Critical care medicine in the United States 2000-2005: an analysis of bed numbers, occupancy rates, payer mix, and costs.
TL;DR: The evolving role, patterns of use, and costs of critical care medicine in the United States from 2000 to 2005 are analyzed to provide a contemporary benchmark for the strategic planning ofcritical care medicine services within the U.S. hospital system.
Abstract: Objectives:To analyze the evolving role, patterns of use, and costs of critical care medicine in the United States from 2000 to 2005.Design:Retrospective study of data from the Hospital Cost Report Information System (Centers for Medicare and Medicaid Services, Baltimore, Maryland).Setting:Nonfedera
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TL;DR: In this article, the authors did an international audit of ICU patients worldwide and assessed variations between hospitals and countries in terms of the ICU mortality, showing that sepsis remains a major health problem worldwide, associated with high mortality rates in all countries.
848 citations
Vanderbilt University Medical Center1, The Ohio State University Wexner Medical Center2, Ohio State University3, Sutter Health4, University of California, San Francisco5, VA Palo Alto Healthcare System6, Stanford University7, Innovative Solutions & Support8, University of North Carolina at Chapel Hill9, Tufts Medical Center10, University of Chicago11, Houston Methodist Hospital12, Society of Critical Care Medicine13, Novant Health14, Saint Joseph Mercy Health System15, University of Pennsylvania16, Johns Hopkins University17
TL;DR: 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.
Abstract: 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 st
571 citations
TL;DR: The increase in the number of hospitalizations for severe sepsis coupled with declining in-hospital mortality and declining geometric mean cost per case may reflect improvements in care or increases in discharges to skilled nursing facilities; however, these findings more likely represent changes in documentation and hospital coding practices that could bias efforts to conduct national surveillance.
Abstract: Objectives:To assess trends in number of hospitalizations, outcomes, and costs of severe sepsis in the United States.Design:Temporal trends study using the Nationwide Inpatient Sample.Patients:Adult patients with severe sepsis (defined as a diagnosis of sepsis and organ dysfunction) diagnosed betwee
571 citations
Additional excerpts
...Hospitalizations Overall 200 (5) 236 (6) 263 (7) 273 (7) 300 (7) ....
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...086 White 142 (4) 169 (5) 201 (7) 193 (7) 209 (6) ....
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...001 Female 201 (5) 235 (6) 265 (8) 269 (7) 292 (7) ....
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...001 Male 199 (5) 237 (6) 261 (7) 278 (7) 308 (7) ....
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TL;DR: In this paper, the authors used linear and proportional odds logistic regression to assess the independent associations between age and duration of delirium with mental health and functional disabilities in patients undergoing treatment in medical or surgical ICUs.
472 citations
TL;DR: There is a large US population of elderly individuals who survived the ICU stay to hospital discharge but who have a high mortality over the subsequent years in excess of that seen in comparable controls, particularly among those who require mechanical ventilation.
Abstract: Context Although hospital mortality has decreased over time in the United States for patients who receive intensive care, little is known about subsequent outcomes for those discharged alive. Objective To assess 3-year outcomes for Medicare beneficiaries who survive intensive care. Design, Setting, and Patients A matched, retrospective cohort study was conducted using a 5% sample of Medicare beneficiaries older than 65 years. A random half of all patients were selected who received intensive care and survived to hospital discharge in 2003 with 3-year follow-up through 2006. From the other half of the sample, 2 matched control groups were generated: hospitalized patients who survived to discharge (hospital controls) and the general population (general controls), individually matched on age, sex, race, and whether they had surgery (for hospital controls). Main Outcome Measure Three-year mortality after hospital discharge. Results There were 35 308 intensive care unit (ICU) patients who survived to hospital discharge. The ICU survivors had a higher 3-year mortality (39.5%; n = 13 950) than hospital controls (34.5%; n = 12 173) (adjusted hazard ratio [AHR], 1.07 [95% confidence interval {CI}, 1.04-1.10]; P Conclusions There is a large US population of elderly individuals who survived the ICU stay to hospital discharge but who have a high mortality over the subsequent years in excess of that seen in comparable controls. The risk is concentrated early after hospital discharge among those who require mechanical ventilation.
332 citations
Additional excerpts
...Surgical patients 7 (4-12) 16 (9-26) 7 (4-11) 3 (2-5) ....
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...Medical patients 4 (2-7) 10 (6-15) 4 (2-7) 4 (2-6) ....
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...Length of stay, median (IQR), d ICU 1 (0-3) 5 (2-9) 1 (0-2) NA NA NA NA Hospitalf 5 (3-9) 12 (7-20) 5 (3-8) 4 (2-6) ....
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References
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TL;DR: One in five Americans die using ICU services and the doubling of persons over the age of 65 yrs by 2030 will require a system-wide expansion in ICU care for dying patients unless the healthcare system pursues rationing, more effective advanced care planning, and augmented capacity to care for Dying patients in other settings.
Abstract: ObjectiveDespite concern over the appropriateness and quality of care provided in an intensive care unit (ICU) at the end of life, the number of Americans who receive ICU care at the end of life is unknown. We sought to describe the use of ICU care at the end of life in the United States using hospi
1,088 citations
TL;DR: It is forecast that the proportion of care provided by intensivists and pulmonologists in the United States will decrease below current standards in less than 10 years, and most anticipated effects are minor in comparison with the growing disease burden created by the aging US population.
Abstract: ContextTwo important areas of medicine, care of the critically ill and management
of pulmonary disease, are likely to be influenced by the aging of the US population.ObjectiveTo estimate current and future requirements for adult critical care
and pulmonary medicine physicians in the United States.Design, Setting, and ParticipantsAnalysis of existing population, patient, and hospital data sets and
prospective, nationally representative surveys of intensive care unit (ICU)
directors (n = 393) and critical care specialists (intensivists) and pulmonary
specialists (pulmonologists) (n = 421), conducted from 1996 to 1999.Main Outcome MeasuresInfluence of patient, physician, regional, hospital, and payer characteristics
on current practice patterns; forecasted future supply of and demand for specialist
care through 2030. Separate models for critical care and pulmonary disease.
Base-case projections with sensitivity analyses to estimate the impact of
future changes in training and retirement, disease prevalence and management,
and health care reform initiatives.ResultsIn 1997, intensivists provided care to 36.8% of all ICU patients. Care
in the ICU was provided more commonly by intensivists in regions with high
managed care penetration. The current ratio of supply to demand is forecast
to remain in rough equilibrium until 2007. Subsequently, demand will grow
rapidly while supply will remain near constant, yielding a shortfall of specialist
hours equal to 22% of demand by 2020 and 35% by 2030, primarily because of
the aging of the US population. Sensitivity analyses suggest that the spread
of current health care reform initiatives will either have no effect or worsen
this shortfall. A shortfall of pulmonologist time will also occur before 2007
and increase to 35% by 2020 and 46% by 2030.ConclusionsWe forecast that the proportion of care provided by intensivists and
pulmonologists in the United States will decrease below current standards
in less than 10 years. While current health care reform initiatives and modification
of existing practice patterns may temporarily forestall this problem, most
anticipated effects are minor in comparison with the growing disease burden
created by the aging US population.
926 citations
TL;DR: The treatment of cancer patients near death is becoming increasingly aggressive over time and greater local availability of hospices was associated with less aggressive treatment near death on multivariate analysis.
Abstract: Purpose To characterize the aggressiveness of end-of-life cancer treatment for older adults on Medicare, and its relationship to the availability of healthcare resources. Patients and methods We analyzed Medicare claims of 28,777 patients 65 years and older who died within 1 year of a diagnosis of lung, breast, colorectal, or other gastrointestinal cancer between 1993 and 1996 while living in one of 11 US regions monitored by the Surveillance, Epidemiology, and End Results Program. Results Rates of treatment with chemotherapy increased from 27.9% in 1993 to 29.5% in 1996 (P =.02). Among those who received chemotherapy, 15.7% were still receiving treatment within 2 weeks of death, increasing from 13.8% in 1993 to 18.5% in 1996 (P Conclusion The treatment of cancer patients near death is becoming increasingly aggressive over time.
875 citations
TL;DR: Intensive care unit costs are highest during the first 2 days of admission, stabilizing at a lower level thereafter, and the mean incremental cost of mechanical ventilation in intensive care unit patients was $1,522 per day (p < .001).
Abstract: Objective:To quantify the mean daily cost of intensive care, identify key factors associated with increased cost, and determine the incremental cost of mechanical ventilation during a day in the intensive care unit.Design:Retrospective cohort analysis using data from NDCHealth’s Hospital Patient Lev
768 citations
"Critical care medicine in the Unite..." refers background in this paper
...Additionally, CCM Medicaid use in limited adult ICU populations has been peripherally reported in two recent studies (78, 79)....
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TL;DR: The findings demonstrate the need for critical care data from all countries, as they are essential for interpretation of studies, and policy decisions regarding critical care services, with wide differences in both numbers of beds and volume of admissions.
Abstract: Objective:Critical care represents a large percentage of healthcare spending in developed countries. Yet, little is known regarding international variation in critical care services. We sought to understand differences in critical care delivery by comparing data on the distribution of services in ei
560 citations
"Critical care medicine in the Unite..." refers background in this paper
...We note, however, that the HCRIS (48, 49) and AHA (1) data sets, as well as the Society of Critical Care Medicine surveys (24, 65, 66), are seriously hampered by the absence of standardized CCM unit and bed classification rules (68)....
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