Critical care medicine in the United States 2000-2005: an analysis of bed numbers, occupancy rates, payer mix, and costs

Trends in Noninvasive and Invasive Mechanical Ventilation Among Medicare Beneficiaries at the End of Life

Importance

End-of-life care is costly, and decedents often experience overtreatment or low-quality care. Noninvasive ventilation (NIV) may be a palliative approach to avoid invasive mechanical ventilation (IMV) among select patients who are hospitalized at the end of life.

Objective

To examine the trends in NIV and IMV use among decedents with a hospitalization in the last 30 days of life.

Design, Setting, and Participants

This population-based cohort study used a 20% random sample of Medicare fee-for-service beneficiaries who had an acute care hospitalization in the last 30 days of life and died between January 1, 2000, and December 31, 2017. Sociodemographic, diagnosis, and comorbidity data were obtained from Medicare claims data. Data analysis was performed from September 2019 to July 2020.

Exposures

Use of NIV or IMV.

Main Outcomes and Measures

Validated International Classification of Diseases, Ninth Revision, Clinical Modification or International Statistical Classification of Diseases, Tenth Revision, Clinical Modification procedure codes were reviewed to identify use of NIV, IMV, both NIV and IMV, or none. Four subcohorts of Medicare beneficiaries were identified using primary admitting diagnosis codes (chronic obstructive pulmonary disease [COPD], congested heart failure [CHF], cancer, and dementia). Measures of end-of-life care included in-hospital death (acute care setting), hospice enrollment at death, and hospice enrollment in the last 3 days of life. Random-effects logistic regression examined NIV and IMV use adjusted for sociodemographic characteristics, admitting diagnosis, and comorbidities.

Results

A total of 2 470 435 Medicare beneficiaries (1 353 798 women [54.8%]; mean [SD] age, 82.2 [8.2] years) were hospitalized within 30 days of death. Compared with 2000, the adjusted odds ratio (AOR) for the increase in NIV use was 2.63 (95% CI, 2.46-2.82; % receipt: 0.8% vs 2.0%) for 2005 and 11.84 (95% CI, 11.11-12.61; % receipt: 0.8% vs 7.1%) for 2017. Compared with 2000, the AOR for the increase in IMV use was 1.04 (95% CI, 1.02-1.06; % receipt: 15.0% vs 15.2%) for 2005 and 1.63 (95% CI, 1.59-1.66; % receipt: 15.0% vs 18.2%) for 2017. In subanalyses comparing 2017 with 2000, similar trends found increased NIV among patients with CHF (% receipt: 1.4% vs 14.2%; AOR, 14.14 [95% CI, 11.77-16.98]) and COPD (% receipt: 2.7% vs 14.5%; AOR, 8.22 [95% CI, 6.42-10.52]), with reciprocal stabilization in IMV use among patients with CHF (% receipt: 11.1% vs 7.8%; AOR, 1.07 [95% CI, 0.95-1.19]) and COPD (% receipt: 17.4% vs 13.2%; AOR, 1.03 [95% CI, 0.88-1.21]). The AOR for increased NIV use was 10.82 (95% CI, 8.16-14.34; % receipt: 0.4% vs 3.5%) among decedents with cancer and 9.62 (95% CI, 7.61-12.15; % receipt: 0.6% vs 5.2%) among decedents with dementia. The AOR for increased IMV use was 1.40 (95% CI, 1.26-1.55; % receipt: 6.2% vs 7.6%) among decedents with cancer and 1.28 (95% CI, 1.17-1.41; % receipt: 5.7% vs 6.2%) among decedents with dementia. Among decedents with NIV vs IMV use, lower rates of in-hospital death (50.3% [95% CI, 49.3%-51.3%] vs 76.7% [95% CI, 75.9%-77.5%]) and hospice enrollment in the last 3 days of life (57.7% [95% CI, 56.2%-59.3%] vs 63.0% [95% CI, 60.9%-65.1%]) were observed along with higher rates of hospice enrollment (41.3% [95% CI, 40.4%-42.3%] vs 20.0% [95% CI, 19.2%-20.7%]).

Conclusions and Relevance

This study found that the use of NIV rapidly increased from 2000 through 2017 among Medicare beneficiaries at the end of life, especially among persons with cancer and dementia. The findings suggest that trials to evaluate the outcomes of NIV are warranted to inform discussions about the goals of this therapy between clinicians and patients and their health care proxies.

Evaluating the Costs and Outcomes of Hospital Nursing Resources: a Matched Cohort Study of Patients with Common Medical Conditions

BACKGROUND

Nursing resources, such as staffing ratios and skill mix, vary across hospitals. Better nursing resources have been linked to better patient outcomes but are assumed to increase costs. The value of investments in nursing resources, in terms of clinical benefits relative to costs, is unclear.

OBJECTIVE

To determine whether there are differential clinical outcomes, costs, and value among medical patients at hospitals characterized by better or worse nursing resources.

DESIGN

Matched cohort study of patients in 306 acute care hospitals.

PATIENTS

A total of 74,045 matched pairs of fee-for-service Medicare beneficiaries admitted for common medical conditions (25,446 sepsis pairs; 16,332 congestive heart failure pairs; 12,811 pneumonia pairs; 10,598 stroke pairs; 8858 acute myocardial infarction pairs). Patients were also matched on hospital size, technology, and teaching status.

MAIN MEASURES

Better (n = 76) and worse (n = 230) nursing resourced hospitals were defined by patient-to-nurse ratios, skill mix, proportions of bachelors-degree nurses, and nurse work environments. Outcomes included 30-day mortality, readmission, and resource utilization-based costs.

KEY RESULTS

Patients in hospitals with better nursing resources had significantly lower 30-day mortality (16.1% vs 17.1%, p < 0.0001) and fewer readmissions (32.3% vs 33.6%, p < 0.0001) yet costs were not significantly different ($18,848 vs 18,671, p = 0.133). The greatest outcomes and cost advantage of better nursing resourced hospitals were in patients with sepsis who had lower mortality (25.3% vs 27.6%, p < 0.0001). Overall, patients with the highest risk of mortality on admission experienced the greatest reductions in mortality and readmission from better nursing at no difference in cost.

CONCLUSIONS

Medicare beneficiaries with common medical conditions admitted to hospitals with better nursing resources experienced more favorable outcomes at almost no difference in cost.

Analyzing clinical and system drivers of satisfaction in the intensive care unit as a component of high quality care

BACKGROUND

Quality improvement in the intensive care unit has transitioned from focusing on mortality to improving care and reducing morbidity.

OBJECTIVE

This study prospectively investigated clinical and system drivers of family satisfaction in a large quaternary hospital ICU.

METHODS

A validated tool was distributed to family members and a registry chart analysis was conducted. The aims were to assess associations with high or low family satisfaction to evaluate unit-level satisfaction. Candidate predictors were selected from univariate logistic regressions and finalized in a multivariate model by a stepwise selection approach.

RESULTS

Overall, 75% (n = 188) of respondents (n = 250) indicated high satisfaction. Respondents with higher satisfaction had a Plan of the Day posted (OR = 3.3, 95% CI: 1.63, 6.89, p = 0.001), and did not live with the patient (OR =0.5, 95% CI: 0.25, 0.96, p = 0.044).

CONCLUSION

This study indicates that communication and transparency of plans contributes to family satisfaction with ICU care.

The potential of real-time analytics to improve care for mechanically ventilated patients in the intensive care unit: an early economic evaluation

Background

Mechanical ventilation services are an important driver of the high costs of intensive care. An optimal interaction between a patient and a ventilator is therefore paramount. Suboptimal interaction is present when patients repeatedly demand, but do not receive, breathing support from a mechanical ventilator (> 30 times in 3 min), also known as an ineffective effort event (IEEV). IEEVs are associated with increased hospital mortality prolonged intensive care stay, and prolonged time on ventilation and thus development of real-time analytics that identify IEEVs is essential. To assist decision-making about further development we estimate the potential cost-effectiveness of real-time analytics that identify ineffective effort events.

Methods

We developed a cost-effectiveness model combining a decision tree and Markov model for long-term outcomes with data on current care from a Greek hospital and literature. A lifetime horizon and a healthcare payer perspective were used. Uncertainty about the results was assessed using sensitivity and scenario analyses to examine the impact of varying parameters like the intensive care costs per day and the effectiveness of treatment of IEEVs.

Results

Use of the analytics could lead to reduced mortality (3% absolute reduction), increased quality adjusted life years (0.21 per patient) and cost-savings (€264 per patient) compared to current care. Moreover, cost-savings for hospitals and health improvements can be incurred even if the treatment’s effectiveness is reduced from 30 to 10%. The estimated savings increase to €1,155 per patient in countries where costs of an intensive care day are high (e.g. the Netherlands). There is considerable headroom for development and the analytics generate savings when the price of the analytics per bed per year is below €7,307. Furthermore, even when the treatment’s effectiveness is 10%, the probability that the analytics are cost-effective exceeds 90%.

Conclusions

Implementing real-time analytics to identify ineffective effort events can lead to health and financial benefits. Therefore, it will be worthwhile to continue assessment of the effectiveness of the analytics in clinical practice and validate our findings. Eventually, their adoption in settings where costs of an intensive care day are high and ineffective efforts are frequent could yield a high return on investment.

Using machine learning tools to predict outcomes for emergency department intensive care unit patients

The number of critically ill patients has increased globally along with the rise in emergency visits. Mortality prediction for critical patients is vital for emergency care, which affects the distribution of emergency resources. Traditional scoring systems are designed for all emergency patients using a classic mathematical method, but risk factors in critically ill patients have complex interactions, so traditional scoring cannot as readily apply to them. As an accurate model for predicting the mortality of emergency department critically ill patients is lacking, this study's objective was to develop a scoring system using machine learning optimized for the unique case of critical patients in emergency departments. We conducted a retrospective cohort study in a tertiary medical center in Beijing, China. Patients over 16 years old were included if they were alive when they entered the emergency department intensive care unit system from February 2015 and December 2015. Mortality up to 7 days after admission into the emergency department was considered as the primary outcome, and 1624 cases were included to derive the models. Prospective factors included previous diseases, physiologic parameters, and laboratory results. Several machine learning tools were built for 7-day mortality using these factors, for which their predictive accuracy (sensitivity and specificity) was evaluated by area under the curve (AUC). The AUCs were 0.794, 0.840, 0.849 and 0.822 respectively, for the SVM, GBDT, XGBoost and logistic regression model. In comparison with the SAPS 3 model (AUC = 0.826), the discriminatory capability of the newer machine learning methods, XGBoost in particular, is demonstrated to be more reliable for predicting outcomes for emergency department intensive care unit patients.

Comparison of qSOFA score, SOFA score, and SIRS criteria for the prediction of infection and mortality among surgical intermediate and intensive care patients

BACKGROUND

It is crucial to rapidly identify sepsis so that adequate treatment may be initiated. Accordingly, the Sequential Organ Failure Assessment (SOFA) and the quick SOFA (qSOFA) scores are used to evaluate intensive care unit (ICU) and non-ICU patients, respectively. As demand for ICU beds rises, the intermediate care unit (IMCU) carries greater importance as a bridge between the ICU and the regular ward. This study aimed to examine the ability of SOFA and qSOFA scores to predict suspected infection and mortality in IMCU patients.

METHODS

Retrospective data analysis included 13,780 surgical patients treated at the IMCU, ICU, or both between January 01, 2012, and September 30, 2018. Patients were screened for suspected infection (i.e., the commencement of broad-spectrum antibiotics) and then evaluated for the SOFA score, qSOFA score, and the 1992 defined systemic inflammatory response syndrome (SIRS) criteria.

RESULTS

Suspected infection was detected in 1306 (18.3%) of IMCU, 1365 (35.5%) of ICU, and 1734 (62.0%) of IMCU/ICU encounters. Overall, 458 (3.3%) patients died (IMCU 45 [0.6%]; ICU 250 [6.5%]; IMCU/ICU 163 [5.8%]). All investigated scores failed to predict suspected infection independently of the analyzed subgroup. Regarding mortality prediction, the qSOFA score performed sufficiently within the IMCU cohort (AUCROC SIRS 0.72 [0.71-0.72]; SOFA 0.52 [0.51-0.53]; qSOFA 0.82 [0.79-0.84]), while the SOFA score was predictive in patients of the IMCU/ICU cohort (AUCROC SIRS 0.54 [0.53-0.54]; SOFA 0.73 [0.70-0.77]; qSOFA 0.59 [0.58-0.59]).

CONCLUSIONS

None of the assessed scores was sufficiently able to predict suspected infection in surgical ICU or IMCU patients. While the qSOFA score is appropriate for mortality prediction in IMCU patients, SOFA score prediction quality is increased in critically ill patients.

SSP: Early prediction of sepsis using fully connected LSTM-CNN model

BACKGROUND

Sepsis is a life-threatening condition that occurs due to the body's reaction to infections, and it is a leading cause of morbidity and mortality in hospitals. Early prediction of sepsis onset facilitates early interventions that promote the survival of suspected patients. However, reliable and intelligent systems for predicting sepsis are scarce.

METHODS

This paper presents a novel technique called Smart Sepsis Predictor (SSP) to predict sepsis onset in patients admitted to an intensive care unit (ICU). SSP is a deep neural network architecture that encompasses long short-term memory (LSTM), convolutional, and fully connected layers to achieve early prediction of sepsis. SSP can work in two modes; Mode 1 uses demographic data and vital signs, and Mode 2 uses laboratory test results in addition to demographic data and vital signs. To evaluate SSP, we have used the 2019 PhysioNet/CinC Challenge dataset, which includes the records of 40,366 patients admitted to the ICU.

RESULTS

To compare SSP with existing state-of-the-art methods, we have measured the accuracy of the SSP in 4-, 8-, and 12-h prediction windows using publicly available data. Our results show that the SSP performance in Mode 1 and Mode 2 is much higher than existing methods, achieving an area under the receiver operating characteristic curve (AUROC) of 0.89 and 0.92, 0.88 and 0.87, and 0.86 and 0.84 for 4 h, 8 h, and 12 h before sepsis onset, respectively.

CONCLUSIONS

Using ICU data, sepsis onset can be predicted up to 12 h in advance. Our findings offer an early solution for mitigating the risk of sepsis onset.

Competence in caring for patients with respiratory insufficiency: A cross-sectional study

OBJECTIVES

To compare nurses' self-assessed competence and perceived need for more training in intensive care units treating patients with respiratory insufficiency before and after completion of a seven-hour educational programme, and to assess whether factors such as age, educational level, years of experience and percentage of employment are associated with these outcomes.

RESEARCH METHODOLOGY

The study had a quantitative, cross-sectional, descriptive design, with two measurement times. The ProffNurse SAS questionnaire was used to assess nurses' self-assessed competence and perceived need for more training.

SETTING

Nurses in one medical/surgical intensive care unit and one medical intensive care unit in a hospital in Norway.

MAIN OUTCOME MEASURES

Nurses' self-assessed competence and perceived need for more training.

RESULTS

The pre- and post-education studies comprised responses from 85 (52%) and 52 (32%) nurses, respectively. The educational programme contributed to increased self-assessed competence in seven items. Self-assessed competence was significantly associated with nurses' educational level, and critical care nurses reported higher self-assessed competence than registered nurses on 50% of the items.

CONCLUSION

The findings fill a gap in knowledge about nurses' competence in treating patients with respiratory insufficiency in intensive care units. Both education days and further education have beneficial effects on self-assessed competence.

Rethinking How We Measure Costs in Implementation Research

BACKGROUND

Hospitals and other health care delivery organizations are sometimes resistant to implementing evidence-based programs, citing unknown budgetary implications.

OBJECTIVE

In this paper, I discuss challenges when estimating health care costs in implementation research.

DESIGN

A case study with intensive care units highlights how including fixed costs can cloud a short-term analysis.

PARTICIPANTS

None.

INTERVENTIONS

None.

MAIN MEASURES

Health care costs, charges and payments.

KEY RESULTS

Cost data should accurately reflect the opportunity costs for the organization(s) providing care. Opportunity costs are defined as the benefits foregone because the resources were not used in the next best alternative. Because there is no database of opportunity costs, cost studies rely on accounting data, charges, or payments as proxies. Unfortunately, these proxies may not reflect the organization's opportunity costs, especially if the goal is to understand the budgetary impact in the next few years.

CONCLUSIONS

Implementation researchers should exclude costs that are fixed in the time period of observation because these assets (e.g., space) cannot be used in the next best alternative. In addition, it is common to use costs from accounting databases where we implicitly assume health care providers are uniformly efficient. If providers are not operating efficiently, especially if there is variation in their efficiency, then this can create further problems. Implementation scientists should be judicious in their use of cost estimates from accounting data, otherwise research results can misguide decision makers.

Epidemiological trends of surgical admissions to the intensive care unit in the United States

BACKGROUND

Epidemiologic assessment of surgical admissions into intensive care units (ICUs) provides a framework to evaluate health care system efficiency and project future health care needs.

METHODS

We performed a 9-year (2008-2016), retrospective, cohort analysis of all adult admissions to 88 surgical ICUs using the prospectively and manually abstracted Cerner Acute Physiology and Chronic Health Evaluation Outcomes database. We stratified patients into 13 surgical cohorts and modeled temporal trends in admission, mortality, surgical ICU length of stay (LOS), and change in functional status (FS) using generalized mixed-effects and Quasi-Poisson models to obtain risk-adjusted outcomes.

RESULTS

We evaluated 78,053 ICU admissions and observed a significant decrease in admissions after transplant and thoracic surgery, with a concomitant increase in admissions after otolaryngological and facial reconstructive procedures (all p < 0.05). While overall risk-adjusted mortality remained stable over the study period; mortality significantly declined in orthopedic, cardiac, urologic, and neurosurgical patients (all p < 0.05). Cardiac, urologic, gastrointestinal, neurosurgical, and orthopedic admissions showed significant reductions in LOS (all p < 0.05). The overall rate of FS deterioration increased per year, suggesting ICU-related disability increased over the study period.

CONCLUSION

Temporal analysis demonstrates a significant change in the type of surgical patients admitted to the ICU over the last decade, with decreasing mortality and LOS in selected cohorts, but an increasing rate of FS deterioration. Improvement in ICU outcomes may highlight the success of health care advancements within certain surgical cohorts, while simultaneously identifying cohorts that may benefit from future intervention. Our findings have significant implications in health care systems planning, including resource and personnel allocation, education, and surgical training.

LEVEL OF EVIDENCE

Economic/decision, level IV.Epidemiologic, level IV.

Feasibility of management of hemodynamically stable patients with acute myocardial infarction following primary percutaneous coronary intervention in the general ward settings

BACKGROUND

Although current guidelines recommend admission to the intensive/coronary care unit (ICU/CCU) for patients with ST-segment elevation myocardial infarction (MI), routine use of the CCU in uncomplicated patients with acute MI remains controversial. We aimed to evaluate the safety of management in the general ward (GW) of hemodynamically stable patients with acute MI after primary percutaneous coronary intervention (PCI).

METHODS

Using a large nationwide administrative database, a cohort of 19426 patients diagnosed with acute MI in 52 hospitals where a CCU was available were retrospectively analyzed. Patients with mechanical cardiac support and Killip classification 4, and those without primary PCI on admission were excluded. A total of 5736 patients were included and divided into the CCU (n = 3488) and GW (n = 2248) groups according to the type of hospitalization room after primary PCI. Propensity score matching was performed, and 1644 pairs were matched. The primary endpoint was in-hospital mortality at 30 days.

RESULTS

The CCU group had a higher rate of Killip classification 3 and ambulance use than the GW group. There was no significant difference in the incidence of in-hospital mortality within 30 days among the matched subjects. Multivariable Cox proportional hazard model analysis among unmatched patients supported the findings (hazard ratio 1.12, 95% confidence interval 0.66-1.91, p = 0.67).

CONCLUSIONS

The use of the GW was not associated with higher in-hospital mortality in hemodynamically stable patients with acute MI after primary PCI. It may be feasible for the selected patients to be directly admitted to the GW after primary PCI.

Ethical dilemmas in COVID-19 times: how to decide who lives and who dies?

The respiratory disease caused by the coronavirus SARS-CoV-2 (COVID-19) is a pandemic that produces a large number of simultaneous patients with severe symptoms and in need of special hospital care, overloading the infrastructure of health services. All of these demands generate the need to ration equipment and interventions. Faced with this imbalance, how, when, and who decides, there is the impact of the stressful systems of professionals who are at the front line of care and, in the background, issues inherent to human subjectivity. Along this path, the idea of using artificial intelligence algorithms to replace health professionals in the decision-making process also arises. In this context, there is the ethical question of how to manage the demands produced by the pandemic. The objective of this work is to reflect, from the point of view of medical ethics, on the basic principles of the choices made by the health teams, during the COVID-19 pandemic, whose resources are scarce and decisions cause anguish and restlessness. The ethical values for the rationing of health resources in an epidemic must converge to some proposals based on fundamental values such as maximizing the benefits produced by scarce resources, treating people equally, promoting and recommending instrumental values, giving priority to critical situations. Naturally, different judgments will occur in different circumstances, but transparency is essential to ensure public trust. In this way, it is possible to develop prioritization guidelines using well-defined values and ethical recommendations to achieve fair resource allocation.

Core outcomes sets for studies evaluating critical illness and patient recovery

PURPOSE OF REVIEW

Given the growing body of critical care clinical research publications, core outcome sets (COSs) are important to help mitigate heterogeneity in outcomes assessed and measurement instruments used, and have potential to reduce research waste. This article provides an update on COS projects in critical care medicine, and related resources and tools for COS developers.

RECENT FINDINGS

We identified 28 unique COS projects, of which 15 have published results as of May 2020. COS topics relevant to critical care medicine include mechanical ventilation, cardiology, stroke, rehabilitation, and long-term outcomes (LTOs) after critical illness. There are four COS projects for coronavirus disease 2019 (COVID-19), with a 'meta-COS' summarizing common outcomes across these projects. To help facilitate COS development, there are existing resources, standards, guidelines, and tools available from the Core Outcome Measures in Effectiveness Trials Initiative (www.comet-initiative.org/) and the National Institutes of Health-funded Improve LTO project (www.improvelto.com/).

SUMMARY

Many COS projects have been completed in critical care, with more on-going COS projects, including foci from across the spectrum of acute critical care, COVID-19, critical care rehabilitation, and patient recovery and LTOs. Extensive resources are accessible to help facilitate rigorous COS development.

Illuminating the dark spaces of healthcare with ambient intelligence

Advances in machine learning and contactless sensors have given rise to ambient intelligence-physical spaces that are sensitive and responsive to the presence of humans. Here we review how this technology could improve our understanding of the metaphorically dark, unobserved spaces of healthcare. In hospital spaces, early applications could soon enable more efficient clinical workflows and improved patient safety in intensive care units and operating rooms. In daily living spaces, ambient intelligence could prolong the independence of older individuals and improve the management of individuals with a chronic disease by understanding everyday behaviour. Similar to other technologies, transformation into clinical applications at scale must overcome challenges such as rigorous clinical validation, appropriate data privacy and model transparency. Thoughtful use of this technology would enable us to understand the complex interplay between the physical environment and health-critical human behaviours.

Early mortality in critical illness - A descriptive analysis of patients who died within 24 hours of ICU admission

PURPOSE

To describe patients who die within 24 h of ICU admission in order to better optimize care delivery.

METHODS

This was a retrospective cohort study of patients ≥18 years old admitted to 17 adult ICUs in Alberta, Canada from January 1, 2016 and June 30, 2017. Data were obtained from a provincial clinical information system and data repository. The primary outcome was incidence of ICU death within 24 h of admission. Secondary outcomes were patient and system factors associated with early death. Variables of interest were identified a priori and examined using multivariable logistic regression.

RESULTS

Of 19,556 patients admitted to ICU in an 18-month period, 3.3% died within 24 h, representing 29.8% of ICU deaths. Factors associated with early death were age (adjusted-OR 0.99, 95% CI, 0.9-1.0), acuity (adjusted-OR 1.3, 95% CI, 1.3-1.4), admission from the Emergency Department (ED; adjusted-OR 1.5, 95% CI, 1.1-1.9) and surgical (adjusted-OR 2.27, 95% CI, 1.4-3.6), neurologic (adjusted-OR 4.6, 95% CI, 3.1-6.9) or trauma diagnosis (adjusted-OR 6.1, 95% CI, 2.4-15.6).

CONCLUSION

Patients who die within 24 h constitute one third of ICU deaths. Age, acuity, admission from the ED and surgical, neurologic or trauma-related admission diagnosis correlate with early death.

Cost-effectiveness of pembrolizumab with axitinib as first-line treatment for advanced renal cell carcinoma

OBJECTIVE

Pembrolizumab/axitinib significantly prolonged overall survival (OS) and progression-free survival (PFS), and increased objective response rate versus sunitinib in the phase III trial KEYNOTE-426 among previously untreated patients with advanced renal cell carcinoma (RCC). This study assessed the cost-effectiveness of pembrolizumab/axitinib versus other first-line treatments of advanced RCC from a US public healthcare payer perspective.

METHODS

A partitioned survival model with three states (progression-free, progressed, death) evaluated lifetime costs and quality-adjusted life-years (QALYs) for pembrolizumab/axitinib and other first-line regimens: sunitinib, pazopanib and avelumab/axitinib in the overall population; and sunitinib, cabozantinib and nivolumab/ipilimumab in the subgroup with intermediate/poor prognostic risk. Costs of treatments, adverse events and medical resources were estimated. OS, PFS and treatment duration were extrapolated using parametric models fitted to KEYNOTE-426 data and hazard ratios from network meta-analyses. Utilities were derived through mixed-effects regressions of KEYNOTE-426 EuroQol-5 Dimensions-3 Levels data.

RESULTS

In the overall population, pembrolizumab/axitinib was associated with incremental cost-effectiveness ratios (ICERs) of $95,725/QALY versus sunitinib and $128,210/QALY versus pazopanib, and was dominant (lower cost, higher effectiveness) versus avelumab/axitinib, with incremental QALY gains of 2.73, 2.40 and 1.80 versus these therapies, respectively. In the intermediate/poor-risk subgroup, base-case ICERs for pembrolizumab/axitinib were $101,030/QALY versus sunitinib, $6989/QALY versus cabozantinib, and $130,934/QALY versus nivolumab/ipilimumab, with incremental QALY gains of 2.62, 1.78 and 1.06 versus these therapies.

CONCLUSIONS

In this economic evaluation, pembrolizumab/axitinib was associated with higher life expectancy and QALYs and, based on typical willingness-to-pay thresholds of $150,000-$180,000/QALY, was found cost-effective versus other first-line treatments for advanced RCC in the US.

Boarding of critically Ill patients in the emergency department

OBJECTIVES

Emergency department boarding is the practice of caring for admitted patients in the emergency department after hospital admission, and boarding has been a growing problem in the United States. Boarding of the critically ill has achieved specific attention because of its association with poor clinical outcomes. Accordingly, the Society of Critical Care Medicine and the American College of Emergency Physicians convened a Task Force to understand the implications of emergency department boarding of the critically ill. The objective of this article is to review the U.S. literature on (1) the frequency of emergency department boarding among the critically ill, (2) the outcomes associated with critical care patient boarding, and (3) local strategies developed to mitigate the impact of emergency department critical care boarding on patient outcomes.

DATA SOURCES AND STUDY SELECTION

Review article.

DATA EXTRACTION AND DATA SYNTHESIS

Emergency department-based boarding of the critically ill patient is common, but no nationally representative frequency estimates has been reported. Boarding literature is limited by variation in the definitions used for boarding and variation in the facilities studied (boarding ranges from 2% to 88% of ICU admissions). Prolonged boarding in the emergency department has been associated with longer duration of mechanical ventilation, longer ICU and hospital length of stay, and higher mortality. Health systems have developed multiple mitigation strategies to address emergency department boarding of critically ill patients, including emergency department-based interventions, hospital-based interventions, and emergency department-based resuscitation care units.

CONCLUSIONS

Emergency department boarding of critically ill patients was common and was associated with worse clinical outcomes. Health systems have generated a number of strategies to mitigate these effects. A definition for emergency department boarding is proposed. Future work should establish formal criteria for analysis and benchmarking of emergency department-based boarding overall, with subsequent efforts focused on developing and reporting innovative strategies that improve clinical outcomes of critically ill patients boarded in the emergency department.

Implementation of an Academic-to-Community Hospital Intensive Care Unit Quality Improvement Program. Qualitative Analysis of Multilevel Facilitators and Barriers

Rationale: Implementation of evidence-based best practices is influenced by a variety of contextual factors. It is vital to characterize such factors to maintain high-quality care. Patients in the intensive care unit (ICU) are critically ill and require complex, interdisciplinary, evidence-based care to enable high-quality outcomes. Objectives: To identify facilitators and barriers to implementation of an academic-to-community hospital ICU interprofessional quality improvement program, "ICU Innovations." Methods: ICU Innovations is a multimodal quality improvement program implemented between 2014 and 2017 in six community ICUs in rural settings serving underserved patients in South Carolina. ICU Innovations includes quarterly on-site seminars and extensive behind the scenes facilitation to catalyze the implementation of evidence-based best practices. We use qualitative analysis to identify contextual factors related to program implementation processes. Guided by an implementation science framework, the Exploration, Adoption/Preparation, Implementation, Sustainment framework, we conducted semistructured key informant interviews with clinician champions at six community ICUs and six parallel interviews with ICU Innovations' leadership. We developed a qualitative coding template based on the framework and identified contextual factors associated with implementation. Standard data on hospital and ICU structure and processes of care were also collected. Results: Outer and inner factors interconnected dynamically to influence implementation of ICU Innovations. Collaborative engagement between the program developers and partner sites (outer context factor) and site program champion leadership and staff readiness for change (inner context factors) were key influences of implementation. Conclusions: This research focused on rural hospital ICUs with limited or nonexistent intensivist leadership. Although enthusiasm for the ICU Innovations program was initially high, implementation was challenging because of multiple contextual factors. Critical steps for implementation of evidence-based practice in rural hospitals include optimizing engagement with external collaborators, maximizing the role of a committed site champion, and conducting thorough site assessments to ensure staff and organizational readiness for change. Identifying barriers and facilitators to program implementation is an on-going process to tailor and improve program initiatives.

The association between self-declared acute care surgery services and critical care resources: Results from a national survey

PURPOSE

We examined differences in critical care structures and processes between hospitals with Acute Care Surgery (ACS) versus general surgeon on call (GSOC) models for emergency general surgery (EGS) care.

METHODS

2811 EGS-capable hospitals were surveyed to examine structures and processes including critical care domains and ACS implementation. Differences between ACS and GSOC hospitals were compared using appropriate tests of association and logistic regression models.

RESULTS

272/1497 hospitals eligible for analysis (18.2%) reported they use an ACS model. EGS patients at ACS hospitals were more likely to be admitted to a combined trauma/surgical ICU or a dedicated surgical ICU. GSOC hospitals had lower adjusted odds of having 24-h ICU coverage, in-house intensivists or respiratory therapists, and 4/6 critical-care protocols.

CONCLUSIONS

Critical care delivery is a key component of EGS care. While harnessing of critical care structures and processes varies across hospitals that have implemented ACS, overall ACS models of care appear to have more robust critical care practices.

Validation of the "CHIIDA" and application for PICU triage in children with complicated mild traumatic brain injury

BACKGROUND

The Children's Intracranial Injury Decision Aid (CHIIDA) was developed to predict which patients with complicated mild traumatic brain injury (cmTBI; GCS ≥13 with depressed skull fracture or intracranial injury) would achieve the composite outcome of neurosurgical intervention, intubation >24 h, or death. The study also explored the CHIIDA as a triage tool to determine need for PICU care. The purpose of this study is to externally validate the CHIIDA and assess its effects on PICU triage.

METHODS

Retrospective cohort study (January 2016 to December 2017) to validate the CHIIDA to predict the composite outcome and assess its effects as a PICU triage tool at a level 1 pediatric trauma center.

RESULTS

Of 345 patients with cmTBI, the composite outcome occurred in 16 patients (4.6%). At a cutoff score of 2, the CHIIDA predicted the composite outcome with a sensitivity of 94% (95% CI 67-99%) and specificity of 69% (95% CI 64-74%), similar to the original study. Using the same cutoff score for PICU triage resulted in 48 (71%) more patients admitted to PICU.

CONCLUSIONS

In our cohort, the CHIIDA predicted the composite outcome well. If applied as a triage tool, it would have resulted in increased unnecessary PICU admissions.

LEVEL OF EVIDENCE

Level III, prognosis.

<p>Cost-Minimization Analysis of Dexmedetomidine Compared to Other Sedatives for Short-Term Sedation During Mechanical Ventilation in the United States</p>

Purpose

Mechanical ventilation (MV) remains a substantial cost driver in intensive care units (ICU) in the United States (US). Evaluations of standard sedation treatments used to relieve pain and discomfort in this setting have found varying impacts on ICU length of stay. This cost analysis examines both length-of=stay costs and the total cost implications among MV patients receiving common sedative treatments (dexmedetomidine, propofol, or midazolam) in short-term sedation settings (<24 hours).

Methods

A cost-minimization model was conducted from the hospital provider perspective. Clinical outcomes were obtained from published literature and included ICU length of stay, MV duration, prescription of sedatives and pain medication, and the occurrence of adverse events. Outcomes costs were obtained from previously conducted ICU cost studies and Medicare payment fee schedules. All costs were estimated in 2018 US Dollars.

Results

The per patient costs associated with dexmedetomidine, propofol, and midazolam were estimated to be $21,115, $27,073, and $27,603, respectively. Dexmedetomidine was associated with a savings of $5958 per patient compared to propofol and a saving of $6487 compared to midazolam. These savings were primarily driven by a reduction in ICU length of stay and the degree of monitoring and management.

Conclusion

Dexmedetomidine was associated with reduced costs when compared to propofol or midazolam used for short-term sedation during MV in the ICU, suggesting sedative choice can have a potential impact on overall cost per episode.

Recombinant Human Plasma Gelsolin Improves Survival and Attenuates Lung Injury in a Murine Model of Multidrug-Resistant Pseudomonas aeruginosa Pneumonia

Background

Plasma gelsolin (pGSN) is an abundant circulating protein quickly consumed by extensive tissue damage. Marked depletion is associated with later poor outcomes in diverse clinical circumstances. Repletion with recombinant human (rhu)-pGSN in animal models of inflammation lessens mortality and morbidity.

Methods

Neutropenic mice were treated with different meropenem doses ±12 mg of rhu-pGSN commencing 1 day before an intratracheal challenge with multidrug-resistant Pseudomonas aeruginosa. Survival, bacterial counts, and pulmonary pathology were compared between corresponding meropenem groups with and without rhu-pGSN.

Results

Overall survival was 35/64 (55%) and 46/64 (72%) in mice given meropenem without and with rhu-pGSN, respectively (Δ = 17%; 95% CI, 1-34). In control mice receiving meropenem 1250 mg/kg/d where the majority died, the addition of rhu-pGSN increased survival from 5/16 (31%) to 12/16 (75%) (Δ = 44%; 95% CI, 13-75). Survival with minor lung injury was found in 26/64 (41%) mice receiving only meropenem, vs 38/64 (59%) in mice given meropenem plus rhu-pGSN (Δ = 19%; 95% CI, 2-36).

Conclusions

In a series of dose-ranging experiments, both mortality and lung injury were reduced by the addition of rhu-pGSN to meropenem against carbapenem-resistant P. aeruginosa. Rhu-pGSN offers a novel candidate therapy for antibiotic-resistant pneumonia.

Surgical Intensive Care Unit Admission Variables Predict Subsequent Readmission

Intensive care unit (ICU) readmissions are associated with increased resource use. Defining predictors may improve resource use. Surgical ICU patients requiring readmission will have different characteristics than those who do not. We conducted a retrospective cohort study of a prospectively maintained database. The Acute Physiology and Chronic Health Evaluation (APACHE) IV quality database identified patients admitted January 1 through December 31, 2011. Patients were divided into groups: NREA = patients admitted to the ICU, discharged, and not readmitted versus REA = patients admitted to the ICU, discharged, and readmitted. Comparisons were made at index admission, not readmission. Categorical variables were compared by Fisher's exact testing and continuous variables by t test. Multivariate logistic regression identified independent predictors of readmission. There were 765 admissions. Seventy-seven patients required readmission 94 times (12.8% rate). Sixty-two patients died on initial ICU admission. Admission severity of illness was significantly higher (APACHE III score: 69.54 ± 21.11 vs 54.88 ± 23.48) in the REA group. Discharge acute physiology scores were equal between groups (47.0 ± 39.2 vs 44.2 ± 34.0, P = nonsignificant). In multivariate analysis, REA patients were more likely admitted to emergency surgery (odds ratio, 1.9; 95% confidence interval, 1.01 ± 3.5) more likely to have a history of immunosuppression (2.7, 1.4 ± 5.3) or higher Acute Physiology Score (1.02; 1.0 ± 1.03) than NREA. Patients who require ICU readmission have a different admission profile than those who do not “bounce back.” Understanding these differences may allow for quality improvement projects such as instituting different discharge criteria for different patient populations.

COVID-19 and US Health Financing: Perils and Possibilities

While the COVID-19 pandemic presents every nation with challenges, the United States’ underfunded public health infrastructure, fragmented medical care system, and inadequate social protections impose particular impediments to mitigating and managing the outbreak. Years of inadequate funding of the nation’s federal, state, and local public health agencies, together with mismanagement by the Trump administration, hampered the early response to the epidemic. Meanwhile, barriers to care faced by uninsured and underinsured individuals in the United States could deter COVID-19 care and hamper containment efforts, and lead to adverse medical and financial outcomes for infected individuals and their families, particularly those from disadvantaged groups. While the United States has a relatively generous supply of Intensive Care Unit beds and most other health care infrastructure, such medical resources are often unevenly distributed or deployed, leaving some areas ill-prepared for a severe respiratory epidemic. These deficiencies and shortfalls have stimulated a debate about policy solutions. Recent legislation, for instance, expanded coverage for testing for COVID-19 for the uninsured and underinsured, and additional reforms have been proposed. However comprehensive health care reform – for example, via national health insurance – is needed to provide full protection to American families during the COVID-19 outbreak and in its aftermath.

Derivation and validation of a new nutritional index for predicting 90 days mortality after ICU admission in a Korean population

BACKGROUND/PURPOSE

Predicting the mortality in patients admitted to the ICU is important for determining a treatment strategy and public health policy. Although many scores have been developed to predict the mortality, these scores were based on Caucasian population. We aimed to develop a new prognostic index, the New nutritional index (NNI), to predict 90-days mortality after ICU admission based on Korean population.

METHODS

Patients (1453) who admitted intensive care unit (ICU) of the Gangnam Severance hospital were analyzed. After exclusion, 984 patients were randomly divided into internal (n = 702) and external validation (n = 282) data set. The new nutritional index (NNI) was developed using univariate and multivariate logistic regression with backward selection of predictors. Receiver operating characteristic (ROC) curve analysis and comparison of the area under the curve (AUC) verified the better predictor of 90 days-mortality after ICU admission.

RESULTS

The NNI better predicted 90 days-mortality compared to modified NUTRIC score, APACHE II scores, SOFA scores, CRP, glucose, total protein, and albumin level in internal and external data sets, with AUC of 0.862 (SE: 0.017, 95% CI: 0.829-0.895) and 0.858 (SE: 0.015, 95% CI: 0.829-0.887), respectively. The calibration plots using external data set for validation showed a close approximation to the logistic calibration of each nomogram, and p-value of Hosmer and Lemeshow test was 0.1804.

CONCLUSION

The NNI has advantages as a predictor of 90 days mortality based on nutritional status in the Korean population.

Comparing Outcomes and Costs of Surgical Patients Treated at Major Teaching and Nonteaching Hospitals: A National Matched Analysis

OBJECTIVE

To compare outcomes and costs between major teaching and nonteaching hospitals on a national scale by closely matching on patient procedures and characteristics.

BACKGROUND

Teaching hospitals have been shown to often have better quality than nonteaching hospitals, but cost and value associated with teaching hospitals remains unclear.

METHODS

A study of Medicare patients at 340 teaching hospitals (resident-to-bed ratios ≥ 0.25) and matched patient controls from 2444 nonteaching hospitals (resident-to-bed ratios < 0.05).We studied 86,751 pairs admitted for general surgery (GS), 214,302 pairs of patients admitted for orthopedic surgery, and 52,025 pairs of patients admitted for vascular surgery.

RESULTS

In GS, mortality was 4.62% in teaching hospitals versus 5.57%, (a difference of -0.95%, <0.0001), and overall paired cost difference = $915 (P < 0.0001). For the GS quintile of pairs with highest risk on admission, mortality differences were larger (15.94% versus 18.18%, difference = -2.24%, P < 0.0001), and paired cost difference = $3773 (P < 0.0001), yielding $1682 per 1% mortality improvement at 30 days. Patterns for vascular surgery outcomes resembled general surgery; however, orthopedics outcomes did not show significant differences in mortality across teaching and nonteaching environments, though costs were higher at teaching hospitals.

CONCLUSIONS

Among Medicare patients, as admission risk of mortality increased, the absolute mortality benefit of treatment at teaching hospitals also increased, though accompanied by marginally higher cost. Major teaching hospitals appear to return good value for the extra resources used in general surgery, and to some extent vascular surgery, but this was not apparent in orthopedic surgery.

Hospitalizations Involving an Intensive Care Unit Admission Among Patients Aged 65 Years and Older Within New York City Hospitals During 2000-2014

OBJECTIVE

To describe hospitalizations involving an intensive care unit (ICU) admission among patients aged 65 years and older within New York City (NYC) hospitals during 2000-2014.

DESIGN

Observational study using an all-payer hospital discharge dataset.

SETTING

The setting was in NYC hospitals.

PATIENTS

Patients aged 65 years and older admitted to an ICU within a NYC hospital during 2000-2014.

INTERVENTIONS

No interventions were carried out.

MEASUREMENTS AND MAIN RESULTS

We calculated the mean annual number of hospitalizations involving an ICU admission. We also examined characteristics of hospitalizations, including the occurrence of in-hospital death and principal diagnosis. There were 5,338,577 hospitalizations of patients aged ≥65 years within NYC hospitals during 2000-2014, of which 765,084 (14.3%) involved an ICU admission. The mean annual number of hospitalizations involving an ICU admission for this age group decreased from 57,938 during 2000-2002 to 45,785 during 2012-2014. The proportion of hospitalizations involving an ICU admission in which in-hospital death occurred decreased from 15.9% during 2000-2002 to 14.5% during 2012-2014. During 2000-2002, 11.6% of hospitalizations involving an ICU admission listed an "infectious" principal diagnosis, increasing to 20.7% during 2012-2014. Listing of a "cardiovascular" principal diagnosis decreased from 46.4% to 33.4% between these time periods. "Infectious" principal diagnoses accounted for 31.0% of all hospitalizations involving an ICU admission in which in-hospital death occurred during the entire study period, while "cardiovascular" principal diagnoses accounted for 21.3%.

CONCLUSIONS

This investigation provides a clearer understanding of ICU utilization among patients aged 65 years and older in NYC. Ongoing monitoring is warranted given projections that the proportion of New Yorkers aged 65 years and older will increase in coming years. In particular, in light of the observed increase of infectious principal diagnoses during the study period, further investigation is needed into the role of infectious disease in causing critical illness in NYC.

Associations between hospital occupancy, intensive care unit transfer delay and hospital mortality

PURPOSE

Hospital occupancy (HospOcc) pressures often lead to longer intensive care unit (ICU) stay after physician recognition of discharge readiness. We evaluated the relationships between HospOcc, extended ICU stay, and patient outcomes.

MATERIALS AND METHODS

7-year retrospective cohort study of 8500 alive discharge encounters from 4 adult ICUs of a tertiary hospital. We estimated associations between i) HospOcc and ICU transfer delay; and ii) ICU transfer delay and hospital mortality.

RESULTS

Median (IQR) ICU transfer delay was 4.8 h (1.6-11.7), 1.4% (119) suffered in-hospital death, and 4% (341) were readmitted. HospOcc was non-linearly related with ICU transfer delay, with a spline knot at 80% (mean transfer delay 8.8 h [95% CI: 8.24, 9.38]). Higher HospOcc level above 80% was associated with longer transfer delays, (mean increase 5.4% per % HospOcc increase; 95% CI, 4.7 to 6.1; P < .001). Longer ICU transfer delay was associated with increasing odds of in-hospital death or ICU readmission (odds ratio 1.01 per hour; 95% CI 1.00 to 1.01; P = .04) but not with ICU readmission alone (OR 1.01 per hour; 95% CI 1.00 to 1.01, P = .14).

CONCLUSIONS

ICU transfer delay exponentially increased above a threshold hospital occupancy and may be associated with increased hospital mortality.

Socioeconomic Status and Bronchiolitis Severity Among Hospitalized Infants

OBJECTIVE

To investigate the relationship between socioeconomic factors and bronchiolitis severity among hospitalized infants.

METHODS

We performed a 17-center, prospective cohort study from 2011 to 2014. Children <1 year old hospitalized with bronchiolitis were enrolled. Socioeconomic factors included estimated median household income (MHI) per home ZIP code, parent-reported household income, number of adults and children in household, and insurance type. We defined higher bronchiolitis severity as receipt of intensive care treatment. Multivariable logistic regression was used to analyze the association between socioeconomic factors and bronchiolitis severity, with the final model adjusted for potential clustering by site.

RESULTS

In multivariable models adjusted for demographic and clinical characteristics, estimated MHI was the socioeconomic factor most strongly associated with severity. Compared to infants with an intermediate MHI ($40,000-$79,999), odds of receiving intensive care treatment were significantly higher for those with MHI of ≥$80,000 (aOR 2.05, 95% CI 1.19-3.53). No significant associations were found for the other socioeconomic factors (all P > .30). While there were no significant differences in clinical presentation between income groups (all P > .25) or in receipt of mechanical ventilation alone (P = .98), infants with estimated MHI ≥$80,000 were significantly more likely to specifically have been admitted to the intensive care unit (P = .01).

CONCLUSIONS

In this multicenter study of infants hospitalized with bronchiolitis, we identified higher median household income as a risk factor for intensive care treatment. This work may yield important biological or nonbiological insights for the future management of infants with bronchiolitis.

Mechanical ventilation and the daily cost of ICU care

Background

Intensive care units represent one of the largest clinical cost centers in hospitals. Mechanical ventilation accounts for a significant share of this cost. There is a relative dearth of information quantifying the impact of ventilation on daily ICU cost. We thus determine daily costs of ICU care, incremental cost of mechanical ventilation per ICU day, and further differentiate cost by underlying diseases.

Methods

Total ICU costs, length of ICU stay, and duration of mechanical ventilation of all 10,637 adult patients treated in ICUs at a German hospital in 2013 were analyzed for never-ventilated patients (N = 9181), patients ventilated at least 1 day, (N = 1455) and all patients (N = 10,637). Total ICU costs were regressed on the number of ICU days. Finally, costs were analyzed separately by ICD-10 chapter of main diagnosis.

Results

Daily non-ventilated costs were €999 (95%CI €924 - €1074), and ventilated costs were €1590 (95%CI €1524 - €1657), a 59% increase. Costs per non-ventilated ICU day differed substantially and were lowest for endocrine, nutritional or metabolic diseases (€844), and highest for musculoskeletal diseases (€1357). Costs per ventilated ICU day were lowest for diseases of the circulatory system (€1439) and highest for cancer patients (€1594). The relative cost increase due to ventilation was highest for diseases of the respiratory system (94%) and even non-systematic for patients with musculoskeletal diseases (13%, p = 0.634).

Conclusions

Results show substantial variability of ICU costs for different underlying diseases and underline mechanical ventilation as an important driver of ICU costs.

Learning Latent Space Representations to Predict Patient Outcomes: Model Development and Validation

Background

Scalable and accurate health outcome prediction using electronic health record (EHR) data has gained much attention in research recently. Previous machine learning models mostly ignore relations between different types of clinical data (ie, laboratory components, International Classification of Diseases codes, and medications).

Objective

This study aimed to model such relations and build predictive models using the EHR data from intensive care units. We developed innovative neural network models and compared them with the widely used logistic regression model and other state-of-the-art neural network models to predict the patient’s mortality using their longitudinal EHR data.

Methods

We built a set of neural network models that we collectively called as long short-term memory (LSTM) outcome prediction using comprehensive feature relations or in short, CLOUT. Our CLOUT models use a correlational neural network model to identify a latent space representation between different types of discrete clinical features during a patient’s encounter and integrate the latent representation into an LSTM-based predictive model framework. In addition, we designed an ablation experiment to identify risk factors from our CLOUT models. Using physicians’ input as the gold standard, we compared the risk factors identified by both CLOUT and logistic regression models.

Results

Experiments on the Medical Information Mart for Intensive Care-III dataset (selected patient population: 7537) show that CLOUT (area under the receiver operating characteristic curve=0.89) has surpassed logistic regression (0.82) and other baseline NN models (<0.86). In addition, physicians’ agreement with the CLOUT-derived risk factor rankings was statistically significantly higher than the agreement with the logistic regression model.

Conclusions

Our results support the applicability of CLOUT for real-world clinical use in identifying patients at high risk of mortality.

Comparing Outcomes and Costs of Medical Patients Treated at Major Teaching and Non-teaching Hospitals: A National Matched Analysis

BACKGROUND

Teaching hospitals typically pioneer investment in new technology and cultivate workforce characteristics generally associated with better quality, but the value of this extra investment is unclear.

OBJECTIVE

Compare outcomes and costs between major teaching and non-teaching hospitals by closely matching on patient characteristics.

DESIGN

Medicare patients at 339 major teaching hospitals (resident-to-bed (RTB) ratios ≥ 0.25); matched patient controls from 2439 non-teaching hospitals (RTB ratios < 0.05).

PARTICIPANTS

Forty-three thousand nine hundred ninety pairs of patients (one from a major teaching hospital and one from a non-teaching hospital) admitted for acute myocardial infarction (AMI), 84,985 pairs admitted for heart failure (HF), and 74,947 pairs admitted for pneumonia (PNA).

EXPOSURE

Treatment at major teaching hospitals versus non-teaching hospitals.

MAIN MEASURES

Thirty-day all-cause mortality, readmissions, ICU utilization, costs, payments, and value expressed as extra cost for a 1% improvement in survival.

KEY RESULTS

Thirty-day mortality was lower in teaching than non-teaching hospitals (10.7% versus 12.0%, difference = - 1.3%, P < 0.0001). The paired cost difference (teaching - non-teaching) was $273 (P < 0.0001), yielding $211 per 1% mortality improvement. For the quintile of pairs with highest risk on admission, mortality differences were larger (24.6% versus 27.6%, difference = - 3.0%, P < 0.0001), and paired cost difference = $1289 (P < 0.0001), yielding $427 per 1% mortality improvement at 30 days. Readmissions and ICU utilization were lower in teaching hospitals (both P < 0.0001), but length of stay was longer (5.5 versus 5.1 days, P < 0.0001). Finally, individual results for AMI, HF, and PNA showed similar findings as in the combined results.

CONCLUSIONS AND RELEVANCE

Among Medicare patients admitted for common medical conditions, as admission risk of mortality increased, the absolute mortality benefit of treatment at teaching hospitals also increased, though accompanied by marginally higher cost. Major teaching hospitals appear to return good value for the extra resources used.

Effect of an Incentive Spirometer Patient Reminder After Coronary Artery Bypass Grafting: A Randomized Clinical Trial

Importance

Incentive spirometers (ISs) were developed to reduce atelectasis and are in widespread clinical use. However, without IS use adherence data, the effectiveness of IS cannot be determined.

Objective

To evaluate the effect of a use-tracking IS reminder on patient adherence and clinical outcomes following coronary artery bypass grafting (CABG) surgery.

Design, Setting, and Participants

This randomized clinical trial was conducted from June 5, 2017, to December 29, 2017, at a tertiary referral teaching hospital and included 212 patients who underwent CABG, of whom 160 participants were randomized (intent to treat), with 145 completing the study per protocol. Participants were stratified by surgical urgency (elective vs nonelective) and sex (men vs women).

Interventions

A use-tracking, IS add-on device (SpiroTimer) with an integrated use reminder bell recorded and timestamped participants' inspiratory breaths. Patients were randomized by hourly reminder "bell on" (experimental group) or "bell off" (control group).

Main Outcomes and Measures

Incentive spirometer use was recorded for the entire postoperative stay and compared between groups. Radiographic atelectasis severity (score, 0-10) was the primary clinical outcome. Secondary respiratory and nonrespiratory outcomes were also evaluated.

Results

A total of 145 per-protocol participants (112 men [77%]; mean age, 69 years [95% CI, 67-70]; 90 [62%] undergoing a nonelective procedure) were evaluated, with 74 (51.0%) in the bell off group and 71 (49.0%) in the bell on group. The baseline medical and motivation-to-recover characteristics of the 2 groups were similar. The mean number of daily inspiratory breaths was greater in bell on (35; 95% CI, 29-43 vs 17; 95% CI, 13-23; P < .001). The percentage of recorded hours with an inspiratory breath event was greater in bell on (58%; 95% CI, 51-65 vs 28%; 95% CI, 23-32; P < .001). Despite no differences in the first postoperative chest radiograph mean atelectasis severity scores (2.3; 95% CI, 2.0-2.6 vs 2.4; 95% CI, 2.2-2.7; P = .48), the mean atelectasis severity scores for the final chest radiographs conducted before discharge were significantly lower for bell on than bell off group (1.5; 95% CI, 1.3-1.8 vs 1.8; 95% CI, 1.6-2.1; P = .04). Of those with early postoperative fevers, fever duration was shorter for bell on (3.2 hours; 95% CI, 2.3-4.6 vs 5.2 hours; 95% CI, 3.9-7.0; P = .04). Having the bell turned on reduced noninvasive positive pressure ventilation use rates (37.2%; 95% CI, 24.1%-52.5% vs 19.2%; 95% CI, 10.2%-33.0%; P = .03) for participants undergoing nonelective procedures. Bell on reduced the median postoperative length of stay (7 days; 95% CI, 6-9 vs 6 days; 95% CI, 6-7; P = .048) and the intensive care unit length of stay for patients undergoing nonelective procedures (4 days; 95% CI, 3-5 vs 3 days; 95% CI, 3-4; P = .02). At 6 months, the bell off mortality rate was higher than bell on (9% vs 0%, P = .048) for participants undergoing nonelective procedures.

Conclusions and Relevance

The incentive spirometer reminder improved patient adherence, atelectasis severity, early postoperative fever duration, noninvasive positive pressure ventilation use, ICU and length of stay, and 6-month mortality in certain patients. With the reminder, IS appears to be clinically effective when used appropriately.

Trial Registration

ClinicalTrials.gov identifier: NCT02952027.

Neurocritical Care Outcomes, Research, and Technology: A Review

Importance

Neurocritical care has grown into an organized specialty that may have consequences for patient care, outcomes, research, and neurointensive care (neuroICU) technology.

Observations

Neurocritical care improves care and outcomes of the patients who are neurocritically ill, and neuroICUs positively affect the financial state of health care systems. The development of neurocritical care as a recognized subspecialty has fostered multidisciplinary research, neuromonitoring, and neurocritical care information technology, with advances and innovations in practice and progress.

Conclusions and Relevance

Neurocritical care has become an important part of health systems and an established subspecialty of neurology. Understanding its structure, scope of practice, consequences for care, and research are important.

Financial impact of adapting robotics to a thoracic practice in an academic institution

Background

In the current healthcare environment there is increasing pressure to deliver high quality care to more people at less cost. Robotic assisted thoracic surgical procedures (RATS) have been shown by some to be more expensive than conventional endoscopic or open surgery. We initiated this study to assess the financial impact of RATS compared to robotic non-thoracic surgery in an academic institution.

Methods

A retrospective study was performed for all patients who underwent any robotically assisted surgical procedure at Temple University Hospital (TUH) in fiscal year 2015. Surgical volume, operative time, length of stay (LOS), case mix index (CMI), direct and indirect costs, hospital charges, surgical charges, contribution margin (CM) and net margin (NM) were collected for the thoracic surgery service in addition to other services which performed more than 20 robotic cases a year. We analyzed the data according to the following strategy: (I) financial performance for both inpatient and outpatient robotic procedures for the entire hospital; (II) compared financial data for robotic and non-robotic surgeries in the thoracic surgery division; (III) compared thoracic surgery data with the STS database for the same time period in order to calculate any potential cost saving (PCS).

Results

In FY15, a total of 696 robotic procedures were performed by the various services at TUH with a mean of 58 cases each month. Although CM was highest for cardiovascular surgery, the highest NM was by thoracic surgery. Despite having the highest volume and a positive CM, the mostly outpatient urology service showed a negative NM in FY15. A CMI-adjusted comparison on 208 of the 589 robotic procedures where there was a comparable group of inpatients who had open procedures, the mean direct cost for non-robotic procedures was $6,239, 9% less than for robotic procedures. The mean total cost for non-robotic procedures was only 3.64% ($435) less than that for robotic procedures ($11,502 vs. $11,937). When compared with the UHC expected LOS, the robotic group had a lower LOS while the non-robotic group had a higher LOS. The mean total direct costs were $3,510 less for the robotic procedures ($16,502 vs. $20,012). When compared to similar cases reported to the STS in FY 2015, the length of stay, conversion rate, transfusion rate, post-operative complications and OR time compared favorably. Using calculations based on published data, the potential cost savings are in the 1 to 2 million dollar range compared to traditional endoscopic or open procedures reported to the STS.

Conclusions

High acuity services such as Thoracic Surgery drive higher CM per case as long as variable costs especially LOS are kept low. Procedures with lower CMI may not provide a high enough CM to offset the fixed and variable costs. Robotic surgical cases performed in the outpatient setting may incur significant losses as the reimbursement does not cover the direct costs. Hospitals should preferentially allocate robotic resources to inpatient procedures with higher CMI and work to decrease overall LOS.

Abnormal shock index exposure and clinical outcomes among critically ill patients: A retrospective cohort analysis

PURPOSE

To assess the predictive value of a single abnormal shock index reading (SI ≥0.9; heart rate/systolic blood pressure [SBP]) for mortality, and association between cumulative abnormal SI exposure and mortality/morbidity.

MATERIALS AND METHODS

Cohort comprised of adult patients with an intensive care unit (ICU) stay ≥24-h (years 2010-2018). SI ≥0.9 exposure was evaluated via cumulative minutes or time-weighted average; SBP ≤100-mmHg was analyzed. Outcomes were in-hospital mortality, acute kidney injury (AKI), and myocardial injury.

RESULTS

18,197 patients from 82 hospitals were analyzed. Any single SI ≥0.9 within the ICU predicted mortality with 90.8% sensitivity and 36.8% specificity. Every 0.1-unit increase in maximum-SI during the first 24-h increased the odds of mortality by 4.8% [95%CI; 2.6-7.0%; p < .001]. Every 4-h exposure to SI ≥0.9 increased the odds of death by 5.8% [95%CI; 4.6-7.0%; p < .001], AKI by 4.3% [95%CI; 3.7-4.9%; p < .001] and myocardial injury by 2.1% [95%CI; 1.2-3.1%; p < .001]. ≥2-h exposure to SBP ≤100-mmHg was significantly associated with mortality.

CONCLUSIONS

A single SI reading ≥0.9 is a poor predictor of mortality; cumulative SI exposure is associated with greater risk of mortality/morbidity. The associations with in-hospital mortality were comparable for SI ≥0.9 or SBP ≤100-mmHg exposure. Dynamic interactions between hemodynamic variables need further evaluation among critically ill patients.

Intensivists in U.S. Acute Care Hospitals

OBJECTIVES

To determine the total numbers of privileged and full-time equivalent intensivists in acute care hospitals with intensivists and compare the characteristics of hospitals with and without intensivists.

DESIGN

Retrospective analysis of the American Hospital Association Annual Survey Database (Fiscal Year 2015).

SETTING

Two-thousand eight-hundred fourteen acute care hospitals with ICU beds.

PATIENTS

None.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of the 2,814 acute care hospitals studied, 1,469 (52%) had intensivists and 1,345 (48%) had no intensivists. There were 28,808 privileged and 19,996 full-time equivalent intensivists in the 1,469 hospitals with intensivists. In these hospitals, the median (25-75th percentile) numbers of privileged and full-time equivalent intensivists were 11 (5-24) and 7 (2-17), respectively. Compared with hospitals without intensivists, hospitals with privileged intensivists were primarily located in metropolitan areas (91% vs 50%; p < 0.001) and at the aggregate level had nearly thrice the number of hospital beds (403,522 [75%] vs 137,146 [25%]), 3.6 times the number of ICU beds (74,222 [78%] vs 20,615 [22%]), and almost twice as many ICUs (3,383 [65%] vs 1,846 [35%]). At the hospital level, hospitals with privileged intensivists had significantly more hospital beds (median, 213 vs 68; p < 0.0001), ICU beds (median, 32 vs 8; p < 0.0001), a higher ratio of ICU to hospital beds (15.6% vs 12.6%; p < 0.0001), and a higher number of ICUs per hospital (2 vs 1; p < 0.0001) than hospitals without intensivists.

CONCLUSIONS

Analyzing the intensivist section of the American Hospital Association Annual Survey database is a novel approach to estimating the numbers of privileged and full-time equivalent intensivists in acute care hospitals with ICU beds in the United States. This methodology opens the door to an enhanced understanding of the current supply and distribution of intensivists as well as future research into the intensivist workforce.

A Survey of Charge Sensitivity and Charge Awareness Among Intensive Care Unit Providers in a Large Academic Medical Center

Little is known about charge sensitivity or charge awareness among intensive care unit (ICU) providers in the United States. In a survey of 295 ICU providers at a large, academic medical center, 92.5% of respondents agreed that controlling health care expenses is partly their responsibility. However, 87.4% of respondents reported that they did not know the charges for most of the tests and medications they prescribe. Among surveyed participants, the correct charge for a medical procedure or test was selected only 35% of the time. While ICU providers overwhelmingly agree that controlling expenses is their responsibility, charge awareness is low and likely limits their ability to make value-based decisions.

Exploring the role of social work in U.S. burn centers

Because burn injuries most often occur within marginalized populations, there is a greater risk for poor psychosocial outcomes and social workers are trained to identify those psychosocial risk and resilience factors. Very little has been written about the role of social workers working in burn critical care teams, therefore leaving a gap in knowledge regarding this specialized area of social work practice. Social workers participating in multidisciplinary burn care teams were invited to participate in this preliminary descriptive study (n = 29). Frequency statistics were calculated for the brief online survey to learn more about professional preparation and continuing education, job responsibilities, and perspectives on job skills. Respondents were primarily white and female, with a mean age of 43.74 years. Most respondents reported holding an MSSW and a state-issued professional license. Responsibilities were described as discharge planning, case management, patient counseling, family counseling, support group facilitation, community education, school reentry/back to work programs, burn prevention, and "other duties", respectively. More than half of the respondents reported responsibilities in other units. With increased understanding of interventions used by social workers inpatient, there can be a greater understanding of patients' continuing needs once discharged.

Mapping structure, process and outcomes in the removal of low-value care practices in Canadian intensive care units: protocol for a mixed-methods exploratory study

INTRODUCTION

The challenge of implementing best evidence into clinical practice is a major problem in modern healthcare that can result in ineffective, inefficient and unsafe care. There is a growing body of literature which suggests that the removal or reduction of low-value care practices (ie, deadoption) is integral to the delivery of high-quality care and the sustainability of our healthcare system. However, currently very little is known about deadoption practices in Canada. We propose to map the current state of deadoption in Canadian intensive care units (ICUs). A key deliverable of this work will include development of an inventory of barriers, facilitators and potential implementation strategies for guiding the deadoption efforts.

METHODS AND ANALYSIS

We will use Canadian adult general systems ICUs as our laboratory of investigation and employ a two-phased sequential exploratory mixed-methods approach: (1) semi-structured interviews with critical care stakeholders to develop an understanding of the structure (ie, healthcare context), process (ie, actions and events in healthcare) and outcomes (ie, effects on health status, quality, knowledge or behaviour) of deadoption (phase I) and (2) surveys with a broader sample of critical care stakeholders to further identify important barriers and facilitators, as well as potential implementation strategies (phase II). Interview data will be analysed through qualitative content analysis and survey data will be analysed through quantitative analyses to identify top barriers and facilitators, as well as top rated strategies.

ETHICS AND DISSEMINATION

Ethical approval has been obtained through the University of Calgary Research Ethics Board (REB 17-2153). Participants involved will have the opportunity to provide feedback on the final written reports to support accurate representation of the data. The findings of this study will be disseminated through peer-reviewed publications and oral presentations with critical care stakeholders across Canada. Patient and family partners will receive an executive summary of the findings.

Seasonal variation of clinical characteristics and prognostic of adult patients admitted to an intensive care unit

OBJECTIVE

To evaluate seasonal variations of clinical characteristics, therapeutic resource use, and outcomes of critically ill patients admitted to an intensive care unit.

METHODS

A retrospective cohort study conducted from January 2011 to December 2016 in adult patients admitted to the intensive care unit (ICU) of a University Hospital. Data were collected on the type of admission, APACHE II, SOFA, and TISS 28 scores at ICU admission. Length of hospital stay and vital status at hospital discharge were recorded. A significance level of 5% was adopted.

RESULTS

During the study period, 3.711 patients were analyzed. Patients had a median age of 60.0 years (interquartile range = 45.0 - 73.0), and 59% were men. The independent risk factors associated with increased hospital mortality rate were age, chronic disease, seasonality, diagnostic category, need for mechanical ventilation and vasoactive drugs, presence of acute kidney injury, and sepsis at admission.

CONCLUSION

It was possible to observe variations of the clinical characteristics and prognosis of patients; summer months presented a higher proportion of clinical and emergency surgery patients, with higher mortality rates. Sepsis at ICU admission did not show seasonal behavior. A seasonal pattern was found for mortality rate.

Impact of mechanical ventilation on the daily costs of ICU care: a systematic review and meta regression

The impact of mechanical ventilation on the daily costs of intensive care unit (ICU) care is largely unknown. We thus conducted a systematic search for studies measuring the daily costs of ICU stays for general populations of adults (age ≥18 years) and the added costs of mechanical ventilation. The relative increase in the daily costs was estimated using random effects meta regression. The results of the analyses were applied to a recent study calculating the excess length-of-stay associated with ICU-acquired (ventilator-associated) pneumonia, a major complication of mechanical ventilation. The search identified five eligible studies including a total of 54 766 patients and ~238 037 patient days in the ICU. Overall, mechanical ventilation was associated with a 25.8% (95% CI 4.7%–51.2%) increase in the daily costs of ICU care. A combination of these estimates with standardised unit costs results in approximate daily costs of a single ventilated ICU day of €1654 and €1580 in France and Germany, respectively. Mechanical ventilation is a major driver of ICU costs and should be taken into account when measuring the financial burden of adverse events in ICU settings.

Time-Limited Trials Among Critically Ill Patients With Advanced Medical Illnesses to Reduce Nonbeneficial Intensive Care Unit Treatments: Protocol for a Multicenter Quality Improvement Study

BACKGROUND

Invasive intensive care unit (ICU) treatments for patients with advanced medical illnesses and poor prognoses may prolong suffering with minimal benefit. Unfortunately, the quality of care planning and communication between clinicians and critically ill patients and their families in these situations are highly variable, frequently leading to overutilization of invasive ICU treatments. Time-limited trials (TLTs) are agreements between the clinicians and the patients and decision makers to use certain medical therapies over defined periods of time and to evaluate whether patients improve or worsen according to predetermined clinical parameters. For patients with advanced medical illnesses receiving aggressive ICU treatments, TLTs can promote effective dialogue, develop consensus in decision making, and set rational boundaries to treatments based on patients' goals of care.

OBJECTIVE

The aim of this study will be to examine whether a multicomponent quality-improvement strategy that uses protocoled TLTs as the default ICU care-planning approach for critically ill patients with advanced medical illnesses will decrease duration and intensity of nonbeneficial ICU care without changing hospital mortality.

METHODS

This study will be conducted in medical ICUs of three public teaching hospitals in Los Angeles County. In Aim 1, we will conduct focus groups and semistructured interviews with key stakeholders to identify facilitators and barriers to implementing TLTs among ICU patients with advanced medical illnesses. In Aim 2, we will train clinicians to use protocol-enhanced TLTs as the default communication and care-planning approach in patients with advanced medical illnesses who receive invasive ICU treatments. Eligible patients will be those who the treating ICU physicians consider to be at high risk for nonbeneficial treatments according to guidelines from the Society of Critical Care Medicine. ICU physicians will be trained to use the TLT protocol through a curriculum of didactic lectures, case discussions, and simulations utilizing actors as family members in role-playing scenarios. Family meetings will be scheduled by trained care managers. The improvement strategy will be implemented sequentially in the three participating hospitals, and outcomes will be evaluated using a before-and-after study design. Key process outcomes will include frequency, timing, and content of family meetings. The primary clinical outcome will be ICU length of stay. Secondary outcomes will include hospital length of stay, days receiving life-sustaining treatments (eg, mechanical ventilation, vasopressors, and renal replacement therapy), number of attempts at cardiopulmonary resuscitation, frequency of invasive ICU procedures, and disposition from hospitalization.

RESULTS

The study began in August 2017. The implementation of interventions and data collection were completed at two of the three hospitals. As of September 2019, the study was at the postintervention stage at the third hospital. We have completed focus groups with physicians at each medical center (N=29) and interviews of family members and surrogate decision makers (N=18). The study is expected to be completed in the first quarter of 2020, and results are expected to be available in mid-2020.

CONCLUSIONS

The successful completion of the aims in this proposal may identify a systematic approach to improve communication and shared decision making and to reduce nonbeneficial invasive treatments for ICU patients with advanced medical illnesses.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/16301.

Telemedicine Coverage of Intensive Care Units: A Narrative Review

Telemedicine coverage of intensive care units is an organizational innovation that has been touted as a means to improve access to and quality of critical care. The purpose of this narrative review is to discuss the different organizational models of intensive care unit telemedicine and factors that have influenced its adoption and to review the existing literature to consider whether it has lived up to its promise. We conclude by suggesting future directions to fill in some of the existing gaps in the literature.

Post-intensive care unit depression among critical care survivors: A nationwide population-based study

AIM

To investigate the incidence of post-intensive care unit (ICU) depression and its risk factors among critical care survivors.

METHODS

The study data were extracted from the database of the National Health Insurance Service of Korea. We retrospectively analyzed data from 161,977 adult patients who were admitted to the ICU for more than 24 hr from January 1, 2012 to December 31, 2014 and survived for more than 1 year after discharge. Risk factors for newly diagnosed depression (Code F32) were analyzed using multiple logistic regression analysis.

RESULTS

The incidence of post-ICU depression was 18.5%. The major risk factors were enteral nutrition (odds ratio [OR] = 2.28, 95% confidence interval [CI] = 2.19-2.36), cerebrovascular disease (OR = 1.59, 95% CI = 1.54-1.64), and hemi/paraplegia (OR = 1.48, 95% CI = 1.41-1.56). It was observed that cardiopulmonary resuscitation (OR = 0.55, 95% CI = 0.50-0.61) and myocardial infarction (OR = 0.75, 95% CI = 0.71-0.79) lowered depression.

CONCLUSIONS

The incidence of post-ICU depression was high and influenced by ICU treatment and physical impairments. Healthcare providers must pay attention to the psychological changes in survivors with major risk factors in the recovery process.

Caring for Critically Ill Patients with the ABCDEF Bundle: Results of the ICU Liberation Collaborative in Over 15,000 Adults

OBJECTIVE

Decades-old, common ICU practices including deep sedation, immobilization, and limited family access are being challenged. We endeavoured to evaluate the relationship between ABCDEF bundle performance and patient-centered outcomes in critical care.

DESIGN

Prospective, multicenter, cohort study from a national quality improvement collaborative.

SETTING

68 academic, community, and federal ICUs collected data during a 20-month period.

PATIENTS

15,226 adults with at least one ICU day.

INTERVENTIONS

We defined ABCDEF bundle performance (our main exposure) in two ways: 1) complete performance (patient received every eligible bundle element on any given day) and 2) proportional performance (percentage of eligible bundle elements performed on any given day). We explored the association between complete and proportional ABCDEF bundle performance and three sets of outcomes: patient-related (mortality, ICU and hospital discharge), symptom-related (mechanical ventilation, coma, delirium, pain, restraint use), and system-related (ICU readmission, discharge destination). All models were adjusted for a minimum of 18 a priori determined potential confounders.

MEASUREMENTS AND RESULTS

Complete ABCDEF bundle performance was associated with lower likelihood of seven outcomes: hospital death within 7 days (adjusted hazard ratio, 0.32; CI, 0.17-0.62), next-day mechanical ventilation (adjusted odds ratio [AOR], 0.28; CI, 0.22-0.36), coma (AOR, 0.35; CI, 0.22-0.56), delirium (AOR, 0.60; CI, 0.49-0.72), physical restraint use (AOR, 0.37; CI, 0.30-0.46), ICU readmission (AOR, 0.54; CI, 0.37-0.79), and discharge to a facility other than home (AOR, 0.64; CI, 0.51-0.80). There was a consistent dose-response relationship between higher proportional bundle performance and improvements in each of the above-mentioned clinical outcomes (all p < 0.002). Significant pain was more frequently reported as bundle performance proportionally increased (p = 0.0001).

CONCLUSIONS

ABCDEF bundle performance showed significant and clinically meaningful improvements in outcomes including survival, mechanical ventilation use, coma, delirium, restraint-free care, ICU readmissions, and post-ICU discharge disposition.