INTERNATIONAL COMPARISONS OF CRITICAL CARE OUTCOME AND RESOURCE CONSUMPTION
Section snippets
THE DENOMINATOR ("AT RISK") POPULATION
Evaluations of critical care populations have typically only analyzed patients admitted to an ICU.41, 71, 84 Thus, there is no information regarding the outcome of patients who may have benefited from, but did not receive, ICU management. If we assume that ICU admission policies are equivalent across ICUs, then we can assume that each ICU provides a similar level of support to the population served. The performance of that ICU in terms of patient treatment and outcome could then be compared.
THE NUMERATOR ("ICU-TREATED") POPULATION
Having described the universe of potential ICU admissions, we believe that those patients admitted to an ICU can now be considered in a broader context of a health delivery system. Problems confounding international comparisons of performance remain. We must consider what constitutes an ICU and adjust for differences in the case-mix of those admitted to an ICU.
The definition of an ICU has plagued researchers since the inception of critical care. With certain standard hospital guidelines, such
THE USE OF RISK-ADJUSTMENT MODELS
Risk-adjustment models have been applied across countries primarily in three ways. First, systems developed in the United States have been exported to other countries for intranational use. For example, APACHE II was used to look at several different ICU outcomes in England.67 Second, models developed in the United States have been used to compare ICU performance in other countries with that in the United States.41, 71, 84 Inferences about relative ICU performance are made in comparison with
CROSS-SECTIONAL VERSUS LONGITUDINAL STUDY DESIGN
Traditionally, investigators assessing ICU performance have examined overall mortality and length of stay (LOS) during the portion of a patient's care that occurred while in the ICU and hospital. This approach takes advantage of available risk stratification tools and allows an ICU to be judged on the basis of all patients treated within its confines.41, 60, 71, 84 A significant drawback of this approach is the limited time period over which an overall disease process is assessed. Ultimately,
OUTCOME
Having defined the study population, the elements of care that represent the critical care delivery system, and the methods by which to control for patient variation and study ICU performance either in isolation or as part of a continuum of care, the remaining challenge is to define the dependent variables by which to compare one delivery system with another. Using the two paradigms that characterize the optimal system described herein, the comparisons can arguably be made by measuring some
INTRASYSTEM HETEROGENEITY
Another difficulty in comparing systems is the natural heterogeneity that exists within a system. Much work has been done on variation in a variety of aspects of health care in the United States over the last 20 years (e.g., upper gastrointestinal endoscopy, coronary artery angiography and surgery, and carotid end-arterectomy rates).1, 18, 33, 54, 65, 82 Though there is less information on variation in critical care, we do know that such differences exist.5, 16, 19, 22, 32, 42, 45, 48, 56, 62,
SUMMARY
Though there are reasonable data to suggest that certain countries, such as the United States, spend considerably more money on the provision of critical care services than others, there is little information regarding the added benefits accrued with this additional expense. Studies to date have suggested little if no difference in outcome but have been limited in their size, design, and choice of outcome measures. Furthermore, significant underlying societal priorities and philosophy may
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2019, Intensive and Critical Care NursingCitation Excerpt :Between 2000 and 2010, annual critical care costs have nearly doubled from $56 to $108 billion annually and these costs account for 1% of the GDP in the US (Halpern et al., 2016; Halpern and Pastores, 2015). The US spends considerable more resources for the provision of critical care than other countries (Angus et al., 1997; Wright et al., 2016). No study to date has described the patients who are perceived by critical care physicians to be receiving inappropriate ICU treatment, including day-to-day clinical status and resource use.
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Do Intensive Care Specialists Improve Patient Outcomes?
2013, Evidence-Based Practice of AnesthesiologyOutcomes of the Surviving Sepsis Campaign in intensive care units in the USA and Europe: A prospective cohort study
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Address reprint requests to Derek C. Angus, MB, ChB, MPH Room 606B, Scaife Hall Critical Care Medicine University of Pittsburgh 200 Lothrop Street Pittsburgh, PA 15213