The daily cost of ICU patients: A micro-costing study in 23 French Intensive Care Units.

OBJECTIVES: To estimate the daily cost of intensive care unit (ICU) stays via micro-costing. METHODS: A multicentre, prospective, observational, cost analysis study was carried out among 21 out of 23 French ICUs randomly selected from French National Hospitals. Each ICU randomly enrolled 5 admitted adult patients with a simplified acute physiology II score ≥ 15 and with at least one major intensive care medical procedure. All health-care human resources used by each patient over a 24-hour period were recorded, as well as all medications, laboratory analyses, investigations, tests, consumables and administrative expenses. All resource costs were estimated from the hospital's perspective (reference year 2009) based on unitary cost data. RESULTS: One hundred and four patients were included (mean age: 62.3 ± 14.9 years, mean SAPS II: 51.5 ± 16.1, mean SOFA on the study day: 6.9 ± 4.3). Over 24 hours, 29 to 186 interventions per patient were performed by different caregivers, leading to a mean total time spent for patient care of 13:32 ± 05:00 h. The total daily cost per patient was € 1425 ± € 520 (95% CI = € 1323 to € 1526). ICU human resources represented 43% of total daily cost. Patient-dependent expenses (€ 842 ± € 521) represented 59% of the total daily cost. The total daily cost was correlated with the daily SOFA score (r = 0.271, P = 0.006) and the bedside-time given by caregivers (r = 0.716, P < 0.0001). CONCLUSION: The average cost of one day of ICU care in French National Hospitals is strongly correlated with the duration of bedside-care carried out by human resources.

Development and validation of a questionnaire for quantitative assessment of perceived discomforts in critically ill patients.

PURPOSE: To develop and validate the IPREA (Inconforts des Patients de REAnimation) questionnaire for the assessment of discomfort perceived by patients related to their intensive care unit (ICU) stay. METHODS: This was a two step-study comprising a phase of item generation conducted in one ICU and a phase of psychometric evaluation during a multicenter prospective cohort study in 14 ICUs. Patients were unselected consecutive adult surviving ICU patients. On the day of ICU discharge, a nurse asked patients to rate the severity of 16 discomfort sources, from 0 to 100. Ten percent of patients were randomly chosen to be questioned again to assess the reproducibility. RESULTS: Of 1,380 eligible patients, 1,113 survived and 868 patients could be questioned. The highest scores were for sleep deprivation (35 ± 33), being restrained by tubing, wires, and cables (33 ± 30), pain (32 ± 30), and thirst (32 ± 34). No multidimensional structure was identified. The mean overall score of discomfort was 22 ± 14. Internal consistency was satisfactory using Cronbach's alpha coefficient (0.78). The test-retest reliability study found average measure intraclass correlations ranging from 0.70 to 0.92. The mean duration of the questionnaire administration was 10 ± 7 min. CONCLUSION: The psychometric properties and acceptability of the IPREA questionnaire make it a potential instrument for measuring discomfort perceived by unselected ICU patients.

10-Allyl-2,3-dihydro-1H-pyrrolo[2,1-c][1,4]benzodiazepine-5,11(10H,11aH)-dione.

The compound, C(15)H(16)N(2)O(2), features a pyrroline ring fused with a seven-membered diazepine ring; the latter system adopts a boat conformation (with the methine C atom as the prow and the two C atoms of the aromatic ring as the stern). A CH(2)-CH(2) segment of the pyrroline ring is disordered over two positions in a 1:1 ratio.

1-Methyl-3-phenyl-quinoxalin-2(1H)-one.

The phenyl substituents in both independent mol-ecules of the title compound, C(15)H(12)N(2)O, are twisted with respect to the quinoxaline system [dihedral angles = 19.3 (1) and 30.4 (1)°].

1-Acetyl-4-phenyl-5a,6,7,8,9,9a-hexa-hydro-5H-1,5-benzodiazepin-2(1H)-one.

The seven-membered ring of the title compound, C(17)H(20)N(2)O(2), adopts an approximate boat conformation while the cyclo-hexyl ring adopts a chair conformation. In the crystal, adjacent mol-ecules are linked by N-H⋯O hydrogen bonds into a zigzag chain running along the c axis of the monoclinic unit cell.

10,10'-Methyl-enebis[2,3-dihydro-1H-benzo[e]pyrrolo[1,2-a][1,4]diazepine-5,11(10H,11aH)-dione] dihydrate.

The organic mol-ecule and uncoordinated water mol-ecule in the crystal of the title compound, C(25)H(24)N(4)O(4)·2H(2)O, both lie on special positions of twofold symmetry. A twofold rotation axis passes through the methyl-ene C atom connecting the two dihydro-benzopyrrolodiazepindionyl parts. The seven-membered C(5)N(2) ring adopts a boat conformation.

1-Benzyl-3-phenyl-quinoxalin-2(1H)-one.

The ten-membered fused ring system in the title compound, C(21)H(16)N(2)O(2), is planar (r.m.s. deviation = 0.03 Å). The phenyl substituent is aligned at 15.1 (1)° with respect to the mean plane through this system, whereas the phenyl ring of the benzyl substitutent is aligned at 84.4 (1)°.

1,5-Dibenzyl-3-propargyl-1,5-benzo-diazepine-2,4-dione.

The title compound, C(26)H(22)N(2)O(2), features a benzene ring fused with a seven-membered diazepine ring; the latter ring adopts a boat conformation (with the propargylallyl-bearing C atom as the prow and the fused-ring C atoms as the stern). The phenyl ring of one of the two benzyl substituents is disordered over two positions in a 0.812 (11):0.188 (11) ratio.

1-Ethyl-3-methyl-quinoxalin-2(1H)-one.

The asymmetric unit of the title compound, C(11)H(12)N(2)O, contains two independent mol-ecules. In the crystal structure, inter-molecular C-H⋯O hydrogen bonds link the mol-ecules. There are π-π contacts between the quinoxaline rings [centroid-centroid distances = 3.446 (2), 3.665 (2), 3.645 (3) and 3.815 (3) Å]. There also exist C-H⋯π contacts between the methyl groups and the quinoxaline rings.

Intermolecular and intramolecular alpha-amidoalkylation reactions using bismuth triflate as the catalyst.

Bismuth(III) triflate was found to promote the formation of stable cyclic N-acyliminium species in remarkable catalytic amounts (1 mol %). The alpha-amidoalkylation process seems to be effective in intermolecular and intramolecular manners leading to alpha-substituted lactams and heterocyclic systems containing azacycles, respectively. By comparing our results with those obtained with the classical Lewis acids as catalysts, it was evidenced clearly that the use of bismuth(III) triflate had been efficient for nearly all alpha-acetoxy lactams we used, except for N-acyliminium precursors bearing a sulfur atom. Also, the process seems to be easy, general, and clean, having diastereoselectivity comparable to protocols using classical Lewis acids and resulting in the formation of polyheterocyclic systems in good to excellent yields (64-99% in acetonitrile as solvent).

Mortality prediction using SAPS II: an update for French intensive care units.

INTRODUCTION: The standardized mortality ratio (SMR) is commonly used for benchmarking intensive care units (ICUs). Available mortality prediction models are outdated and must be adapted to current populations of interest. The objective of this study was to improve the Simplified Acute Physiology Score (SAPS) II for mortality prediction in ICUs, thereby improving SMR estimates. METHOD: A retrospective data base study was conducted in patients hospitalized in 106 French ICUs between 1 January 1998 and 31 December 1999. A total of 77,490 evaluable admissions were split into a training set and a validation set. Calibration and discrimination were determined for the original SAPS II, a customized SAPS II and an expanded SAPS II developed in the training set by adding six admission variables: age, sex, length of pre-ICU hospital stay, patient location before ICU, clinical category and whether drug overdose was present. The training set was used for internal validation and the validation set for external validation. RESULTS: With the original SAPS II calibration was poor, with marked underestimation of observed mortality, whereas discrimination was good (area under the receiver operating characteristic curve 0.858). Customization improved calibration but had poor uniformity of fit; discrimination was unchanged. The expanded SAPS II exhibited good calibration, good uniformity of fit and better discrimination (area under the receiver operating characteristic curve 0.879). The SMR in the validation set was 1.007 (confidence interval 0.985-1.028). Some ICUs had better and others worse performance with the expanded SAPS II than with the customized SAPS II. CONCLUSION: The original SAPS II model did not perform sufficiently well to be useful for benchmarking in France. Customization improved the statistical qualities of the model but gave poor uniformity of fit. Adding simple variables to create an expanded SAPS II model led to better calibration, discrimination and uniformity of fit, producing a tool suitable for benchmarking.

[Costs, costs and more costs: which one should we use?]. / Notions et mesure des coûts en fonction de la perspective choisie.

A cost is not an intrinsic feature of a product in the same way as temperature is for water and air. It is a calculation based on theory and convention. Costs may be characterised by their object (an hospital admission, a hospitalization day, a diagnostic related group, a treatment phase), their contents (costs directly attributable to the patient, controllable costs, including not only departmental operating costs but also costs resulting from the department's activity, full costs including administrative and infrastructure overhead costs), the point of reference from where the costs are considered (from the point of view of the family, the health professionals suppliers, the buyers, the health care system, or society) and the time when the costs were calculated. The cost framework which must be considered in any economic evaluation must relate to the budgetary concerns of the party whose involvement is sought in a health care project. There is no all encompassing study in this field; an evaluation performed for one type of contributor must only consider this party's point of view.

[Volume and costs of the hospital management of cancer in France in 1999]. / Volume et coût de la prise en charge hospitalière du cancer en France en 1999.

The volume of hospitalization care for cancer is hardly measured; this, in particular, because there are various structures assuming those responsibilities and heterogeneous information systems. The objective of this study is to present a model of precise algorithm of selection of hospital stays for cancers from French National databases of hospital discharges, and its results for 1999. Cancer stays are selected firstly, according to the presence of a tumor diagnosis code. Then, a refine in/out sort is done, based on a precise criteria grid issued from an expert group. A financial valorisation of hospital activity is realised from national cost weight scale. On the whole, the 1999 cancer database contains 5,428,518 inpatients and outpatients stays. Cancer weight 15.8 % of the whole hospitalization care activity, and costs around 6.04 billion. Surgery is the first expense with 2,100 millions, then chemotherapy with 1 135 millions and radiotherapy with 670 millions. Digestive tumors represent about 26 % of total cost, tumors of the respiratory system and breast tumor 11 % each. A work of validation of this algorithm is being realized on a sample of care providers.