patients (30.97 and 39.73 exposed patient days per 100 patient days in the ICU, respectively). No difference in treatment intensity, however, was found from zero-inflated Poisson regression models permitting more adequate consideration of patient days with low treatment probability: for all antibacterials the adjusted rate ratio (aRR) was 1.02 (95%CI: 0.98–1.07). Treatment intensities were higher in elderly patients for penicillins (aRR 1.37 (95%CI: 1.26–1.48)), cephalosporins (aRR 1.20 (95%CI: 1.09–1.31)), carbapenems (aRR 1.35 (95%CI: 1.20–1.50)), fluoroquinolones (aRR 1.17 (95%CI: 1.05–1.30), and imidazoles (aRR 1.34 (95%CI: 1.23–1.46)). Conclusions Elderly patients were generally less likely to be treated with antibacterials. This observation, however, did not persist in patients with comparable treatment probability. In these, antibacterial treatment intensity did not differ between younger and older ICU patients, for some antibacterial classes treatment intensity was even higher in the latter. Patient-level covariates are instrumental for a nuanced evaluation of age-effects in antibacterial treatment in the ICU. Electronic supplementary material The online version of this article (10.1186/s12913-019-4204-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Dominik Beier
- Department of Anesthesiology and Surgical Intensive Care Medicine, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.,Department of Biometry and Statistics, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Christel Weiß
- Department of Biometry and Statistics, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Michael Hagmann
- Department of Biometry and Statistics, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Ümniye Balaban
- Department of Anesthesiology and Surgical Intensive Care Medicine, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.,Department of Biometry and Statistics, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Manfred Thiel
- Department of Anesthesiology and Surgical Intensive Care Medicine, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Verena Schneider-Lindner
- Department of Anesthesiology and Surgical Intensive Care Medicine, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany. .,Department of Community Health Sciences, University of Manitoba, S113 - 750 Bannatyne Avenue, Winnipeg, Manitoba, R3E 0W3, Canada.
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Guidet B, Vallet H, Boddaert J, de Lange DW, Morandi A, Leblanc G, Artigas A, Flaatten H. Caring for the critically ill patients over 80: a narrative review. Ann Intensive Care 2018; 8:114. [PMID: 30478708 PMCID: PMC6261095 DOI: 10.1186/s13613-018-0458-7] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 11/14/2018] [Indexed: 12/25/2022] Open
Abstract
Background There is currently no international recommendation for the admission or treatment of the critically ill older patients over 80 years of age in the intensive care unit (ICU), and there is no valid prognostic severity score that includes specific geriatric assessments. Main body In this review, we report recent literature focusing on older critically ill patients in order to help physicians in the multiple-step decision-making process. It is unclear under what conditions older patients may benefit from ICU admission. Consequently, there is a wide variation in triage practices, treatment intensity levels, end-of-life practices, discharge practices and frequency of geriatrician’s involvement among institutions and clinicians. In this review, we discuss important steps in caring for critically ill older patients, from the triage to long-term outcome, with a focus on specific conditions in the very old patients. Conclusion According to previous considerations, we provide an algorithm presented as a guide to aid in the decision-making process for the caring of the critically ill older patients. Electronic supplementary material The online version of this article (10.1186/s13613-018-0458-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bertrand Guidet
- Assistance Publique - Hôpitaux de Paris (AP-HP), Service de Réanimation Médicale, Hôpital Saint-Antoine, 184 rue du Faubourg Saint-Antoine, 75012, Paris, France. .,Sorbonne Universités, Université Pierre et Marie Curie - Paris 06, Paris, France. .,INSERM, UMR_S 1136, Institute Pierre Louis d'Épidémiologie et de Santé Publique, 75013, Paris, France.
| | - Helene Vallet
- INSERM, UMR_S 1136, Institute Pierre Louis d'Épidémiologie et de Santé Publique, 75013, Paris, France.,Assistance Publique - Hôpitaux de Paris (AP-HP), Service de gériatrie, Hôpital Pitié salpêtrière, 75013, Paris, France
| | - Jacques Boddaert
- Sorbonne Universités, Université Pierre et Marie Curie - Paris 06, Paris, France.,Assistance Publique - Hôpitaux de Paris (AP-HP), Service de gériatrie, Hôpital Pitié salpêtrière, 75013, Paris, France
| | - Dylan W de Lange
- Department of Intensive Care, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Alessandro Morandi
- Department of Rehabilitation Hospital Ancelle di Cremona, Cremona, Italy.,Geriatric Research Group, Brescia, Italy
| | - Guillaume Leblanc
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec City, QC, Canada.,Centre de recherche du CHU de Québec - Université Laval, Population Health and Optimal Health Practices Research Unit (Trauma - Emergency - Critical Care Medicine), Université Laval, Québec City, QC, Canada
| | - Antonio Artigas
- Department of Intensive Care Medecine, CIBER EnfermedadesRespiratorias, Corporacion Sanitaria Universitaria Parc Tauli, Autonomous University of Barcelona, Sabadell, Spain
| | - Hans Flaatten
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Ting PS, Chen L, Yang WC, Huang TS, Wu CC, Chen YY. Gender and age disparity in the initiation of life-supporting treatments: a population-based cohort study. BMC Med Ethics 2017; 18:62. [PMID: 29141641 PMCID: PMC5688717 DOI: 10.1186/s12910-017-0222-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Accepted: 11/08/2017] [Indexed: 11/17/2022] Open
Abstract
Background The relationships between age and the life-supporting treatments use, and between gender and the life-supporting treatments use are still controversial. Using extracorporeal membrane oxygenation as an example of life-supporting treatments, the objectives of this study were: (1) to examine the relationship between age and the extracorporeal membrane oxygenation use; (2) to examine the relationship between age and the extracorporeal membrane oxygenation use; and (3) to deliberate the ethical and societal implications of age and gender disparities in the initiation of extracorporeal membrane oxygenation. Methods This is a population-based, retrospective cohort study. Taiwan’s extracorporeal membrane oxygenation cases from 2000 to 2010 were collected. The annual incidence rate of extracorporeal membrane oxygenation use adjusting for both age and gender distribution for each year from 2000 to 2010 was derived using the population of 2000 as the reference population. The trend of extracorporeal membrane oxygenation use was examined using time-series linear regression analysis. We conducted joinpoint regression for estimating the trend change of extracorporeal membrane oxygenation use. Results The trends of extracorporeal membrane oxygenation use both for different gender groups, and for different age groups have been significantly increasing over time. Men were more likely to be supported by extracorporeal membrane oxygenation than women. Women’s perspectives toward life and death, and women’s perception of well-being may be associated with the phenomenon. In addition, the patients at the age of 65 or older were more likely to be supported by extracorporeal membrane oxygenation than those younger than 65. Family autonomy/family-determination, and the Confucian tradition of filial piety and respecting elders may account for this phenomenon. Conclusions This study showed gender and age disparities in the initiation of extracorporeal membrane oxygenation use in Taiwan, which may be accounted for by the cultural and societal values in Taiwan. For a healthcare professional who deals with patients’/family members’ medical decision-making to initiate life-supporting treatments, he/she should be sensitive not only to the legality, but also the societal and ethical issues involved.
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Affiliation(s)
- Peng-Sheng Ting
- Department of Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Likwang Chen
- Institute of Population Health Sciences, National Health Research Institutes, Miaoli, Taiwan
| | - Wei-Chih Yang
- Institute of Population Health Sciences, National Health Research Institutes, Miaoli, Taiwan
| | - Tien-Shang Huang
- Department of Medical Education, Cathay General Hospital, Miaoli, Taiwan
| | - Chau-Chung Wu
- Graduate Institute of Medical Education and Bioethics, National Taiwan University College of Medicine, Taipei, Taiwan.,Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yen-Yuan Chen
- Graduate Institute of Medical Education and Bioethics, National Taiwan University College of Medicine, Taipei, Taiwan. .,Department of Medical Education, National Taiwan University Hospital, Taipei, Taiwan.
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Skjaker SA, Hoel H, Dahl V, Stavem K. Factors associated with life-sustaining treatment restriction in a general intensive care unit. PLoS One 2017; 12:e0181312. [PMID: 28719660 PMCID: PMC5515429 DOI: 10.1371/journal.pone.0181312] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Accepted: 06/29/2017] [Indexed: 11/29/2022] Open
Abstract
Purpose Few previous studies have investigated associations between clinical variables available after 24 hours in the intensive care unit (ICU), including the Charlson Comorbidity Index (CCI), and decisions to restrict life-sustaining treatment. The aim of this study was to identify factors associated with the life-sustaining treatment restriction and to explore if CCI contributes to explaining decisions to restrict life-sustaining treatment in the ICU at a university hospital in Norway from 2007 to 2009. Methods Patients’ Simplified Acute Physiology Score II (SAPS II), age, sex, type of admission, and length of hospital stay prior to being admitted to the unit were recorded. We retrospectively registered the CCI for all patients based on the medical records prior to the index stay. A multivariable logistic regression analysis was used to assess factors associated with treatment restriction during the ICU stay. Results We included 936 patients, comprising 685 (73%) medical, 204 (22%) unscheduled and 47 (5%) scheduled surgical patients. Treatment restriction was experienced by 241 (26%) patients during their ICU stay. The variables that were significantly associated with treatment restriction in multivariable analysis were older age (odds ratio [OR] = 1.48 per 10 years, 95% confidence interval [CI] = 1.28–1.72 per 10 years), higher SAPS II (OR = 1.05, 95% CI = 1.04–1.07) and CCI values relative to the reference of CCI = 0: CCI = 2 (OR = 2.08, 95% CI = 1.20–3.61) and CCI≥3 (OR = 2.72, 95% CI = 1.65–4.47). Conclusions In multivariable analysis, older age, greater illness severity after 24 h in the ICU and greater comorbidity at hospital admission were independently associated with subsequent life-sustaining treatment restriction. The CCI score contributed additional information independent of the SAPS II illness severity rating.
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Affiliation(s)
- Stein Arve Skjaker
- Section of Orthopaedic Emergency, Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
- * E-mail:
| | - Henrik Hoel
- Department of Surgery, Sykehuset Innlandet Kongsvinger, Kongsvinger, Norway
| | - Vegard Dahl
- Department of Anaesthesiology, Surgical Division, Akershus University Hospital, Lørenskog, Norway
| | - Knut Stavem
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Pulmonary Medicine, Medical Division, Akershus University Hospital, Lørenskog, Norway
- Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
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Akroute AR, Bondas T. Critical care nurses and relatives of elderly patients in intensive care unit–Ambivalent interaction. Intensive Crit Care Nurs 2016; 34:59-72. [DOI: 10.1016/j.iccn.2015.08.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Revised: 07/19/2015] [Accepted: 08/07/2015] [Indexed: 12/31/2022]
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Karlsson V, Bergbom I, Ringdal M, Jonsson A. After discharge home: a qualitative analysis of older ICU patients' experiences and care needs. Scand J Caring Sci 2015; 30:749-756. [PMID: 26662180 DOI: 10.1111/scs.12301] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 09/07/2015] [Indexed: 01/22/2023]
Abstract
Most patients in intensive care units suffer from critical diseases/injuries and are in need of life-saving medical treatment. Recovery after such diseases/injuries may be lengthy and may vary. Little is known about older patients' own assessment of recovery following intensive care. The aim of this study was to explore and describe older patients' experiences of recovery and need of care within 2 months following discharge from hospital after being cared for in an intensive care unit. Fifteen patients 65 years or older, who had received care in an intensive care unit, were telephone-interviewed 2 months following discharge. The interview texts were analysed using qualitative content analysis. Six themes were identified: 'Discharge - a matter of physicians' and nurses' decisions', 'Wanted to go home', 'Feeling well and feeling better, but…', 'Recovered or not, that is the question', 'In need of help from others' and 'In need of care'. Patients trusted in the medical experts' assessment of their condition as regarded hospital discharge, but they also stated that they wanted to go home, as soon as possible, to their own familiar and private environment. Patients did not see the hospital as a place for recovery. Patients claimed that they were used to taking care of themselves within the limits of their strength and energy. If they need help, they first of all turn to family members or relatives. Patients who reported comorbidity did not assess themselves as recovered, while others stated that they had recovered but also suffered from a variety of discomforting symptoms.
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Affiliation(s)
- Veronika Karlsson
- School of Health and Education, Skövde University College, Skövde, Sweden.,Department of Anesthesia and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ingegerd Bergbom
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mona Ringdal
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Annikki Jonsson
- School of Health Science, Borås University College, Borås, Sweden
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Chen CY, Wu CJ, Pan CF, Chen HH, Chen YW. Influence of Age on Critically Ill Patients with Cirrhosis. INT J GERONTOL 2015. [DOI: 10.1016/j.ijge.2014.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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21
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Elderly in the Intensive Care Unit: Age and Mortality. INT J GERONTOL 2015. [DOI: 10.1016/j.ijge.2015.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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22
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Joynt GM, Lipman J, Hartog C, Guidet B, Paruk F, Feldman C, Kissoon N, Sprung CL. The Durban World Congress Ethics Round Table IV: health care professional end-of-life decision making. J Crit Care 2014; 30:224-30. [PMID: 25454075 DOI: 10.1016/j.jcrc.2014.10.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Revised: 10/11/2014] [Accepted: 10/14/2014] [Indexed: 11/26/2022]
Abstract
INTRODUCTION When terminal illness exists, it is common clinical practice worldwide to withhold (WH) or withdraw (WD) life-sustaining treatments. Systematic documentation of professional opinion and perceived practice similarities and differences may allow recommendations to be developed. MATERIALS AND METHODS Speakers from invited faculty of the World Federation of Societies of Intensive and Critical Care Medicine Congress that took place in Durban (2013), with an interest in ethics, were approached to participate in an ethics round table. Key domains of health care professional end-of-life decision making were defined, explored by discussion, and then questions related to current practice and opinion developed and subsequently answered by round-table participants to establish the presence or absence of agreement. RESULTS Agreement was established for the desirability for early goal-of-care discussions and discussions between health care professionals to establish health care provider consensus and confirmation of the grounds for WH/WD, before holding formal WH/WD discussions with patients/surrogates. Nurse and other health care professional involvement were common in most but not all countries/regions. Principles and practical triggers for initiating discussions on WH/WD, such as multiorgan failure, predicted short-term survival, and predicted poor neurologic outcome, were identified. CONCLUSIONS There was majority agreement for many but not all statements describing health care professional end-of-life decision making.
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Affiliation(s)
- Gavin M Joynt
- Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, NT, Hong Kong.
| | | | - Christiane Hartog
- Center for Sepsis Control and Care, University of Jena, Jena, Germany
| | | | - Fathima Paruk
- University of the Witwatersrand, Johannesburg, South Africa
| | - Charles Feldman
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Niranjan Kissoon
- BC Children's Hospital, University of British Columbia, Vancouver, Canada
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Guidet B, Hodgson E, Feldman C, Paruk F, Lipman J, Koh Y, Vincent JL, Azoulay E, Sprung CL. The Durban World Congress Ethics Round Table Conference Report: II. Withholding or withdrawing of treatment in elderly patients admitted to the intensive care unit. J Crit Care 2014; 29:896-901. [PMID: 25216948 DOI: 10.1016/j.jcrc.2014.08.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Revised: 07/31/2014] [Accepted: 08/02/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Life-sustaining treatment (LST) limitation for elderly patients is highly controversial. In that context, it is useful to evaluate the attitudes to LST in the elderly among experienced intensive care unit (ICU) physicians with different backgrounds and cultures. METHODS A panel of 22 international ICU physicians from 13 countries responded to a questionnaire related to withholding (WH) and withdrawing (WD) LST in elderly patients using a semi-Likert scale. RESULTS Most experts disagree or strongly disagree (77%) that age should be used as the sole criterion for WH or WD LST, and almost all disagree (91%) that there should be a specific age for such decision making. However, the vast majority (91%) acknowledge that age should be an important consideration in conjunction with other factors. Disagreement for consideration of prioritizing the young over the old in normal ICU operations was reported in 68%, whereas in an emergency triage situation, disagreement dropped to 18%. CONCLUSIONS There is a consensus among ICU physicians that age cannot be the sole criterion on which health care decisions should be made. In that perspective, it is important to provide data showing that outcome differences between elderly and nonelderly patients are partly related to decisions to forgo LSTs.
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Affiliation(s)
- Bertrand Guidet
- Assistance Publique, Hôpitaux de Paris, Hôpital Saint-Antoine, service de réanimation médicale, Paris, F-75012, France; Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique, F-75013, Paris, France; INSERM, UMR_S 1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique, F-75013, Paris, France.
| | - Eric Hodgson
- Department of Anaesthesia & Critical Care, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, eThekwini-Durban, South Africa
| | - Charles Feldman
- Division of Pulmonology, Department of Internal Medicine, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Fathima Paruk
- Department of Anaesthesiology, University of the Witwatersrand, Johannesburg, South Africa
| | - Jeffrey Lipman
- Department of Anaesthesiology and Critical Care, The University of Queensland School of Medicine: Department of Intensive Care Medicine l Royal Brisbane and Women's Hospital, Herston, QLD 4029
| | - Younsuck Koh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, Univ. of Ulsan College of Medicine, 388-1 Pungnap Dong Songpa Ku, Seoul, 138-736, Korea
| | - Jean Louis Vincent
- Dept of Intensive Care, Université Libre de Bruxelles, Erasme Univ Hospital
| | - Elie Azoulay
- AP-HP, Hôpital Saint-Louis, Medical ICU, University Paris-7 Paris-Diderot, UFR de Médecine, 1 avenue Claude Vellefaux, 75010 Paris, France
| | - Charles L Sprung
- General Intensive Care Unit, Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Center, PO Box 12000, Jerusalem, Israel 91120
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Zhao Q, Zhang X, Fang Y, Gong J, Gu B, Ma G. Current situation and associated factors of withdrawing or withholding life support to patients in an intensive care unit of cancer center in China. PLoS One 2014; 9:e98545. [PMID: 24870360 PMCID: PMC4037202 DOI: 10.1371/journal.pone.0098545] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Accepted: 05/04/2014] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES To investigate the current situation and analyze the associated factors of withdrawing or withholding life support in the intensive care unit (ICU) of our cancer center. METHODS Three hundred and twenty-two cancer patients in critical status were admitted to our ICU in 2010 and 2011. They were included in the study and were classified into two groups: withdrawing or withholding life support (WWLS), and full life support (FLS). Demographic information and clinical data were collected and compared between the two groups. Factors associated with withdrawing or withholding life support were analyzed with univariate and multivariate logistic regression analysis. RESULTS Eighty-two of the 322 cases (25.5% of all) made the decisions to withdraw or withhold life support. Emergency or critical condition at hospital admission, higher scores of Acute Physiology and Chronic Health Evaluation II (APACHE II) in 12 hours after ICU admission, financial difficulties and humanistic care requirements are important factors associated with withdrawing or withholding life support. CONCLUSIONS Withdrawing or withholding life support is not uncommon in critically ill cancer patients in China. Characteristics and associated factors of the decision-making are related to the current medical system, medical resources and traditional culture of the country.
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Affiliation(s)
- Qingyu Zhao
- Intensive Care Unit, Sun Yat-sen University Cancer Center, Guangzhou, China
- * E-mail:
| | - Xiaodan Zhang
- Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Yi Fang
- Intensive Care Unit, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Jian Gong
- Intensive Care Unit, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Baochun Gu
- Intensive Care Unit, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Gang Ma
- Intensive Care Unit, Sun Yat-sen University Cancer Center, Guangzhou, China
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25
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Faverio P, Aliberti S, Bellelli G, Suigo G, Lonni S, Pesci A, Restrepo MI. The management of community-acquired pneumonia in the elderly. Eur J Intern Med 2014; 25:312-9. [PMID: 24360244 PMCID: PMC4102338 DOI: 10.1016/j.ejim.2013.12.001] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Revised: 12/01/2013] [Accepted: 12/02/2013] [Indexed: 12/27/2022]
Abstract
Pneumonia is one of the main causes of morbidity and mortality in the elderly. The elderly population has exponentially increased in the last decades and the current epidemiological trends indicate that it is expected to further increase. Therefore, recognizing the special needs of older people is of paramount importance. In this review we address the main differences between elderly and adult patients with pneumonia. We focus on several aspects, including the atypical clinical presentation of pneumonia in the elderly, the methods to assess severity of illness, the appropriate setting of care, and the management of comorbidities. We also discuss how to approach the common complications of severe pneumonia, including acute respiratory failure and severe sepsis. Moreover, we debate whether or not elderly patients are at higher risk of infection due to multi-drug resistant pathogens and which risk factors should be considered when choosing the antibiotic therapy. We highlight the differences in the definition of clinical stability and treatment failure between adults and elderly patients. Finally, we review the main outcomes, preventive and supportive measures to be considered in elderly patients with pneumonia.
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Affiliation(s)
- Paola Faverio
- Department of Health Science, University of Milan Bicocca, Clinica Pneumologica, AO San Gerardo, Via Pergolesi 33, Monza, Italy; University of Texas Health Science Center at San Antonio, TX, USA
| | - Stefano Aliberti
- Department of Health Science, University of Milan Bicocca, Clinica Pneumologica, AO San Gerardo, Via Pergolesi 33, Monza, Italy.
| | - Giuseppe Bellelli
- Department of Health Science, University of Milan Bicocca, Geriatric Clinic, AO San Gerardo, Via Pergolesi 33, Monza, Italy
| | - Giulia Suigo
- Department of Health Science, University of Milan Bicocca, Clinica Pneumologica, AO San Gerardo, Via Pergolesi 33, Monza, Italy
| | - Sara Lonni
- Department of Health Science, University of Milan Bicocca, Clinica Pneumologica, AO San Gerardo, Via Pergolesi 33, Monza, Italy
| | - Alberto Pesci
- Department of Health Science, University of Milan Bicocca, Clinica Pneumologica, AO San Gerardo, Via Pergolesi 33, Monza, Italy
| | - Marcos I Restrepo
- University of Texas Health Science Center at San Antonio, TX, USA; South Texas Veterans Healthcare System Audie L. Murphy Division, San Antonio, TX, USA; Veterans Evidence Based Research Dissemination and Implementation Center (VERDICT), San Antonio, TX, USA
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HOEL H, SKJAKER SA, HAAGENSEN R, STAVEM K. Decisions to withhold or withdraw life-sustaining treatment in a Norwegian intensive care unit. Acta Anaesthesiol Scand 2014; 58:329-36. [PMID: 24405518 DOI: 10.1111/aas.12246] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2013] [Indexed: 12/23/2022]
Abstract
BACKGROUND To withhold and withdraw treatment are important and difficult decisions made in the intensive care unit (ICU). The aim of this study was to investigate the incidence of withholding or withdrawing treatment, characteristics of the patients, and how these decision processes were handled and documented in a general ICU from 2007 to 2009 in a university hospital in Norway. METHODS Patient characteristics and outcomes of treatment were prospectively registered. We retrospectively reviewed the medical records for information on limitations in treatment. RESULTS In total, 1287 patients were admitted to the ICU. The ICU mortality was 208 (16%), and the hospital mortality was 341 (26%). In total, 301 patients (23%) had treatment withheld or withdrawn. Medical and unscheduled surgical patients with limitations in treatment had higher Simplified Acute Physiology Score II (P < 0.001) and were older (P < 0.001) than those without limitations in treatment. The most common main reason for withdrawing treatment was poor prognosis. According to the medical records, the patient was involved in the decision-making regarding withdrawal of treatment in only 2% of the cases, and the patient's relatives were involved in the decision-making in 77% of the cases. In 12% of the cases, type of treatment withdrawn was not documented. CONCLUSION Withholding or withdrawing treatment in the ICU was common. Medical and unscheduled surgical patients with limitations in treatment were older and more severely ill than patients without limitations. There is a potential for better documentation of the processes regarding withholding or withdrawing life-sustaining intensive care treatment.
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Affiliation(s)
- H. HOEL
- Institute of Clinical Medicine; University of Oslo; Oslo Norway
| | - S. A. SKJAKER
- Institute of Clinical Medicine; University of Oslo; Oslo Norway
| | - R. HAAGENSEN
- Department of Anaesthesiology; Akershus University Hospital; Akershus Norway
| | - K. STAVEM
- Institute of Clinical Medicine; University of Oslo; Oslo Norway
- Department of Pulmonary Medicine; Medical Division; Akershus University Hospital; Akershus Norway
- Health Services Research Unit; Akershus University Hospital; Akershus Norway
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27
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Affiliation(s)
- H. FLAATTEN
- Department of Anaesthesia and Intensive Care; Haukeland University Hospital - General ICU; Bergen Norway
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NIELSSON MS, CHRISTIANSEN CF, JOHANSEN MB, RASMUSSEN BS, TØNNESEN E, NØRGAARD M. Mortality in elderly ICU patients: a cohort study. Acta Anaesthesiol Scand 2014; 58:19-26. [PMID: 24117049 DOI: 10.1111/aas.12211] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2013] [Indexed: 01/19/2023]
Abstract
BACKGROUND The population is aging. We examined changes in the proportion of elderly (≥ 80 years) intensive care unit (ICU) patients during 2005-2011 and the association between age and mortality controlling for preexisting morbidity. METHODS Through the Danish National Patient Registry, we identified a cohort of 49,938 ICU admissions (47,596 patients) in Northern Denmark from 2005 to 2011. Patients were subdivided in age groups (15-49, 50-64, 65-79 and ≥ 80 years) and calendar year. We estimated 30-day and 31-365-day mortality and mortality rate ratios (MRRs), stratified by admission type (medical and elective/acute surgical patients). Mortality was compared between age groups adjusting for sex and preexisting morbidity using 50-64-year-olds as reference. RESULTS The proportion of elderly patients increased from 11.7% of all ICU patients in 2005 to 13.8% in 2011. Among the elderly, the 30-day mortality was 43.7% in medical, 39.6% in acute surgical, and 11.6% in elective surgical ICU patients. The corresponding adjusted 30-day MRRs compared with the 50-64-year-olds were 2.7 [95% confidence interval (CI) 2.5-3.0] in medical, 2.7 (95% CI 2.4-3.0) in acute surgical, and 5.2 (95% CI 4.1-6.6) in elective surgical ICU patients. The 31-365-day mortality among elderly patients was 25.4% in medical, 26.9% in acute, and 11.9% in elective surgical ICU patients, corresponding to adjusted MRRs of 2.5 (95% CI 2.1-2.9), 2.2 (95% CI 1.9-2.5), and 1.9 (95% CI 1.6-2.3), respectively. CONCLUSIONS During 2005-2011, there was an 18% increase in the proportion of elderly ICU patients. Advancing age is associated with increased mortality even after controlling for preexisting morbidity.
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Affiliation(s)
- M. S. NIELSSON
- Department of Clinical Epidemiology; Aarhus University Hospital; Aarhus Denmark
- Department of Anaesthesia and Intensive Care Medicine; Aalborg University Hospital; Aalborg Denmark
| | - C. F. CHRISTIANSEN
- Department of Clinical Epidemiology; Aarhus University Hospital; Aarhus Denmark
| | - M. B. JOHANSEN
- Department of Clinical Epidemiology; Aarhus University Hospital; Aarhus Denmark
| | - B. S. RASMUSSEN
- Department of Anaesthesia and Intensive Care Medicine; Aalborg University Hospital; Aalborg Denmark
| | - E. TØNNESEN
- Department of Anaesthesia and Intensive Care Medicine; Aarhus University Hospital; Aarhus Denmark
| | - M. NØRGAARD
- Department of Clinical Epidemiology; Aarhus University Hospital; Aarhus Denmark
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CHRISTENSEN K, HANSEN TG, RASMUSSEN LS. Intensive care units and the oldest-old: are we doing good, too little, or too much? Acta Anaesthesiol Scand 2013; 57:681-3. [PMID: 23745653 DOI: 10.1111/aas.12110] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
| | - T. G. HANSEN
- Department of Anaesthesia & Intensive Care; Odense University Hospital and Clinical Institute - Anesthesiology; University of Southern Denmark; Odense; Denmark
| | - L. S. RASMUSSEN
- Department of Anaesthesia; Center of Head and Orthopaedics; Copenhagen University Hospital, Rigshospitalet; Copenhagen; Denmark
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