Am J Respir Crit Care Med 2002 Feb 15;165(4):540-50
Economic evaluations are increasingly common in the critical care literature, although approaches to their conduct are not standardized. The American Thoracic Society convened a workshop to address methodologic and reporting issues for economic analyses in critical care and to determine how guidelines from the U.S. Public Health Service Panel on Cost-effectiveness in Health and Medicine (PCEHM) were applicable to critical care. We identified several issues that hamper cost-effectiveness analyses (CEAs) in the critically ill. Data on the effectiveness of intensive care unit (ICU) interventions are often lacking; ICU patients are complex, with multiple concurrent problems and interventions; most ICU therapies are only supportive, and therefore may not individually result in improved outcome; accurate cost data are not commonly available and are difficult to obtain; there is no standardized approach for measuring or valuing costs across countries; typical outcomes in ICU studies (e.g., short-term mortality) are not ideal for CEAs while preferred outcomes for CEAs (e.g., long-term quality-adjusted survival) are rarely collected; valuing the importance of appropriate end-of-life care, an important aspect of ICU care, is difficult, and the burden of critical illness on family members is not easily captured in a CEA. Nevertheless, many of these problems are not unique to critical care, and we believe the PCEHM guidelines can be adapted to the critical care setting. We recommend all CEAs in the critically ill include a PCEHM reference case, where the cost-effectiveness ratio is calculated by adopting a societal perspective, estimating long-term costs and quality of life after ICU care, applying a 3% annual discount rate to costs and effects, and conducting multiway sensitivity analyses. Because elements of the reference case, such as long-term costs and quality of life, may only be estimated using modeling and assumptions, we also recommend inclusion of a "data-rich" case, where the cost-effectiveness ratio is generated as closely as possible from data on actual patient outcomes and costs (e.g., hospital costs per hospital survivor). We recommend that investigators conducting a CEA concurrently with a randomized trial make the proposed model available (e.g., via the Internet) before unblinding of trial data to minimize bias. Adopting a standard approach to CEAs of ICU therapies will provide a valid and more transparent evidence base for health care policy with regard to care of the critically ill.
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PMID: 11850349, UI: 21837739
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Anaesth Intensive Care 2002 Jun;30(3):308-15
Intensive Care Unit, Princess Alexandra Hospital, Brisbane, Queensland.
[Medline record in process]
Evaluation of the performance of the APACHE III (Acute Physiology and Chronic Health Evaluation) ICU (intensive care unit) and hospital mortality models at the Princess Alexandra Hospital, Brisbane is reported. Prospective collection of demographic, diagnostic, physiological, laboratory, admission and discharge data of 5681 consecutive eligible admissions (1 January 1995 to 1 January 2000) was conducted at the Princess Alexandra Hospital, a metropolitan Australian tertiary referral medical/surgical adult ICU ROC (receiver operating characteristic) curve areas for the APACHE III ICU mortality and hospital mortality models demonstrated excellent discrimination. Observed ICU mortality (9.1%) was significantly overestimated by the APACHE III model adjusted for hospital characteristics (10.1%), but did not significantly differ from the prediction of the generic APACHE III model (8.6%). In contrast, observed hospital mortality (14.8%) agreed well with the prediction of the APACHE III model adjusted for hospital characteristics (14.6%), but was significantly underestimated by the unadjusted APACHE III model (13.2%). Calibration curves and goodness-of-fit analysis using Hosmer-Lemeshow statistics, demonstrated that calibration was good with the unadjusted APACHE III ICU mortality model, and the APACHE III hospital mortality model adjusted for hospital characteristics. Post hoc analysis revealed a declining annual SMR (standardized mortality rate) during the study period. This trend was present in each of the non-surgical, emergency and elective surgical diagnostic groups, and the change was temporally related to increased specialist staffing levels. This study demonstrates that the APACHE III model performs well on independent assessment in an Australian hospital. Changes observed in annual SMR using such a validated model support an hypothesis of improved survival outcomes 1995-1999.
PMID: 12075637, UI: 22070865
Br J Anaesth 2002 Apr;88(4):577-9
Department of Anesthesiology, Rambam Medical Center, Haifa, Israel.
BACKGROUND: With the increasing number of critically ill patients, and shortage of intensive care unit and ward beds, some postoperative patients stay for an unnecessarily long period in the postanaesthesia care unit (PACU), until a suitable bed is available. METHODS: We prospectively studied this patient overflow admission to the PACU over 33 months. Four hundred patients with a mean age of 53.1 yr (range 0.2-94) were studied. Two hundred and eighty one (70.3%) patients were mechanically ventilated on admission to the PACU and 311 (77.8%) had invasive monitoring. Mean length of stay in the PACU was 12.9 (SD 10.6) h. RESULTS: The busiest hours of admission were 01-11 am. Eighteen (4.5%) patients died in the PACU, while waiting for an intensive care unit bed. The main problems were insufficient medical and nursing coverage, and inadequate communication and visiting facilities for patient's families. CONCLUSION: Patient overflow to the PACU is a common problem that requires attention. Guidelines for medical and nursing coverage, patient triage, and communication with relatives need to be outlined.
PMID: 12066735, UI: 22061552
Crit Care Med 2002 Jun;30(6):1386-7
Weill Medical College of Cornell University; New York, NY.
PMID: 12072701, UI: 22067368
Crit Care Med 2002 Jun;30(6):1242-5
Laboratoire CSSB, Groupe RMN, UFR SMBH, Bobigny Cedex, France. lemoyec@smbh.univ-paris13.fr
OBJECTIVE: Aminoglycoside and glycopeptide antibiotics are responsible for renal toxicity. In most cases, the nephrotoxicity is limited to a reversible tubular injury, but an acute and sustained renal failure may occur. The aim of our study was to explore the renal function of patients given these antimicrobial agents with proton magnetic resonance spectroscopy of urine. This technique is able to detect, in urine samples, a wide range of metabolites reflecting renal tubular function. The variables assessed by magnetic resonance spectroscopy were compared with the routine markers of renal function: creatinine, urea, and 24-hr urine volume. DESIGN: Prospective clinical study. SETTING: Intensive care unit. PATIENTS: All patients in an intensive care unit receiving an aminoglycoside and/or a glycopeptide were included in the study if they presented with signs of renal dysfunction. All experiments were performed on urine samples collected for the routine follow-up of these patients. INTERVENTION: Proton spectra were acquired with water suppression, and the peak intensity of each metabolite was reported in relationship to the intensity of the creatinine peak. MEASUREMENTS AND MAIN RESULTS: The ratio values obtained by magnetic resonance spectroscopy were compared with the values of creatininemia and blood urea obtained routinely by biochemistry and with the value of the 24-hr urine volume by logistic regression and general linear models. This statistical analysis showed that the ratio of dimethylamine to creatinine was highly correlated with creatininemia. CONCLUSIONS: Dimethylamine is an osmolyte released from the medullar region of the kidney. Thus, our study demonstrated that nephrotoxicity from aminoglycosides and glycopeptides is not limited to proximal tubular toxicity but also may involve the medullar region (Henle loop and collecting duct) of the nephron.
PMID: 12072675, UI: 22067342
Crit Care Med 2002 Jun;30(6):1214-23
Department of Anesthesiology, CHUM, Notre-Dame Hospital, Quebec, Canada.
OBJECTIVE: Transesophageal echocardiography is a diagnostic and monitoring modality. The objectives of our study were to compare the diagnoses obtained with continuous transesophageal echocardiography and hemodynamic monitoring in the intensive care unit, to determine interobserver variability of diagnosis obtained with both modalities, and to evaluate its impact. DESIGN: Prospective cohort study. SETTING: Surgical intensive care unit. PATIENTS: Consecutive hemodynamically unstable patients after cardiac surgery. INTERVENTIONS: At admission, unstable patients were monitored during 4 hrs with transesophageal echocardiography and standard hemodynamic monitoring. The critical care physician evaluated the patients based on all information except the transesophageal echocardiography at 0, 2, and 4 hrs and formulated a hypothesis on the most likely cause of hemodynamic instability. Transesophageal echocardiography information was provided after each evaluation. To evaluate interobserver variability, all the hemodynamic and echocardiographic information was gathered, randomized, and evaluated by five clinicians for the hemodynamic data and five echocardiographers for the transesophageal echocardiography data. The evaluators were blinded to all other information. Kappa statistics were used to evaluate agreement. Impact of transesophageal echocardiography was assessed retrospectively by using the Deutsch scale. RESULTS: Twenty patients qualified for the study. The agreement between the hemodynamic and echocardiographic diagnosis showed a kappa at admission, 2 hrs, and 4 hrs of 0.33, 0.47, and 0.28. The interobserver agreement for the initial diagnosis (p =.014) and between all evaluators (p <.001) was significantly higher in the echocardiographic compared with the hemodynamic group. The transesophageal echocardiographic information was considered retrospectively to be essential in 34% and valuable in 34% of cases. CONCLUSIONS: These observations support the belief that transesophageal echocardiographic monitoring in the intensive care unit is associated with higher interobserver agreement in diagnosing and excluding significant causes of hemodynamic instability for postoperative cardiac surgical patients.
PMID: 12072671, UI: 22067338
Crit Care Med 2002 Jun;30(6):1187-90
Critical Care Service, Mayo Clinic, Rochester MN 55905, USA.
OBJECTIVE: Acute abdominal complication in the medical intensive care unit may be underdiagnosed and can add significant risk of death. We hypothesize that delays in surgery because of atypical presentation, such as the absence of peritoneal signs, may contribute to mortality. DESIGN: Retrospective cohort study (1995-2000). SETTING: Medical intensive care unit in a tertiary care center. PATIENTS: Medical intensive care unit patients with clinical, surgical, or autopsy diagnosis of acute abdominal catastrophe (gangrenous or perforated viscus). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Seventy-seven patients (1.3%) met inclusion criteria. Ischemic bowel was the most common diagnosis, followed by perforated ulcer, bowel obstruction, and cholecystitis. Actual mortality rate was higher than predicted by Acute Physiology and Chronic Health Evaluation (APACHE) III scores at the time of medical intensive care unit admission (63% vs. 31%). Twenty-six patients (34%) did not have surgery, and none of these survived. Fifty-one patients underwent surgery and 28 survived (56%). Delay in surgical evaluation (p <.01) and intervention (p <.03), APACHE III scores (p <.01), renal insufficiency (p <.01), and a diagnosis of ischemic bowel (p <.01) were associated with increased mortality rates. Surgical delay was more likely to occur in patients with altered mental state (p <.01), no peritoneal signs (p <.01), previous opioids (p <.03), antibiotics (p <.02), and mechanical ventilation (p <.02). CONCLUSION: Delays in surgical evaluation and intervention are critical contributors to mortality rate in patients who develop acute abdominal complications in a medical intensive care unit.
PMID: 12072666, UI: 22067333
Crit Care Med 2002 Jun;30(6 Suppl):S362-4
University of Washington School of Medicine, Harborview Medical Center, Seattle, WA.
Stress-related mucosal disease develops in patients in the intensive care unit and can result in clinically important bleeding, which is associated with increased mortality. Patients in the intensive care unit without either mechanical ventilation or coagulopathy, which are the primary risk factors for such bleeding, do not seem to need or to benefit from prophylactic acid suppression for stress-related mucosal disease. Although histamine-2-receptor antagonists significantly reduce clinically important bleeding in patients in the intensive care unit and are widely used for prophylaxis, their benefits are limited by the rapid development of tolerance. Previous data suggested that agents that elevate the intragastric pH may increase the susceptibility of patients in the intensive care unit to nosocomial pneumonia. However, the largest study to date showed that intravenous histamine-2-receptor antagonists may not significantly increase the risk of ventilator-associated pneumonia or mortality compared with sucralfate, an agent that does not affect intragastric pH. Intravenous proton pump inhibitors are more potent and longer-acting inhibitors of gastric acid production than intravenous histamine-2-receptor antagonists. The ability of proton pump inhibitors to prevent stress-related mucosal disease and clinically important bleeding seems to be clinically meaningful. Preliminary findings have shown that intermittent administration of intravenous pantoprazole, the first proton pump inhibitor available by this route in the United States, is as effective in raising intragastric pH on the first day as a continuous infusion of a histamine-2-receptor antagonist in clinical trials conducted within an intensive care unit setting. This suggests that for stress ulcer prophylaxis, intermittent dosing with an intravenous proton pump inhibitor may be an alternative to high-dose continuous infusions of a histamine-2-receptor antagonist. These agents must be compared in clinical trials conducted in an intensive care unit setting.
PMID: 12072662, UI: 22067329
JAMA 2002 Jun 26;287(24):3200
PMID: 12076204, UI: 22072440
Lancet 2002 May 18;359(9319):1781-2
PMID: 12049900, UI: 22045716
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