Critical care at the end of life: a population-level cohort study of cost and outcomes

ED observation unit-based delayed comfort care pathway for ED patients on life support

BACKGROUND

Critically ill ED patients on life support may undergo transition to comfort care as decided by the surrogate decision maker. When several hours are needed for loved ones to arrive and say farewell before initiating comfort care ("delayed comfort care"), these patients require prolonged ED stays or costly intensive care unit (ICU) admissions.

METHODS

A novel ED observation unit (EDOU)-based delayed comfort care pathway for ED patients on invasive mechanical ventilation and/or vasopressors was created in 2013 at Stanford Hospital. Inclusion criteria are: agreement by the surrogate decision maker to no titration of life support and initiation of comfort care within 18 h of EDOU admission. Exclusion criteria are: potential for organ donation and lack of a private room or nursing resources in the EDOU. Feasibility was assessed by analyzing the electronic health record for all patients who utilized the pathway between 8/2013 and 2/2023. The primary outcome was the proportion of patients who had initiation of comfort care after all expected loved ones arrived to the bedside. We also analyzed patient characteristics, clinical operation data, and safety data.

RESULTS

23 patients were identified in the study cohort. The average patient age was 76, and 48 % were female. Three ED diagnoses for the cohort were intracranial hemorrhage (57 %), cardiac arrest (26 %), and respiratory failure (17 %). All patients were intubated, and six were also on vasopressors on arrival to the EDOU. 100 % of patients had all expected family members arrive to bedside prior to initiation of comfort care. All patients had initiation of comfort care within 18 h of EDOU admission (median time from EDOU arrival to extubation 1.1 h (IQR 0.2-3.2)). No patients had adverse events in the EDOU, died before comfort care initiation, or were transferred to ICU.

CONCLUSION

The EDOU-based delayed comfort care pathway is a feasible way to deliver compassionate end of life care for patients on life support. It can be considered in hospitals with an EDOU especially if their private ED beds and ICU resources are scarce.

Laboratory Test Use and Values in the Last Year of Life-a Matched Cohort Design

Background

As individuals approach death, they experience declines in their cognitive, physical, motor, sensory, physiologic, and psychosocial functions. In this exploratory study we examined individuals' physiologic changes in the last year of life by examining laboratory tests commonly used in clinical practice.

Methods

Using health administrative datasets, we conducted an observational matched cohort study to assess laboratory test use and values over a decedent's last 12 months and a matched observation window for non-decedents. Laboratory tests included tests for electrolytes: potassium and sodium; complete blood count: hemoglobin and leukocytes; diabetes: hemoglobin A1c; and kidney or liver function: albumin-serum, alanine aminotransferase, and creatinine.

Results

We identified 376,463 decedents, 367,474 (97.6%) of whom were matched to non-decedents (similar age and sex). For each test, the proportion of non-decedents who received the test was stable over the 12-month observation period. A higher proportion of decedents had a laboratory test than non-decedents for all but the diabetes test. As decedents neared death, there was a gradual increase in test use until their final month of life, when test use dramatically increased. Across all laboratory tests, test values remained similar for non-decedents over the 12-month observation period. However, for decedents, there were differences in the magnitude and direction of the test values over the 12 months.

Conclusion

Our findings indicate distinct changes in decedents' laboratory test use and values over their last 12 months. Future work should explore whether laboratory tests could predict survival or improve the performance of mortality prediction models.

Coaching doctors to improve ethical decision-making in adult hospitalized patients potentially receiving excessive treatment. The CODE stepped-wedge cluster randomized controlled trial

PURPOSE

The aim of this study was to assess whether coaching doctors to enhance ethical decision-making in teams improves (1) goal-oriented care operationalized via written do-not-intubate and do-not attempt cardiopulmonary resuscitation (DNI-DNACPR) orders in adult patients potentially receiving excessive treatment (PET) during their first hospital stay and (2) the quality of the ethical climate.

METHODS

We carried out a stepped-wedge cluster randomized controlled trial in the medical intensive care unit (ICU) and 9 referring internal medicine departments of Ghent University Hospital between February 2022 and February 2023. Doctors and nurses in charge of hospitalized patients filled out the ethical decision-making climate questionnaire (ethical decision-making climate questionnaire, EDMCQ) before and after the study, and anonymously identified PET via an electronic alert during the entire study period. All departments were randomly assigned to a 4-month coaching. At least one month of coaching was compared to less than one month coaching and usual care. The first primary endpoint was the incidence of written DNI-DNACPR decisions. The second primary endpoint was the EDMCQ before and after the study period. Because clinicians identified less PET than required to detect a difference in written DNI-DNACPR decisions, a post-hoc analysis on the overall population was performed. To reduce type I errors, we further restricted the analysis to one of our predefined secondary endpoints (mortality up to 1 year).

RESULTS

Of the 442 and 423 clinicians working before and after the study period, respectively 270 (61%) and 261 (61.7%) filled out the EDMCQ. Fifty of the 93 (53.7%) doctors participated in the coaching for a mean (standard deviation [SD]) of 4.36 (2.55) sessions. Of the 7254 patients, 125 (1.7%) were identified as PET, with 16 missing outcome data. Twenty-six of the PET and 624 of the overall population already had a written DNI-DNACPR decision at study entry, resulting in 83 and 6614 patients who were included in the main and post hoc analysis, respectively. The estimated incidence of written DNI-DNACPR decisions in the intervention vs. control arm was, respectively, 29.7% vs. 19.6% (odds ratio 4.24, 95% confidence interval 4.21-4.27; P < 0.001) in PET and 3.4% vs. 1.9% (1.65, 1.12-2.43; P = 0.011) in the overall study population. The estimated mortality at one year was respectively 85% vs. 83.7% (hazard ratio 2.76, 1.26-6.04; P = 0.011) and 14.5% vs. 15.1% (0.89, 0.72-1.09; P = 0.251). The mean difference in EDMCQ before and after the study period was 0.02 points (- 0.18 to 0.23; P = 0.815).

CONCLUSION

This study suggests that coaching doctors regarding ethical decision-making in teams safely improves goal-oriented care operationalized via written DNI-DNACPR decisions in hospitalized patients, however without concomitantly improving the quality of the ethical climate.

Opportunities to Improve End-of-Life Care Quality among Patients with Short Terminal Admissions

CONTEXT

Little is known about Veterans who die during a short terminal admission, which renders them ineligible for the Department of Veterans Affairs (VA) Bereaved Family Survey.

OBJECTIVES

We sought to describe this population and identify opportunities to improve end-of-life (EOL) care quality.

METHODS

Retrospective, cohort analysis of Veteran decedents who died in a VA inpatient setting between October 2018-September 2019. Veterans were dichotomized by short (<24 hours) and long (≥24 hours) terminal admissions; sociodemographics, clinical characteristics, VA and non-VA healthcare use, and EOL care quality indicators were compared.

RESULTS

Among 17,033 inpatient decedents, 723 (4%) had short terminal admissions. Patients with short compared to long terminal admissions were less likely to have a VA hospitalization (38% vs. 54%) in the last 90 days of life and were more likely to die in an intensive care (49% vs 21%) or acute care (27% vs 18%) unit. Patients with a short compared to long admission were about half as likely to receive hospice (33% vs 64%) or palliative care (33% vs 69%). Most patients with short admissions (76%) had a life-limiting condition (e.g., cancer, chronic obstructive pulmonary disease) and those with cancer were more likely to receive palliative care compared to those with non-cancer conditions.

CONCLUSION

Veterans with short terminal admissions are less likely to receive hospice or palliative care compared to patients with long terminal admissions. Many patients with short terminal admissions, such as those with life-limiting conditions (especially cancer), receive aspects of high-quality EOL care, however, opportunities for improvement exist.

Surgeon Sex and Health Care Costs for Patients Undergoing Common Surgical Procedures

Importance

Prior research has shown differences in postoperative outcomes for patients treated by female and male surgeons. It is important to understand, from a health system and payer perspective, whether surgical health care costs differ according to the surgeon's sex.

Objective

To examine the association between surgeon sex and health care costs among patients undergoing surgery.

Design, Setting, and Participants

This population-based, retrospective cohort study included adult patients undergoing 1 of 25 common elective or emergent surgical procedures between January 1, 2007, and December 31, 2019, in Ontario, Canada. Analysis was performed from October 2022 to March 2023.

Exposure

Surgeon sex.

Main Outcome and Measure

The primary outcome was total health care costs assessed 1 year following surgery. Secondarily, total health care costs at 30 and 90 days, as well as specific cost categories, were assessed. Generalized estimating equations were used with procedure-level clustering to compare costs between patients undergoing equivalent surgeries performed by female and male surgeons, with further adjustment for patient-, surgeon-, anesthesiologist-, hospital-, and procedure-level covariates.

Results

Among 1 165 711 included patients, 151 054 were treated by a female surgeon and 1 014 657 were treated by a male surgeon. Analyzed at the procedure-specific level and accounting for patient-, surgeon-, anesthesiologist-, and hospital-level covariates, 1-year total health care costs were higher for patients treated by male surgeons ($24 882; 95% CI, $20 780-$29 794) than female surgeons ($18 517; 95% CI, $16 080-$21 324) (adjusted absolute difference, $6365; 95% CI, $3491-9238; adjusted relative risk, 1.10; 95% CI, 1.05-1.14). Similar patterns were observed at 30 days (adjusted absolute difference, $3115; 95% CI, $1682-$4548) and 90 days (adjusted absolute difference, $4228; 95% CI, $2255-$6202).

Conclusions and Relevance

This analysis found lower 30-day, 90-day, and 1-year health care costs for patients treated by female surgeons compared with those treated by male surgeons. These data further underscore the importance of creating inclusive policies and environments supportive of women surgeons to improve recruitment and retention of a more diverse and representative workforce.

Limitation of Non-Beneficial Interventions and their Impact on the Intensive Care Unit Costs

Introduction

Using a plan to limit non-beneficial life support interventions has significantly reduced harm and loss of dignity for patients at the end of life. The association of these limitations with patients' clinical characteristics and health care costs in the intensive care unit (ICU) needs further scientific evidence.

Aim of the study

To explore decisions to limit non-beneficial life support interventions, their correlation with patients' clinical data, and their effect on the cost of care in the ICU.

Material and Methods

We included all patients admitted to the general ICU of a hospital in Greece in a two-year (2019-2021) prospective study. Data collection included patient demographic and clinical variables, data related to decisions to limit (withholding, withdrawing) non-beneficial interventions (NBIs), and economic data. Comparisons were made between patients with and without limitation decisions.

Results

NBIs were limited in 164 of 454 patients (36.12%). Patients with limitation decisions were associated with older age (70y vs. 62y; p<0,001), greater disease severity score (APACHE IV, 71 vs. 50; p<0,001), longer length of stay (7d vs. 4.5d; p<0,001), and worse prognosis of death (APACHE IV PDR, 48.9 vs. 17.35; p<0,001). All cost categories and total cost per patient were also higher than the patient without limitation of NBIs (9247,79€ vs. 8029,46€, p<0,004). The mean daily cost has not differed between the groups (831,24€ vs. 832,59€; p<0,716). However, in the group of patients with limitations, all cost categories, including the average daily cost (767.31€ vs. 649.12€) after the limitation of NBIs, were reduced to a statistically significant degree (p<0.001).

Conclusions

Limiting NBIs in the ICU reduces healthcare costs and may lead to better management of ICU resource use.

Characteristics and Outcomes of Very Elderly Patients Admitted to Intensive Care: A Retrospective Multicenter Cohort Analysis

OBJECTIVES

To characterize and compare trends in ICU admission, hospital outcomes, and resource utilization for critically ill very elderly patients (≥ 80 yr old) compared with the younger cohort (16-79 yr old).

DESIGN

A retrospective multicenter cohort study.

SETTING

One-hundred ninety-four ICUs contributing data to the Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation Adult Patient Database between January 2006 and December 2018.

PATIENTS

Adult (≥ 16 yr) patients admitted to Australian and New Zealand ICUs.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Very elderly patients with a mean ± sd age of 84.8 ± 3.7 years accounted for 14.8% (232,582/1,568,959) of all adult ICU admissions. They had higher comorbid disease burden and illness severity scores compared with the younger cohort. Hospital (15.4% vs 7.8%, p < 0.001) and ICU mortality (8.5% vs 5.2%, p < 0.001) were higher in the very elderly. They stayed fewer days in ICU, but longer in hospital and had more ICU readmissions. Among survivors, a lower proportion of very elderly was discharged home (65.2% vs 82.4%, p < 0.001), and a higher proportion was discharged to chronic care/nursing home facilities (20.1% vs 7.8%, p < 0.001). Although there was no change in the proportion of very elderly ICU admissions over the study period, they showed a greater decline in risk-adjusted mortality (6.3% [95% CI, 5.9%-6.7%] vs 4.0% [95% CI, 3.7%-4.2%] relative reduction per year, p < 0.001) compared with the younger cohort. The mortality of very elderly unplanned ICU admissions improved faster than the younger cohort ( p < 0.001), whereas improvements in mortality among elective surgical ICU admissions were similar in both groups ( p = 0.45).

CONCLUSIONS

The proportion of ICU admissions greater than or equal to 80 years old did not change over the 13-year study period. Although their mortality was higher, they showed improved survivorship over time, especially in the unplanned ICU admission subgroup. A higher proportion of survivors were discharged to chronic care facilities.

Treatment Patterns in Men Prescribed Benign Prostatic Obstruction or Overactive Bladder Medications in Canada: A Retrospective Population-based Study

OBJECTIVE

To characterize first therapeutic change and healthcare resource utilization in older men initiating an overactive bladder (OAB) or benign prostatic obstruction (BPO) medication.

METHODS

A retrospective cohort study using health administrative data from ICES in Ontario, Canada (from April 01, 2010 to December 31, 2018) was conducted in men aged ≥66 years with ≥1 OAB (β3 agonist, antimuscarinic) or BPO (α-blocker, 5-α-reductase inhibitor) prescription and ≥1-year postindex data (index=first observed dispensation).

EXCLUSIONS

prescriptions for these drugs ≤1 year preindex, a related procedure ≤5 years. Patients were grouped by condition based on index prescription. Treatment changes in relation to OAB and BPO were characterized by type. Costs and healthcare resource utilization pre- and post-index were compared.

RESULTS

Age, geographic region, and income were similar between groups. The most common initial treatments were antimuscarinics (78.1%) in the OAB group and alpha-blockers (86.4%) in the BPO group. The OAB group was more likely to experience a therapeutic change and had a shorter time to first change in therapy (78 [30,231] vs 104 [30,350] days) and higher mean healthcare costs both pre- ($12,354 vs $11,497) and postindex ($14,423 vs $12,852). The most common first therapeutic change in both groups was discontinuing treatment (OAB: 75.6%; BPO: 69.9%).

CONCLUSION

Men initiating OAB medications changed therapy sooner than those initiating BPO medications. Most discontinued first-line therapy without initiating further treatment, suggesting unmet need in this population.

ICU Bereaved Surrogates' Transition Through States of Co-Occurring Prolonged Grief Disorder, Posttraumatic Stress Disorder, and Depression Symptoms

OBJECTIVES

Grief-related psychological distress often co-occurs to conjointly impair function during bereavement. Knowledge of comorbid grief-related psychological distress is limited: no longitudinal study has examined dynamic patterns of co-occurring prolonged grief disorder (PGD), posttraumatic stress disorder (PTSD), and depression, and previous assessment time frames have been variable and potentially inadequate given the duration criterion for PGD. Therefore, the purpose of this study was to investigate the transition of distinct symptom states based on the co-occurrence of PGD, PTSD, and depression symptoms for ICU bereaved surrogates over their first two bereavement years.

DESIGN

Prospective, longitudinal, observational study.

SETTING

Medical ICUs at two academically affiliated medical centers in Taiwan.

PATIENTS/PARTICIPANTS

Three hundred three family surrogates responsible for decision-making for critically ill patients at high risk of death (Acute Physiology and Chronic Evaluation II scores > 20) from a disease.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

Participants were assessed by 11 items of the Prolonged Grief Disorder (PG-13) scale, the Impact of Event Scale-Revised, and the depression subscale of the Hospital Anxiety and Depression Scale at 6, 13, 18, and 24 months postloss. PGD-PTSD-depression-symptom states and their evolution were examined by latent transition analysis. The following four distinct PGD-PTSD-depression-symptom states (prevalence) were initially identified: resilient (62.3%), subthreshold depression-dominant (19.9%), PGD-dominant (12.9%), and PGD-PTSD-depression comorbid (4.9%) states. These PGD-PTSD-depression-symptom states remained highly stable during the first two bereavement years, with transitions predominantly toward resilience. Prevalence for each state at 24 months postloss was 82.1%, 11.4%, 4.0%, and 2.5%, respectively.

CONCLUSIONS

Four highly stable PGD-PTSD-depression-symptom states were identified, highlighting the importance of screening for subgroups of ICU bereaved surrogates with increased PGD or comorbid PGD, PTSD, and depression symptoms during early bereavement.

Temporal reciprocal relationships among anxiety, depression, and posttraumatic stress disorder for family surrogates from intensive care units over their first two bereavement years

BACKGROUND/OBJECTIVE

Bereaved family surrogates from intensive care units (ICU) are at risk of comorbid anxiety, depression, and post-traumatic stress disorder (PTSD), but the temporal reciprocal relationships among them have only been examined once among veterans. This study aimed to longitudinally investigate these never-before-examined temporal reciprocal relationships for ICU family members over their first two bereavement years.

METHODS

In this prospective, longitudinal, observational study, symptoms of anxiety, depression, and PTSD were assessed among 321 family surrogates of ICU decedents from 2 academically affiliated hospitals in Taiwan by the anxiety and depression subscales of the Hospital Anxiety and Depression Scale, and the Impact of Event Scale-Revised, respectively at 1, 3, 6, 13, 18, and 24 months postloss. Cross-lagged panel modeling was conducted to longitudinally examine the temporal reciprocal relationships among anxiety, depression, and PTSD.

RESULTS

Examined psychological-distress levels were markedly stable over the first 2 bereavement years: autoregressive coefficients for symptoms of anxiety, depression, and PTSD were 0.585-0.770, 0.546-0.780, and 0.440-0.780, respectively. Cross-lag coefficients showed depressive symptoms predicted PTSD symptoms in the first bereavement year, whereas PTSD symptoms predicted depressive symptoms in the second bereavement year. Anxiety symptoms predicted symptoms of depression and PTSD at 13 and 24 months postloss, whereas depressive symptoms predicted anxiety symptoms at 3 and 6 months postloss while PTSD symptoms predicted anxiety symptoms during the second bereavement year.

CONCLUSIONS

Different patterns of temporal relationships among symptoms of anxiety, depression, and PTSD over the first 2 bereavement years present important opportunities to target symptoms of specific psychological distress at different points during bereavement to prevent the onset, exacerbation, or maintenance of subsequent psychological distress.

Coaching doctors to improve ethical decision-making in adult hospitalised patients potentially receiving excessive treatment: Study protocol for a stepped wedge cluster randomised controlled trial

BACKGROUND

Fast medical progress poses a significant challenge to doctors, who are asked to find the right balance between life-prolonging and palliative care. Literature indicates room for enhancing openness to discuss ethical sensitive issues within and between teams, and improving decision-making for benefit of the patient at end-of-life.

METHODS

Stepped wedge cluster randomized trial design, run across 10 different departments of the Ghent University Hospital between January 2022 and January 2023. Dutch speaking adult patients and one of their relatives will be included for data collection. All 10 departments were randomly assigned to start a 4-month coaching period. Junior and senior doctors will be coached through observation and debrief by a first coach of the interdisciplinary meetings and individual coaching by the second coach to enhance self-reflection and empowering leadership and managing group dynamics with regard to ethical decision-making. Nurses, junior doctors and senior doctors anonymously report perceptions of excessive treatment via the electronic patient file. Once a patient is identified by two or more different clinicians, an email is sent to the second coach and the doctor in charge of the patient. All nurses, junior and senior doctors will be invited to fill out the ethical decision making climate questionnaire at the start and end of the 12-months study period. Primary endpoints are (1) incidence of written do-not-intubate and resuscitate orders in patients potentially receiving excessive treatment and (2) quality of ethical decision-making climate. Secondary endpoints are patient and family well-being and reports on quality of care and communication; and clinician well-being. Tertiairy endpoints are quantitative and qualitative data of doctor leadership quality.

DISCUSSION

This is the first randomized control trial exploring the effects of coaching doctors in self-reflection and empowering leadership, and in the management of team dynamics, with regard to ethical decision-making about patients potentially receiving excessive treatment.

Palliative Approach to Care Education for Multidisciplinary Staff of Long-Term Care Homes: A Pretest Post-Test Study

This study used a single-group pre-test and post-test design to evaluate an educational workshop for multidisciplinary staff working in long-term care homes on implementing a palliative approach to care and perceptions about advanced care planning conversations. Two outcomes were measured to assess the preliminary efficacy of the educational workshop at baseline and 1-month post-intervention. Knowledge regarding implementing a palliative approach to care was assessed using the End-of-Life Professional Caregivers Survey and changes in staff perception toward ACP conversations were assessed using the Staff Perceptions Survey. Findings suggest that staff experienced an improvement in self-reported knowledge regarding a palliative approach to care (p ≤ .001); and perceptions of knowledge, attitude, and comfort related to advance care planning discussions (p ≤ .027). The results indicate that educational workshops can assist in improving multidisciplinary staff's knowledge about a palliative approach to care and comfort in carrying out advance care planning discussions with residents, family care partners, and among long-term care staff.

Is this as good as it gets? Implications of an asymptotic mortality decline and approaching the nadir in pediatric intensive care

Despite advances in medicine, some children will always die; a decline in pediatric intensive care unit (PICU) mortality to zero will never be achieved. The mortality decline is correspondingly asymptotic, yet we remain preoccupied with mortality outcomes. Are we at the nadir, and are we, thus, as good as we can get? And what should we focus to benchmark our units, if not mortality? In the face of changing case-mix and rising complexity, dramatic reductions in PICU mortality have been observed globally. At the same time, survivors have increasing disability, and deaths are often characterized by intensive life-sustaining therapies preceded by prolonged admissions, emphasizing the need to consider alternate outcome measures to evaluate our successes and failures. What are the costs and implications of reaching this nadir in mortality outcomes? We highlight the failings of our fixation with survival and an imperative to consider alternative outcomes in our PICUs, including the costs for both patients that survive and die, their families, healthcare providers, and society including perspectives in low resource settings. We describe the implications for benchmarking, research, and training the next generation of providers.Conlusion: Although survival remains a highly relevant metric, as PICUs continue to strive for clinical excellence, pushing boundaries in research and innovation, with endeavors in safety, quality, and high-reliability systems, we must prioritize outcomes beyond mortality, evaluate "costs" beyond economics, and find novel ways to improve the care we provide to all of our pediatric patients and their families. What is Known: • The fall in PICU mortality is asymptotic, and a decline to zero is not achievable. Approaching the nadir, we challenge readers to consider implications of focusing on medical and technological advances with survival as the sole outcome of interest. What is New: • Our fixation with survival has costs for patients, families, staff, and society. In the changing PICU landscape, we advocate to pivot towards alternate outcome metrics. • By considering the implications for benchmarking, research, and training, we may better care for patients and families, educate trainees, and expand what it means to succeed in the PICU.

Cost of Futile ICU Care in One Ontario Hospital

Critical care is a costly and finite resource that provides the ability to manage patients with life-threatening illnesses in the most advanced forms available. However, not every condition benefits from critical care. There are unrecoverable health states in which it should not be used to perpetuate. Such situations are considered futile. The determination of medical futility remains controversial. In this study we describe the length of stay (LOS), cost, and long-term outcomes of 12 cases considered futile and that have been or were considered for adjudication by Ontario’s Consent and Capacity Board (CBB). A chart review was undertaken to identify patients admitted to the Intensive Care Unit (ICU), whose care was deemed futile and cases were considered for, or brought before the CCB. Costs for each of these admissions were determined using the case-costing system of The Ottawa Hospital Data Warehouse. All 12 patients identified had a LOS of greater than 4 months (range: 122-704 days) and a median age 83.5 years. Seven patients died in hospital, while 5 were transferred to long term or acute care facilities. All patients ultimately died without returning to independent living situations. The total cost of care for these 12 patients was $7 897 557.85 (mean: $658 129.82). There is a significant economic cost of providing resource-intensive critical care to patients in which these treatments are considered futile. Clinicians should carefully consider the allocation of finite critical care resources in order to utilize them in a way that most benefits patients.

Intensity of outpatient physician care in the last year of life: a population-based retrospective descriptive study

BACKGROUND

For many patients, health care needs increase toward the end of life, but little is known about the extent of outpatient physician care during that time. The objective of this study was to describe the volume and mix of outpatient physician care over the last 12 months of life among patients dying with different end-of-life trajectories.

METHODS

We conducted a retrospective descriptive study involving adults (aged ≥ 18 yr) who died in Ontario between 2013 and 2017, using linked provincial health administrative databases. Decedents were grouped into 5 mutually exclusive end-of-life trajectories (terminal illness, organ failure, frailty, sudden death and other). Over the last 12 months and 3 months of life, we examined the number of physician encounters, the number of unique physician specialties involved per patient and specialty of physician, the number of unique physicians involved per patient, the 5 most frequent types of specialties involved and the number of encounters that took place in the home; these patterns were examined by trajectory.

RESULTS

Decedents (n = 359 559) had a median age of 78 (interquartile range 66-86) years. The mean number of outpatient physician encounters over the last year of life was 16.8 (standard deviation [SD] 13.7), of which 9.0 (SD 9.2) encounters were with family physicians. The mean number of encounters ranged from 11.6 (SD 10.4) in the frailty trajectory to 24.2 (SD 15.0) in the terminal illness trajectory across 3.1 (SD 2.0) to 4.9 (SD 2.1) unique specialties, respectively. In the last 3 months of life, the mean number of physician encounters was 6.8 (SD 6.4); a mean of 4.1 (SD 5.4) of these were with family physicians.

INTERPRETATION

Multiple physicians are involved in outpatient care in the last 12 months of life for all end-of-life trajectories, with family physicians as the predominant specialty. Those who plan health care models of the end of life should consider support for family physicians as coordinators of patient care.

Change in inappropriate critical care over time

PURPOSE

Intensive care interventions that prolong life without achieving meaningful benefit are considered clinically "inappropriate". In 2012, the frequency of perceived-inappropriate critical care was 10.8% at one academic health system; and we aimed to re-evaluate this frequency.

METHODS

For 4 months in 2017, we surveyed critical care physicians daily and asked whether each patient was receiving appropriate, probably inappropriate, or inappropriate critical care. Patients were categorized into three groups: 1) patients for whom treatment was never inappropriate, 2) patients with at least one assessment that treatment was probably inappropriate, but no inappropriate treatment assessments, and 3) patients who had at least one assessment of inappropriate treatment.

RESULTS

Fifty-five physicians made 10,105 assessments on 1424 patients. Of these, 94 (6.6%) patients received at least one assessment of inappropriate critical care, which is lower than 2012 (10.8% (p < 0.01)). Comparing 2017 and 2012, patient age, MS-DRG, length of stay, and hospital mortality were not significantly different (p > 0.05). Inpatient mortality in 2017 was 73% for patients receiving inappropriate critical care.

CONCLUSIONS

Over five years the proportion of patients perceived to be receiving inappropriate critical care dropped by 40%. Understanding the reasons for such change might elucidate how to continue to reduce inappropriate critical care.

Analyzing Outcomes Among Older Adults With Necrotizing Soft-Tissue Infections in the United States

BACKGROUND

Necrotizing soft-tissue infections (NSTIs) encompass a group of severe, life-threatening diseases with high morbidity and mortality. Evidence suggests advanced age is associated with worse outcomes. To date, no large data sets exist describing outcomes in older individuals, and risk factor identification is lacking.

METHODS

Retrospective data were obtained from the 2015 Medicare 100% sample. Included in the analysis were those aged ≥65 y with a primary diagnosis of an NSTI (gas gangrene, necrotizing fasciitis, cutaneous gangrene, or Fournier's gangrene). Risk factors for in-hospital mortality and discharge disposition were examined. Continuous variables were assessed using central tendency, t-tests, and Wilcoxon rank-sum tests. Categorical variables were assessed using the chi-squared and Fisher's exact tests. Statistical significance was defined as P < 0.05.

RESULTS

1427 patient records were reviewed. 59% of patients were male, and the overall mean age was 75.4±8.6 y. 1385 (97.0%) patients required emergency surgery for their NSTI diagnosis. The overall mortality was 5.3%. Several underlying comorbidities were associated with higher rates of mortality including cancer (OR: 3.50, P = 0.0009), liver disease (OR: 2.97, P = 0.03), and kidney disease (OR: 2.15, P = 0.01). While associated with high in-hospital mortality, these diagnoses were not associated with a difference in the rate of discharge to home compared with skilled nursing or rehab. Overall, patients discharged to skilled nursing facilities or rehab had higher rates of underlying comorbidities than patients who were discharged home (3 or more comorbid illness 84.3% versus 68.6%, P < 0.0001); however, no individual comorbid illness was associated with discharge location.

CONCLUSIONS

In our Medicare data set, we identified several medical comorbidities that are associated with increased rates of in-hospital mortality. Patients with underlying cancers had the highest odds of increased mortality. The effect on outcomes of the potentially immunosuppressive cancer treatments in these patients is unknown. These data suggest that patients with underlying illnesses, especially cancer, kidney disease, or liver disease have higher mortalities and are more likely to be discharged to skilled nursing facilities or rehab. It is unclear why these illnesses were associated with these worse outcomes while others including diabetes and heart disease were not. These data suggest that these particular comorbid illnesses may have special prognostic implications, although further analysis is necessary to identify the causative factors.

Trends in clinical profiles, organ support use and outcomes of patients with cancer requiring unplanned ICU admission: a multicenter cohort study

PURPOSE

To describe trends in outcomes of cancer patients with unplanned admissions to intensive-care units (ICU) according to cancer type, organ support use, and performance status (PS) over an 8-year period.

METHODS

We retrospectively analyzed prospectively collected data from all cancer patients admitted to 92 medical-surgical ICUs from July/2011 to June/2019. We assessed trends in mortality through a Bayesian hierarchical model adjusted for relevant clinical confounders and whether there was a reduction in ICU length-of-stay (LOS) over time using a competing risk model.

RESULTS

32,096 patients (8.7% of all ICU admissions; solid tumors, 90%; hematological malignancies, 10%) were studied. Bed/days use by cancer patients increased up to more than 30% during the period. Overall adjusted mortality decreased by 9.2% [95% credible interval (CI), 13.1-5.6%]. The largest reductions in mortality occurred in patients without need for organ support (9.6%) and in those with need for mechanical ventilation (MV) only (11%). Smallest reductions occurred in patients requiring MV, vasopressors, and dialysis (3.9%) simultaneously. Survival gains over time decreased as PS worsened. Lung cancer patients had the lowest decrease in mortality. Each year was associated with a lower sub-hazard for ICU death [SHR 0.93 (0.91-0.94)] and a higher chance of being discharged alive from the ICU earlier [SHR 1.01 (1-1.01)].

CONCLUSION

Outcomes in critically ill cancer patients improved in the past 8 years, with reductions in both mortality and ICU LOS, suggesting improvements in overall care. However, outcomes remained poor in patients with lung cancer, requiring multiple organ support and compromised PS.

Outcomes and Costs of Patients Admitted to the ICU Due to Spontaneous Intracranial Hemorrhage

OBJECTIVES

Spontaneous intracranial hemorrhage, including subarachnoid hemorrhage and intracerebral hemorrhage, is associated with significant morbidity and mortality. Although many of these patients will require ICU admission, little is known regarding their outcomes and the costs incurred. We evaluated this population in order to identify outcomes and cost patterns.

DESIGN

Retrospective cohort analysis of a health administrative database.

SETTING

Two ICUs within a single hospital system.

PATIENTS

Eight-thousand four-hundred forty-seven patients admitted to ICU from 2011 to 2014, of whom 332 had a diagnosis of spontaneous intracranial hemorrhage. Control patients were defined as randomly selected age, sex, and comorbidity index-matched nonintracranial hemorrhage ICU patients (1:4 matching ratio).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Mean age of ICU intracranial hemorrhage patients was 60.1 years, and 120 (36.1%) died prior to discharge. Intracranial hemorrhage was associated with a mean total cost of $75,869, compared with $52,471 in control patients (p < 0.01). Mean cost per survivor of intracranial hemorrhage patients was $118,813. Subarachnoid hemorrhage was associated with significantly higher mean total costs than intracerebral hemorrhage ($92,794 vs $53,491; p < 0.01) and higher mean cost per day ($4,377 vs $3,604; p < 0.01). Patients with intracranial hemorrhage who survived to hospital discharge were significantly costlier than decedents ($100,979 vs $30,872; p < 0.01). Intracranial hemorrhage associated with oral anticoagulant use had a mean total cost of $152,373, compared with $66,548 in nonoral anticoagulant intracranial hemorrhage (p < 0.01).

CONCLUSIONS

Patients admitted to ICU with intracranial hemorrhage have high costs and high mortality, leading to elevated cost per survivor. Subarachnoid hemorrhage patients incur greater costs than intracerebral hemorrhage patients, and oral anticoagulant-associated intracerebral hemorrhage is particularly costly. Our findings provide novel information regarding financial impact of this common ICU population.

Resource utilisation and description of patients perceived as receiving inappropriate critical care

OBJECTIVE

Medical interventions that do not offer the patient meaningful benefit due to inconsistency with prognoses are often considered "inappropriate" by clinicians. We described the clinical details and resource utilisation of patients who were assessed as receiving inappropriate treatment.

DESIGN

Chart abstraction was performed on 123 patients who were assessed by their critical care physician as having received inappropriate treatment to document clinical characteristics, diagnostic testing, life-sustaining treatments and nursing assessments of daily pain and level of consciousness.

RESULTS

The mean age was 67 and on admission, 41% had cancer and 25% had advanced pulmonary disease. At least one of the following three conditions was noted in 57% of the patients: severe neurological injury, overwhelming sepsis or irreversible respiratory failure. Patients were less likely to be alert (OR 0.39, CI 0.16-0.91, p = 0.03) on days they were assessed as receiving inappropriate critical care. After they were assessed as receiving inappropriate critical care, they received 172 imaging studies, 151 procedures, 522 days of mechanical ventilation (excludes one patient who received 1020 days of mechanical ventilation), 254 days of vasopressors, 226 days of hemodialysis and 10 attempts at cardiopulmonary resuscitation.

CONCLUSIONS

Patients assessed as receiving inappropriate critical care receive resource-intensive medical care, largely while non-alert.

Reduction of healthcare costs by implementing palliative family conference with the decision to withdraw life-sustaining treatments

BACKGROUND

Evidence regarding the impact of early palliative family conferences (PFCs) and decision to withdraw life-sustaining treatment (DTW) on healthcare costs in an intensive care unit (ICU) setting is inconsistent.

METHODS

We retrospectively analyzed patients who died in an ICU from 2013 to 2016. PFCs held within 7 days after ICU admission and DTWs were verified by reviewing medical records and claims data. Comparisons were first made between patients with and without DTWs, and secondly, between DTW patients with and without PFCs within 7 days. Propensity score matching methods were used to examine the difference in costs between patients with and without DTWs and PFCs within 7 days.

RESULTS

Of the 579 patients included, those with DTWs (n = 73) had a longer ICU stay than those without (n = 506) (12.9 ± 7.1 vs. 8.4 ± 9.6 days, p < 0.001). The DTW patients were more likely to have a "do-not-resuscitate" order (p < 0.001) and PFCs within 7 days (p < 0.001) and had lower healthcare costs (USD 7358 ± 4116 vs. 8669 ± 9,535, p = 0.038). After matching, healthcare cost reduction for patients with DTWs, compared with those without DTWs, was USD 3467 [95% CI, 915-6019] (p < 0.001). Compared with DTW patients without PFCs within 7 days, the costs for DTW patients with PFCs within 7 days further reduced to USD 3042 [95%CI, 1358-4725] (p < 0.001).

CONCLUSION

Palliative family conferences held within 7 days after ICU admission with decisions to withdraw life-sustaining treatments significantly lowered healthcare costs.

Comparison of outcomes and costs between adult diabetic ketoacidosis patients admitted to the ICU and step-down unit

PURPOSE

There is wide variation in the utilization of Intensive Care Unit (ICU) beds for treatment and monitoring of adult patients with Diabetic Ketoacidosis (DKA). We sought to compare the outcomes and hospital costs of adult DKA patients admitted to ICUs as compared to those admitted to step-down units.

MATERIALS AND METHODS

We included consecutive adult patients from two hospitals with a diagnosis of DKA. Patients were either admitted to the ICU, or a step-down unit, which has a nurse-to-patient ratio of 2:1, but does not have capability for mechanical ventilation or administration of vasoactive agents. The primary outcome was in-hospital mortality.

RESULTS

We included 872 patients in the analysis. 71 (8.1%) were admitted to ICU, while 801 (91.9%) were admitted to a step-down unit. We found no difference in in-hospital mortality between patients admitted to the ICU and those admitted to the step-down unit (adjusted odds ratio [OR]: 1.14, 95% confidence interval [CI]: 0.87-2.64). Mean total hospital costs were significantly higher for patients admitted to the ICU ($20,428 vs. $6484, P < 0.001).

CONCLUSIONS

Adult DKA patients admitted to a step-down unit had comparable in-hospital mortality and lower hospital costs as compared to those admitted to the ICU.

The cost of treatment and its related complications for men who receive surgery or radiation therapy for prostate cancer

INTRODUCTION

We sought to examine the costs related to treatment and treatment-related complications for patients treated with surgery or radiation for localized prostate cancer.

METHODS

We performed a population-based, retrospective cohort study of men who underwent open radical prostatectomy or radiation from 2004-2009 in Ontario, Canada. Costs, including initial treatment and inpatient hospitalization, emergency room visit, outpatient consultation, physician billings, and medication costs, were determined for five years following treatment using a validated costing algorithm. Multivariable negative binomial regression was used to assess the association between treatment modality and costs.

RESULTS

A total of 28 849 men underwent treatment for localized prostate cancer from 2004- 2009. In the five years following treatment, men who underwent radiation (n=12 675) had 21% higher total treatment and treatment-related costs than men who underwent surgery ($16 716/person vs. $13 213/person). Based on multivariable analysis, while men who underwent XRT had a lower relative cost in their first year after treatment (relative rate [RR] 0.97; 95% confidence interval [CI] 0.94-1.0; p=0.025), after year 2, annual costs were significantly higher in the radiation group compared to the surgery group (total cost for year 5, RR 1.44; 95% CI 1.17-1.76; p<0.0001). Our results were similar when restricted to young, healthy men and to older men.

CONCLUSIONS

Men who undergo radiation have significantly higher five-year total treatment-related costs compared to men who undergo open radical prostatectomy. While surgery was associated with slightly higher initial costs, radiotherapy had higher costs in subsequent years.

Emergency Department disposition decisions and associated mortality and costs in ICU patients with suspected infection

Background

Following emergency department (ED) assessment, patients with infection may be directly admitted to the intensive care unit (ICU) or alternatively admitted to hospital wards or sent home. Those admitted to the hospital wards or sent home may experience future deterioration necessitating ICU admission.

Methods

We used a prospectively collected registry from two hospitals within a single tertiary care hospital network between 2011 and 2014. Patient information, outcomes, and costs were stored in the hospital data warehouse. Patients were categorized into three groups: (1) admitted directly from the ED to the ICU; (2) initially admitted to the hospital wards, with ICU admission within 72 hours of initial presentation; or (3) sent home from the ED, with ICU admission within 72 hours of initial presentation. Using multivariable logistic regression, we sought to compare outcomes and total costs between groups. Total costs were evaluated using a generalized linear model.

Results

A total of 657 patients were included; of these, 338 (51.4%) were admitted directly from the ED to the ICU, 246 (37.4%) were initially admitted to the wards and then to the ICU, and 73 (11.1%) were initially sent home and then admitted to the ICU. In-hospital mortality was lowest among patients admitted directly to the ICU (29.5%), as compared with patients admitted to the ICU from wards (42.7%) or home (61.6%) (P < 0.001). As compared with direct ICU admission, disposition to the ward was associated with an adjusted OR of 1.75 (95% CI, 1.22–2.50; P < 0.01) for mortality, and disposition home was associated with an adjusted OR of 4.02 (95% CI, 2.32–6.98). Mean total costs were lowest among patients directly admitted to the ICU ($26,748), as compared with those admitted from the wards ($107,315) and those initially sent home ($71,492) (P < 0.001). Cost per survivor was lower among patients directly admitted to the ICU ($37,986) than either those initially admitted to the wards ($187,230) or those sent home ($186,390) (P < 0.001).

Conclusions

In comparison with direct admission to the ICU, patients with suspected infection admitted to the ICU who have previously been discharged home or admitted to the ward are associated with higher in-hospital mortality and costs.

Electronic supplementary material

The online version of this article (10.1186/s13054-018-2096-8) contains supplementary material, which is available to authorized users.

Outcomes and Costs of Patients Admitted to the Intensive Care Unit Due to Accidental or Intentional Poisoning

INTRODUCTION

Acute poisoning represents a major cause of morbidity and mortality, and many of these patients are admitted to the intensive care unit (ICU). However, little is known regarding ICU costs of acute poisoning.

METHODS

This was a retrospective matched database analysis of patients admitted to the ICU with acute poisoning from 2011 to 2014. It was performed in 2 ICUs within a single tertiary care hospital system. All patient information, outcomes, and costs were stored in the hospital data warehouse. Control patients were defined as randomly selected age-, sex-, severity index-, and comorbidity index-matched nonpoisoned ICU patients (1:4 matching ratio).

RESULTS

A total of 8452 critically ill patients were admitted during the study period, of whom 277 had a diagnosis of acute poisoning. The mean age was 44.5 years, and the most common xenobiotics implicated were sedative hypnotics (20.2%), antidepressants (15.2%), and opioids (10.5%). Of these, 73.6% of poisonings were deemed intentional. In-hospital mortality of poisoned patients was 5.1%, compared to 11.1% for control patients (P < .01). The median ICU length of stay (LOS) for poisoned patients was 3.0 days, compared with 4.0 days for control patients (P < .01). The mean total cost for poisoned patients was CAD$18 958. Control patients had a significantly higher mean total cost of CAD$60 628 (P < .01). The xenobiotics associated with the highest costs were acetaminophen (CAD$18 585), toxic alcohols (CAD$16 771), and opioids (CAD$12 967).

CONCLUSIONS

In our cohort, we confirmed the long-held belief that patients admitted to the ICU with a primary diagnosis of poisoning have a lower mortality rate, ICU LOS, and overall cost per ICU admission than nonpoisoned patients. However, poisoned patients still accrue significant daily costs, with the highest costs attributed to xenobiotics with known antidotes, such as acetaminophen, toxic alcohols, and opioids.