1
|
Smeele NVR, Chorus CG, Schermer MHN, de Bekker-Grob EW. Towards machine learning for moral choice analysis in health economics: A literature review and research agenda. Soc Sci Med 2023; 326:115910. [PMID: 37121066 DOI: 10.1016/j.socscimed.2023.115910] [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: 11/11/2022] [Revised: 04/06/2023] [Accepted: 04/13/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND Discrete choice models (DCMs) for moral choice analysis will likely lead to erroneous model outcomes and misguided policy recommendations, as only some characteristics of moral decision-making are considered. Machine learning (ML) is recently gaining interest in the field of discrete choice modelling. This paper explores the potential of combining DCMs and ML to study moral decision-making more accurately and better inform policy decisions in healthcare. METHODS An interdisciplinary literature search across four databases - PubMed, Scopus, Web of Science, and Arxiv - was conducted to gather papers. Based on the Preferred Reporting Items for Systematic and Meta-analyses (PRISMA) guideline, studies were screened for eligibility on inclusion criteria and extracted attributes from eligible papers. Of the 6285 articles, we included 277 studies. RESULTS DCMs have shortcomings in studying moral decision-making. Whilst the DCMs' mathematical elegance and behavioural appeal hold clear interpretations, the models do not account for the 'moral' cost and benefit in an individual's utility calculation. The literature showed that ML obtains higher predictive power, model flexibility, and ability to handle large and unstructured datasets. Combining the strengths of ML methods with DCMs has the potential for studying moral decision-making. CONCLUSIONS By providing a research agenda, this paper highlights that ML has clear potential to i) find and deepen the utility specification of DCMs, and ii) enrich the insights extracted from DCMs by considering the intrapersonal determinants of moral decision-making.
Collapse
Affiliation(s)
- Nicholas V R Smeele
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, the Netherlands; Erasmus Choice Modelling Centre, Erasmus University Rotterdam, Rotterdam, the Netherlands; Erasmus Centre for Health Economics Rotterdam, Erasmus University Rotterdam, Rotterdam, the Netherlands.
| | - Caspar G Chorus
- Department of Engineering Systems and Services, Delft University of Technology, Delft, the Netherlands; Faculty of Industrial Design Engineering, Delft University of Technology, Delft, the Netherlands
| | - Maartje H N Schermer
- Department of Medical Ethics, Philosophy and History of Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Esther W de Bekker-Grob
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, the Netherlands; Erasmus Choice Modelling Centre, Erasmus University Rotterdam, Rotterdam, the Netherlands; Erasmus Centre for Health Economics Rotterdam, Erasmus University Rotterdam, Rotterdam, the Netherlands
| |
Collapse
|
2
|
Factors that influence intensive care admission decisions for older people: A systematic review. Aust Crit Care 2023; 36:274-284. [PMID: 35144889 DOI: 10.1016/j.aucc.2021.12.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 11/30/2021] [Accepted: 12/19/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The population worldwide is rapidly ageing, and demand for intensive care is increasing. People aged 85 years and above, known as the oldest old, are particularly vulnerable to critical illness owing to the physiological effects of ageing. Evidence surrounding admission of the oldest old to the intensive care is limited. OBJECTIVE The objective of this study was to systematically and comprehensively review and synthesise the published research investigating factors that influence decisions to admit the oldest old to the intensive care unit. METHOD This was a systematic review and narrative synthesis. Following a comprehensive search of CINAHL, Embase, and Medline databases, peer-reviewed primary research articles examining factors associated with admission or refusal to admit the oldest old to intensive care were selected. Data were extracted into tables and narratively synthesised. RESULTS Six studies met the inclusion criteria. Three studies identified factors associated with admission such as greater premorbid self-sufficiency, patient preferences, alignment between patient and physicians' goals of treatment, age less than 85 years, and absence of cancer, or previous intensive care admission. Factors associated with refusal to admit were identified in all six studies and included limited or no bed availability, level of ICU physician experience, patients being deemed too ill or too well to benefit, and older age. CONCLUSIONS Published research investigating decision-making about admission or refusal to admit the oldest old to the intensive care unit is scant. The ageing population and increasing demand for intensive care unit resources has amplified the need for greater understanding of factors that influence decisions to admit or refuse admission of the oldest old to the intensive care unit. Such knowledge may inform guidelines regarding complex practice decisions about admission of the oldest old to an intensive care unit. Such guidelines would ensure the specialty needs of this population are considered and would reduce admission decisions that might disadvantage older people.
Collapse
|
3
|
Lepre RDL, Mezzaroba AL, Cardoso LTQ, Matsuo T, Grion CMC. Refusal of beds and triage of patients admitted to intensive care units in Brazil: a cross-sectional national survey. Rev Bras Ter Intensiva 2022; 34:484-491. [PMID: 36888829 PMCID: PMC9987007 DOI: 10.5935/0103-507x.20220264-pt] [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: 07/26/2022] [Accepted: 11/27/2022] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE To obtain data on bed refusal in intensive care units in Brazil and to evaluate the use of triage systems by professionals. METHODS A cross-sectional survey. Using the Delphi methodology, a questionnaire was created contemplating the objectives of the study. Physicians and nurses enrolled in the research network of the Associação de Medicina Intensiva Brasileira (AMIBnet) were invited to participate. A web platform (SurveyMonkey®) was used to distribute the questionnaire. The variables in this study were measured in categories and expressed as proportions. The chi-square test or Fisher's exact test was used to verify associations. The significance level was set at 5%. RESULTS In total, 231 professionals answered the questionnaire, representing all regions of the country. The national intensive care units had an occupancy rate of more than 90% always or frequently for 90.8% of the participants. Among the participants, 84.4% had already refused admitting patients to the intensive care unit due to the capacity of the unit. Half of the Brazilian institutions (49.7%) did not have triage protocols for admission to intensive beds. CONCLUSIONS Bed refusal due to high occupancy rates is common in Brazilian intensive care units. Even so, half of the services in Brazil do not adopt protocols for triage of beds.
Collapse
Affiliation(s)
- Rafaela de Lemos Lepre
- Departamento de Clínica Cirúrgica, Universidade Estadual de Londrina - Londrina (PR), Brasil
| | - Ana Luiza Mezzaroba
- Departamento de Clínica Médica, Universidade Estadual de Londrina - Londrina (PR), Brasil
| | | | - Tiemi Matsuo
- Departamento de Estatística, Universidade Estadual de Londrina - Londrina (PR), Brasil
| | | |
Collapse
|
4
|
Jones RP. A pragmatic method to compare international critical care beds: Implications to pandemic preparedness and non-pandemic planning. Int J Health Plann Manage 2022; 37:2167-2182. [PMID: 35332580 DOI: 10.1002/hpm.3458] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 01/22/2022] [Accepted: 03/08/2022] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The current method for assessing critical care (CCU) bed numbers between countries is unreliable. METHODS A pragmatic method is presented using a logarithmic relationship between CCU beds per 1000 deaths and deaths per 1000 population, both of which are readily available. The method relies on the importance of the nearness to death effect, and on the effect of population size. RESULTS The method was tested using CCU bed numbers from 65 countries. A series of logarithmic relationships can be seen. High versus low countries can be distinguished by adjusting all countries to a common crude mortality rate. Hence at 9.5 deaths per 1000 population 'high' CCU bed countries average of around 30 CCU beds per 1000 deaths, while 'very low' countries only average 3 CCU beds per 1000 deaths. The United Kingdom falls among countries with low critical care provision with an average of 8 CCU beds per 1000 deaths, and during the COVID-19 epidemic UK industry intervened to rapidly manufacture various types of ventilators to avoid a catastrophe. CCU bed numbers in India are around 8.1 per 1000 deaths, which places it in the low category. However, such beds are inequitably distributed with the poorest states all in the 'very low' category. In India only around 50% of CCU beds have a ventilator. CONCLUSION A feasible region is defined for the optimum number of CCU beds.
Collapse
|
5
|
Merlo F, Lepori M, Malacrida R, Albanese E, Fadda M. Physicians' Acceptance of Triage Guidelines in the Context of the COVID-19 Pandemic: A Qualitative Study. Front Public Health 2021; 9:695231. [PMID: 34395369 PMCID: PMC8360847 DOI: 10.3389/fpubh.2021.695231] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 07/05/2021] [Indexed: 11/28/2022] Open
Abstract
Aims: One of the major ethical challenges posed by the Covid-19 pandemic comes in the form of fair triage decisions for critically ill patients in situations where life-saving resources are limited. In Spring 2020, the Swiss Academy of Medical Sciences (SAMS) issued specific guidelines on triage for intensive-care treatment in the context of the Covid-19 pandemic. While evidence has shown that the capacities of intensive care medicine throughout Switzerland were sufficient to take care of all critically ill patients during the first wave of the outbreak, no evidence is available regarding the acceptance of these guidelines by ICU staff. The aim of this qualitative study was to explore the acceptance and perceived implementation of the SAMS guidelines among a sample of senior physicians involved in the care of Covid-19 patients in the Canton of Ticino. Specific objectives included capturing and describing physicians' attitudes toward the guidelines, any challenges experienced in their application, and any perceived factors that facilitated or would facilitate their application. Methods: We conducted face-to-face and telephone interviews with a purposive sample of nine senior physicians employed as either head of unity, deputy-head of unit, or medical director in either one of the two Covid-19 hospitals in the Canton of Ticino during the peak of the outbreak. Interviews were transcribed verbatim and thematically analyzed using an inductive approach. Results: We found that participants held different views regarding the nature of the guidelines, saw decisions on admission as a matter of collective responsibility, argued that decisions should be based on a medical futility principle rather than an age criterion, and found that difficulties to address end-of-life issues led to a comeback of paternalism. Conclusions: Results highlight the importance of clarifying the nature of the guidelines, establishing authority, and responsibility during triaging decisions, recognizing and addressing sources of interference with patients' autonomy, and the need of a cultural shift in timely and efficiently addressing end-of-life issues.
Collapse
Affiliation(s)
- Federica Merlo
- Faculty of Biomedical Sciences, Institute of Public Health, Università della Svizzera italiana, Lugano, Switzerland.,Sasso Corbaro Foundation, Bellinzona, Switzerland
| | - Mattia Lepori
- Ente Ospedaliero Cantonale, Area Medica Direzione Generale, Bellinzona, Switzerland
| | | | - Emiliano Albanese
- Faculty of Biomedical Sciences, Institute of Public Health, Università della Svizzera italiana, Lugano, Switzerland
| | - Marta Fadda
- Faculty of Biomedical Sciences, Institute of Public Health, Università della Svizzera italiana, Lugano, Switzerland
| |
Collapse
|
6
|
Hesselink G, Straten L, Gallée L, Brants A, Holkenborg J, Barten DG, Schoon Y. Holding the frontline: a cross-sectional survey of emergency department staff well-being and psychological distress in the course of the COVID-19 outbreak. BMC Health Serv Res 2021; 21:525. [PMID: 34051760 PMCID: PMC8164246 DOI: 10.1186/s12913-021-06555-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 05/19/2021] [Indexed: 11/10/2022] Open
Abstract
Background The coronavirus disease 2019 (COVID-19) outbreak has been associated with stress and challenges for healthcare professionals, especially for those working in the front-line of treating COVID-19 patients. This study aimed to: 1) assess changes in well-being and perceived stress symptoms of Dutch emergency department (ED) staff in the course of the first COVID-19 wave, and 2) assess and explore stressors experienced by ED staff since the COVID-19 outbreak. Methods We conducted a cross-sectional study. An online questionnaire was administered during June–July 2020 to physicians, nurses and non-clinical staff of four EDs in the Netherlands. Well-being and stress symptoms (i.e., cognitive, emotional and physical) were scored for the periods pre, during and after the first COVID-19 wave using the World Health Organization Well-Being Index (WHO-5) and a 10-point Likert scale. Stressors were assessed and explored by rating experiences with specific situations (i.e., frequency and intensity of distress) and in free-text narratives. Quantitative data were analyzed with descriptive statistics and generalized estimating equations (GEE). Narratives were analyzed thematically. Results In total, 192 questionnaires were returned (39% response). Compared to pre-COVID-19, the mean WHO-5 index score (range: 0–100) decreased significantly with 14.1 points (p < 0.001) during the peak of the first wave and 3.7 points (< 0.001) after the first wave. Mean self-perceived stress symptom levels almost doubled during the peak of the first wave (≤0.005). Half of the respondents reported experiencing more moral distress in the ED since the COVID-19 outbreak. High levels of distress were primarily found in situations where the staff was unable to provide or facilitate necessary emotional support to a patient or family. Analysis of 51 free-texts revealed witnessing suffering, high work pressure, fear of contamination, inability to provide comfort and support, rapidly changing protocols regarding COVID-19 care and personal protection, and shortage of protection equipment as important stressors. Conclusions The first COVID-19 wave took its toll on ED staff. Actions to limit drop-out and illness among staff resulting from psychological distress are vital to secure acute care for (non-)COVID-19 patients during future infection waves. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06555-5.
Collapse
Affiliation(s)
- Gijs Hesselink
- Department of Emergency Medicine, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands. .,IQ healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, P.O. Box 9101, 114 IQ healthcare, 6500 HB, Nijmegen, The Netherlands.
| | - Lise Straten
- Department of Emergency Medicine, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lars Gallée
- Department of Emergency Medicine, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Anne Brants
- Department of Emergency Medicine, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Joris Holkenborg
- Department of Emergency Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Dennis G Barten
- Department of Emergency Medicine, VieCuri Medical Center, Venlo, The Netherlands
| | - Yvonne Schoon
- Department of Emergency Medicine, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Geriatrics, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| |
Collapse
|
7
|
Putot S, Jouanny P, Barben J, Mazen E, Da Silva S, Dipanda M, Asgassou S, Nuss V, Laborde C, Mihai AM, Vovelle J, Manckoundia P, Putot A. Level of Medical Intervention in Geriatric Settings: Decision Factors and Correlation With Mortality. J Am Med Dir Assoc 2021; 22:2587-2592. [PMID: 33992608 DOI: 10.1016/j.jamda.2021.04.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/06/2021] [Accepted: 04/11/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Level of medical intervention (LMI) has to be adapted to each patient in geriatric care. LMI scales intend to help nonintensive care (NIC) decisions, giving priority to patient choice and collegial discussion. In the present study, we aimed to assess the parameters associated with the NIC decision and whether these parameters differ from those associated with in-hospital mortality. DESIGN Prospective observational study. SETTING AND PARTICIPANTS All consecutive patients from a French 62-bed acute geriatric unit over 1 year. METHODS Factors from the geriatric assessment associated with the decision of NIC were compared with those associated with in-hospital and 1-year mortality, in univariate and multivariate analyses. RESULTS In total, 1654 consecutive patients (median age 87 years) were included. Collegial reflection led to NIC decision for 532 patients (32%). In-hospital and 1-year mortality were 22% and 54% in the NIC group vs 2% and 27% in the rest of the cohort (P < .001 for both). In multivariable analysis, high Charlson Comorbidity Index [odds ratio (OR) 1.15, 95% confidence interval (CI) 1.06-1.23, per point], severe neurocognitive disorders (OR 2.78, 95% CI 1.67-4.55), dependence (OR 1.92, 95% CI 1.45-2.59), and nursing home residence (OR 2.38, 95% CI 1.85-3.13) were highly associated with NIC decision but not with in-hospital mortality. Conversely, acute diseases had little impact on LMI despite their high short-term prognostic burden. CONCLUSIONS AND IMPLICATIONS Neurocognitive disorders and dependence were strongly associated with NIC decision, even though they were not significantly associated with in-hospital mortality. The decision-making process of LMI therefore seems to go beyond the notion of short-term survival.
Collapse
Affiliation(s)
- Sophie Putot
- Service de médecine interne gériatrie, Pôle Personnes Agées, Centre Hospitalier Universitaire, Dijon, Bourgogne Franche-Comté, France
| | - Pierre Jouanny
- Service de médecine interne gériatrie, Pôle Personnes Agées, Centre Hospitalier Universitaire, Dijon, Bourgogne Franche-Comté, France; Institut National de la Santé et de la Recherche Médicale U1093 Cognition Action Plasticité, Université de Bourgogne Franche-Comté, Dijon, Bourgogne Franche-Comté, France
| | - Jeremy Barben
- Service de médecine interne gériatrie, Pôle Personnes Agées, Centre Hospitalier Universitaire, Dijon, Bourgogne Franche-Comté, France
| | - Emmanuel Mazen
- Service de médecine interne gériatrie, Pôle Personnes Agées, Centre Hospitalier Universitaire, Dijon, Bourgogne Franche-Comté, France
| | - Sofia Da Silva
- Service de médecine interne gériatrie, Pôle Personnes Agées, Centre Hospitalier Universitaire, Dijon, Bourgogne Franche-Comté, France
| | - Mélanie Dipanda
- Service de médecine interne gériatrie, Pôle Personnes Agées, Centre Hospitalier Universitaire, Dijon, Bourgogne Franche-Comté, France
| | - Sanaa Asgassou
- Service de médecine interne gériatrie, Pôle Personnes Agées, Centre Hospitalier Universitaire, Dijon, Bourgogne Franche-Comté, France
| | - Valentine Nuss
- Service de médecine interne gériatrie, Pôle Personnes Agées, Centre Hospitalier Universitaire, Dijon, Bourgogne Franche-Comté, France
| | - Caroline Laborde
- Service de médecine interne gériatrie, Pôle Personnes Agées, Centre Hospitalier Universitaire, Dijon, Bourgogne Franche-Comté, France
| | - Anca M Mihai
- Service de médecine interne gériatrie, Pôle Personnes Agées, Centre Hospitalier Universitaire, Dijon, Bourgogne Franche-Comté, France
| | - Jérémie Vovelle
- Service de médecine interne gériatrie, Pôle Personnes Agées, Centre Hospitalier Universitaire, Dijon, Bourgogne Franche-Comté, France
| | - Patrick Manckoundia
- Service de médecine interne gériatrie, Pôle Personnes Agées, Centre Hospitalier Universitaire, Dijon, Bourgogne Franche-Comté, France; Institut National de la Santé et de la Recherche Médicale U1093 Cognition Action Plasticité, Université de Bourgogne Franche-Comté, Dijon, Bourgogne Franche-Comté, France
| | - Alain Putot
- Service de médecine interne gériatrie, Pôle Personnes Agées, Centre Hospitalier Universitaire, Dijon, Bourgogne Franche-Comté, France.
| |
Collapse
|
8
|
Dahine J, Hébert PC, Ziegler D, Chenail N, Ferrari N, Hébert R. Practices in Triage and Transfer of Critically Ill Patients: A Qualitative Systematic Review of Selection Criteria. Crit Care Med 2020; 48:e1147-e1157. [PMID: 32858530 PMCID: PMC7493782 DOI: 10.1097/ccm.0000000000004624] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To identify and appraise articles describing criteria used to prioritize or withhold a critical care admission. DATA SOURCES PubMed, Embase, Medline, EBM Reviews, and CINAHL Complete databases. Gray literature searches and a manual review of references were also performed. Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines were followed. STUDY SELECTION We sought all articles and abstracts of original research as well as local, provincial, or national policies on the topic of ICU resource allocation. We excluded studies whose population of interest was neonatal, pediatric, trauma, or noncritically ill. Screening of 6,633 citations was conducted. DATA EXTRACTION Triage and/or transport criteria were extracted, based on type of article, methodology, publication year, and country. An appraisal scale was developed to assess the quality of identified articles. We also developed a robustness score to further appraise the robustness of the evidence supporting each criterion. Finally, all criteria were extracted, evaluated, and grouped by theme. DATA SYNTHESIS One-hundred twenty-nine articles were included. These were mainly original research (34%), guidelines (26%), and reviews (21%). Among them, we identified 200 unique triage and transport criteria. Most articles highlighted an exclusion (71%) rather than a prioritization mechanism (17%). Very few articles pertained to transport of critically ill patients (4%). Criteria were classified in one of four emerging themes: patient, condition, physician, and context. The majority of criteria used were nonspecific. No study prospectively evaluated the implementation of its cited criteria. CONCLUSIONS This systematic review identified 200 criteria classified within four themes that may be included when devising triage programs including the coronavirus disease 2019 pandemic. We identified significant knowledge gaps where research would assist in improving existing triage criteria and guidelines, aiming to decrease arbitrary decisions and variability.
Collapse
Affiliation(s)
- Joseph Dahine
- Département de médecine spécialisée, Centre intégré de santé et services sociaux de Laval (CISSS de Laval), Hôpital Cité-de-la-Santé, Université de Montréal, Laval, QC, Canada
| | - Paul C. Hébert
- Département de médecine, Centre Hospitalier de l’Université de Montréal, Université de Montréal et Centre de Recherche, Montreal, QC, Canada
| | - Daniela Ziegler
- Bibliothèque, Centre hospitalier de l’Université de Montréal, Montreal, QC, Canada
| | | | - Nicolay Ferrari
- Centre de recherche du Centre hospitalier de l’Université de Montréal, Montreal, QC, Canada
| | - Réjean Hébert
- Department of Health Management, Evaluation and Policy, School of Public Health, Université de Montréal, Montreal, QC, Canada
| |
Collapse
|
9
|
Bassford C, Griffiths F, Svantesson M, Ryan M, Krucien N, Dale J, Rees S, Rees K, Ignatowicz A, Parsons H, Flowers N, Fritz Z, Perkins G, Quinton S, Symons S, White C, Huang H, Turner J, Brooke M, McCreedy A, Blake C, Slowther A. Developing an intervention around referral and admissions to intensive care: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07390] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BackgroundIntensive care treatment can be life-saving, but it is invasive and distressing for patients receiving it and it is not always successful. Deciding whether or not a patient will benefit from intensive care is a difficult clinical and ethical challenge.ObjectivesTo explore the decision-making process for referral and admission to the intensive care unit and to develop and test an intervention to improve it.MethodsA mixed-methods study comprising (1) two systematic reviews investigating the factors associated with decisions to admit patients to the intensive care unit and the experiences of clinicians, patients and families; (2) observation of decisions and interviews with intensive care unit doctors, referring doctors, and patients and families in six NHS trusts in the Midlands, UK; (3) a choice experiment survey distributed to UK intensive care unit consultants and critical care outreach nurses, eliciting their preferences for factors used in decision-making for intensive care unit admission; (4) development of a decision-support intervention informed by the previous work streams, including an ethical framework for decision-making and supporting referral and decision-support forms and patient and family information leaflets. Implementation feasibility was tested in three NHS trusts; (5) development and testing of a tool to evaluate the ethical quality of decision-making related to intensive care unit admission, based on the assessment of patient records. The tool was tested for inter-rater and intersite reliability in 120 patient records.ResultsInfluences on decision-making identified in the systematic review and ethnographic study included age, presence of chronic illness, functional status, presence of a do not attempt cardiopulmonary resuscitation order, referring specialty, referrer seniority and intensive care unit bed availability. Intensive care unit doctors used a gestalt assessment of the patient when making decisions. The choice experiment showed that age was the most important factor in consultants’ and critical care outreach nurses’ preferences for admission. The ethnographic study illuminated the complexity of the decision-making process, and the importance of interprofessional relationships and good communication between teams and with patients and families. Doctors found it difficult to articulate and balance the benefits and burdens of intensive care unit treatment for a patient. There was low uptake of the decision-support intervention, although doctors who used it noted that it improved articulation of reasons for decisions and communication with patients.LimitationsLimitations existed in each of the component studies; for example, we had difficulty recruiting patients and families in our qualitative work. However, the project benefited from a mixed-method approach that mitigated the potential limitations of the component studies.ConclusionsDecision-making surrounding referral and admission to the intensive care unit is complex. This study has provided evidence and resources to help clinicians and organisations aiming to improve the decision-making for and, ultimately, the care of critically ill patients.Future workFurther research is needed into decision-making practices, particularly in how best to engage with patients and families during the decision process. The development and evaluation of training for clinicians involved in these decisions should be a priority for future work.Study registrationThe systematic reviews of this study are registered as PROSPERO CRD42016039054, CRD42015019711 and CRD42015019714.FundingThe National Institute for Health Research Health Services and Delivery Research programme. The University of Aberdeen and the Chief Scientist Office of the Scottish Government Health and Social Care Directorates fund the Health Economics Research Unit.
Collapse
Affiliation(s)
- Chris Bassford
- Warwick Medical School, University of Warwick, Coventry, UK
- Department of Anaesthesia, Critical Care and Pain, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | | | - Mia Svantesson
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Mandy Ryan
- Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Nicolas Krucien
- Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Jeremy Dale
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Sophie Rees
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Karen Rees
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Agnieszka Ignatowicz
- Warwick Medical School, University of Warwick, Coventry, UK
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Helen Parsons
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Nadine Flowers
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Zoe Fritz
- Warwick Medical School, University of Warwick, Coventry, UK
- Department of Acute Medicine, Cambridge University Hospitals NHS Trust, Cambridge, UK
- The Healthcare Improvement Studies (THIS) Institute, University of Cambridge, Cambridge, UK
| | - Gavin Perkins
- Warwick Medical School, University of Warwick, Coventry, UK
- Heartlands Hospital, University Hospitals Birmingham, Birmingham, UK
| | - Sarah Quinton
- Warwick Medical School, University of Warwick, Coventry, UK
- Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | | | | | - Huayi Huang
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Jake Turner
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Mike Brooke
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Aimee McCreedy
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Caroline Blake
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Anne Slowther
- Warwick Medical School, University of Warwick, Coventry, UK
| |
Collapse
|
10
|
Near-simultaneous intensive care unit (ICU) admissions and all-cause mortality: a cohort study. Intensive Care Med 2019; 45:1559-1569. [PMID: 31531716 DOI: 10.1007/s00134-019-05753-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 08/19/2019] [Indexed: 01/25/2023]
Abstract
PURPOSE Prior studies have reported the adverse effects of strain on patient outcomes. There is a paucity of literature about a type of strain that may be caused by near-simultaneous intensive care unit (ICU) admissions. We hypothesized that when multiple admissions arrive nearly at the same time, the ICU teams are excessively strained, and this leads to unfavorable patient outcomes. METHODS This is a retrospective cohort study of consecutive adult patients admitted to an academic medical ICU of a tertiary referral center over five consecutive years. Primary outcomes were the all-cause hospital and ICU mortality. RESULTS We enrolled 13,234 consecutive ICU admissions during the study period. One-fourth of the admissions had an elapsed time since the last admission (ETLA) of < 55 min. Near-simultaneous admissions (NSA) had on average, a higher unadjusted odds ratio (OR) of ICU death of 1.16 (95% CI 1-1.35, P = 0.05), adjusted 1.23 (95% CI 1.04-1.44, P = 0.01), unadjusted hospital death of 1.11 (95% CI 0.99-1.24, P = 0.06), adjusted 1.20 (95% 1.05-1.35, P = 0.004), and a lower adjusted OR of home discharge of 0.91 (95% CI 0.84-0.99, P = 0.04). NSA was associated with 0.16 (95% CI 0.04-0.29, P = 0.01) added days in the ICU. For each incremental unit increase of the logarithmic transformation of ETLA [log (ETLA in minutes)], the average adjusted hospital mortality OR incrementally decreased by an added average OR of 0.93 (95% CI 0.89‒0.97, P = 0.001). CONCLUSION Our results suggest that near-simultaneous ICU admissions (NSA) are frequent and are associated with a dose-dependent effect on mortality, length of stay, and odds of home versus nursing facility discharge.
Collapse
|
11
|
Fumis RRL, Schettino GDPP, Rogovschi PB, Corrêa TD. Would you like to be admitted to the ICU? The preferences of intensivists and general public according to different outcomes. J Crit Care 2019; 53:193-197. [PMID: 31271954 DOI: 10.1016/j.jcrc.2019.06.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 06/17/2019] [Accepted: 06/20/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Discussions about invasiveness of care (advanced directives) and end-of-life issues have become frequent among intensivists and patients. Nevertheless, there are considerable divergences in the attitudes between intensivists and patients toward end-of-life care in the intensive care units (ICU). METHODS The goal was to compare the preferences between intensivists and general public regarding ICU admission of a hypothetical patient with six different clinical outcomes. For that, intensivists and the general public (university graduate professionals outside the area of health) were invited to participate in this study. A survey was conducted with a hypothetical patient with six different clinical outcomes ranging from ICU discharge without any neurological sequelae, nor dependence for daily activities, to death. The WHOQOL-BREF was applied. Comparisons were made between the answers provided by intensivists regarding what they would choose for themselves and their patients, and the preferences of general public. RESULTS Between July 2013 and July 2016, 300 participants in 5 hospitals in São Paulo, Brazil were invited to participate in this study, of whom 257 (85.7%) responded the survey. Eighty-two intensivists responded what they would choose for themselves, 81 intensivists responded what they would choose for their patients, and 94 people from general public responded what they would choose for themselves. Quality of life did not differ among the groups. In all scenarios, except when the outcome was severe disability or death, intensivists were more likely to choose ICU admission for their patients than for themselves (p < .05 for all). Compared with general public, intensivists were more likely to choose ICU admission for themselves only when the best clinical scenario outcome is considered (p < .001). General public was significantly less prone to choosing ICU admission than intensivists when choosing for their patients, in three out of six scenarios (p < .001 for all). CONCLUSIONS Considerable divergences exist between intensivists' and patients' preferences toward end-of-life care. Advanced care planning and effective ongoing communication among intensivists, patients and relatives are essential to improve end-of-life decisions and the quality of care.
Collapse
Affiliation(s)
| | | | - Pedro Bribean Rogovschi
- Dept. of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil; Dept. of Critical Care Medicine, Hospital Municipal Dr. Moysés Deutsch, São Paulo, Brazil
| | | |
Collapse
|
12
|
Luo L, Li J, Xu X, Shen W, Xiao L. A Data-Driven Hybrid Three-Stage Framework for Hospital Bed Allocation: A Case Study in a Large Tertiary Hospital in China. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2019; 2019:7370231. [PMID: 31191709 PMCID: PMC6525901 DOI: 10.1155/2019/7370231] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 03/06/2019] [Accepted: 04/02/2019] [Indexed: 02/05/2023]
Abstract
Beds are key, scarce medical resources in hospitals. The bed occupancy rate (BOR) amongst different departments within large tertiary hospitals is very imbalanced, a situation which has led to problems between the supply of and the demand for bed resources. This study aims to balance the utilization of existing beds in a large tertiary hospital in China. We developed a data-driven hybrid three-stage framework incorporating data analysis, simulation, and mixed integer programming to minimize the gaps in BOR among different departments. The first stage is to calculate the length of stay (LOS) and BOR of each department and identify the departments that need to be allocated beds. In the second stage, we used a fitted arrival distribution and median LOS as the input to a generic simulation model. In the third stage, we built a mixed integer programming model using the results obtained in the first two stages to generate the optimal bed allocation strategy for different departments. The value of the objective function, Z, represents the severity of the imbalance in BOR. Our case study demonstrated the effectiveness of the proposed data-driven hybrid three-stage framework. The results show that Z decreases from 0.7344 to 0.0409 after re-allocation, which means that the internal imbalance has eased. Our framework provides hospital bed policy makers with a feasible solution for bed allocation.
Collapse
Affiliation(s)
- Li Luo
- Business School of Sichuan University, No. 24 South Section 1, Yihuan Road, Chengdu, China
| | - Jialing Li
- Business School of Sichuan University, No. 24 South Section 1, Yihuan Road, Chengdu, China
| | - Xueru Xu
- Business School of Sichuan University, No. 24 South Section 1, Yihuan Road, Chengdu, China
| | - Wenwu Shen
- West China Hospital of Sichuan University, No. 17 People's South Road, Chengdu, China
| | - Lin Xiao
- Business School of Sichuan University, No. 24 South Section 1, Yihuan Road, Chengdu, China
| |
Collapse
|
13
|
Ramos JGR, Ranzani OT, Perondi B, Dias RD, Jones D, Carvalho CRR, Velasco IT, Forte DN. A decision-aid tool for ICU admission triage is associated with a reduction in potentially inappropriate intensive care unit admissions. J Crit Care 2019; 51:77-83. [PMID: 30769294 DOI: 10.1016/j.jcrc.2019.02.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 02/01/2019] [Accepted: 02/01/2019] [Indexed: 12/31/2022]
Abstract
PURPOSE Intensive care unit (ICU) admission triage occurs frequently and often involves highly subjective decisions that may lead to potentially inappropriate ICU admissions. In this study, we evaluated the effect of implementing a decision-aid tool for ICU triage on ICU admission decisions. METHODS This was a prospective, before-after study. Urgent ICU referrals to ten ICUs in a tertiary hospital in Brazil were assessed before and after the implementation of the decision-aid tool. Our primary outcome was the proportion of potentially inappropriate ICU referrals (defined as priority 4B or 5 referrals, accordingly to the Society of Critical Care Medicine guidelines of 1999 and 2016, respectively) admitted to the ICU within 48 h. We conducted multivariate analyses to adjust for potential confounders and evaluated the interaction between phase and triage priority. RESULTS Of the 2201 patients analyzed, 1184 (53.8%) patients were admitted to the ICU. After adjustment for confounders, implementation of the decision-aid tool was associated with a reduction in potentially inappropriate ICU admissions using either the 1999 [adjOR (95% CI) = 0.36 (0.13-0.97)] or 2016 [adjOR (95%CI) = 0.35 (0.13-0.96)] definitions. CONCLUSION Implementation of a decision-aid tool for ICU triage was associated with a reduction in potentially inappropriate ICU admissions.
Collapse
Affiliation(s)
- Joao Gabriel Rosa Ramos
- Medical Sciences PhD program, Faculdade de Medicina FMUSP, Universidade de São Paulo, Sao Paulo, Brazil; Intensive Care Unit, Hospital Sao Rafael, Salvador, Brazil.
| | - Otavio T Ranzani
- Pulmonary Division, Heart Institute (InCor), Hospital das Clinicas (HCFMUSP), Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Beatriz Perondi
- Emergency Department, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo, Brazil
| | - Roger Daglius Dias
- Emergency Department, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo, Brazil; Emergency Department, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Daryl Jones
- Monash University, School of Public Health and Preventive Medicine, Australia; University of Melbourne, Australia; Austin Health, Melbourne, Australia.
| | - Carlos Roberto Ribeiro Carvalho
- Pulmonary Division, Heart Institute (InCor), Hospital das Clinicas (HCFMUSP), Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil.
| | - Irineu Tadeu Velasco
- Emergency Medicine Discipline, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo, Brazil.
| | - Daniel Neves Forte
- Medical Sciences PhD program, Faculdade de Medicina FMUSP, Universidade de São Paulo, Sao Paulo, Brazil; Teaching and Research on Palliative Care Program, Hospital Sirio-Libanes, Sao Paulo, Brazil
| |
Collapse
|
14
|
Gopalan PD, Pershad S. Decision-making in ICU - A systematic review of factors considered important by ICU clinician decision makers with regard to ICU triage decisions. J Crit Care 2018; 50:99-110. [PMID: 30502690 DOI: 10.1016/j.jcrc.2018.11.027] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 11/13/2018] [Accepted: 11/21/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND The ICU is a scarce resource within a high-stress, high-stakes, time-sensitive environment where critically ill patients with life-threatening conditions receive expensive life-sustaining care under the guidance of expert qualified personnel. The implications of decisions such as suitability for admission into ICU are potentially dire and difficult. OBJECTIVES To conduct a systematic review of clinicians' subjective perceptions of factors that influence the decision to accept or refuse patients referred to ICU. RESULTS Twenty studies yielded 56 different factors classified into patient, physician and environmental. Common, important factors were: acute illness severity and reversibility; presence and severity of comorbidities; patient age, functional status, state-of-mind and wishes; physician level of experience and perception of patient QOL; and bed availability. Within-group variability among physicians and thought-deed discordance were demonstrated. CONCLUSIONS The complex and dynamic ICU triage decision is affected by numerous interacting factors. The literature provides some indication of these factors, but fail to show complexities and interactions between them. A decision tree is proposed. Further research should include a reflection on how decisions for admission to ICU are made, such that a better understanding of these processes can be achieved allowing for improved individual and group consistency.
Collapse
Affiliation(s)
- Pragasan Dean Gopalan
- Discipline of Anaesthesiology & Critical Care, School of Clinical Medicine, Nelson R Mandela School of Medicine, University of KwaZulu Natal, 719 Umbilo Road, Durban 4001, South Africa; Intensive Care Unit, King Edward VIII Hospital, Congella, Durban, South Africa.
| | - Santosh Pershad
- Discipline of Anaesthesiology & Critical Care, School of Clinical Medicine, Nelson R Mandela School of Medicine, University of KwaZulu Natal, 719 Umbilo Road, Durban 4001, South Africa; Intensive Care Unit, Inkosi Albert Luthuli Central Hospital, 800 Vusi Mzimela Road, Cato Manor, Durban, South Africa.
| |
Collapse
|
15
|
Ramos JGR, Passos RDH, Baptista PBP, Forte DN. Factors potentially associated with the decision of admission to the intensive care unit in a middle-income country: a survey of Brazilian physicians. Rev Bras Ter Intensiva 2018; 29:154-162. [PMID: 28977256 PMCID: PMC5496749 DOI: 10.5935/0103-507x.20170025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 01/15/2017] [Indexed: 01/09/2023] Open
Abstract
Objective To evaluate the factors potentially associated with the decision of
admission to the intensive care unit in Brazil. Methods An electronic survey of Brazilian physicians working in intensive care
units. Fourteen variables that were potentially associated with the decision
of admission to the intensive care unit were rated as important (from 1 to
5) by the respondents and were later grouped as "patient-related,"
"scarcity-related" and "administrative-related" factors. The workplace and
physician characteristics were evaluated for correlation with the factor
ratings. Results During the study period, 125 physicians completed the survey. The scores on
patient-related factors were rated higher on their potential to affect
decisions than scarcity-related or administrative-related factors, with a
mean ± SD of 3.42 ± 0.7, 2.75 ± 0.7 and 2.87 ±
0.7, respectively (p < 0.001). The patient's underlying illness prognosis
was rated by 64.5% of the physicians as always or frequently affecting
decisions, followed by acute illness prognosis (57%), number of intensive
care unit beds available (56%) and patient's wishes (53%). After controlling
for confounders, receiving specific training on intensive care unit triage
was associated with higher ratings of the patient-related factors and
scarcity-related factors, while working in a public intensive care unit (as
opposed to a private intensive care unit) was associated with higher ratings
of the scarcity-related factors. Conclusions Patient-related factors were more frequently rated as potentially affecting
intensive care unit admission decisions than scarcity-related or
administrative-related factors. Physician and workplace characteristics were
associated with different factor ratings.
Collapse
Affiliation(s)
- João Gabriel Rosa Ramos
- Programa de Pós-Graduação em Ciências Médicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil.,Unidade de Terapia Intensiva, Hospital São Rafael - Salvador (BA), Brasil.,Faculdade de Medicina, UNIME - Lauro de Freitas (BA), Brasil
| | - Rogerio da Hora Passos
- Unidade de Terapia Intensiva, Hospital São Rafael - Salvador (BA), Brasil.,Unidade de Terapia Intensiva, Hospital Português - Salvador (BA), Brasil
| | - Paulo Benigno Pena Baptista
- Unidade de Terapia Intensiva, Hospital São Rafael - Salvador (BA), Brasil.,Faculdade de Medicina, UNIME - Lauro de Freitas (BA), Brasil
| | - Daniel Neves Forte
- Unidade de Terapia Intensiva, Disciplina de Emergências Clínicas, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil.,Equipe de Cuidados Paliativos, Hospital Sírio-Libanês - São Paulo (SP), Brasil
| |
Collapse
|