Use of intensive care-specific interventions in major teaching and other hospitals: a regional comparison.

OBJECTIVE: To compare the use of 40 specific medical interventions in intensive care units (ICUs) of major teaching and other hospitals DESIGN: Retrospective cohort study. SETTING: Thirty-eight ICUs in 28 hospitals in a large metropolitan region. PATIENTS: A total of 12,929 consecutive eligible admissions to medical, surgical, neurologic, or mixed medical/surgical ICUs between January 1, and June 30, 1994. MEASUREMENTS: The use of 40 diagnostic and therapeutic interventions during the first 24 hrs of ICU admission were obtained from patient medical records and a weighted intervention score was determined for each patient. Admission severity of illness was measured by using the Acute Physiology and Chronic Health Evaluation III methodology. MAIN RESULTS: Patients at the five teaching hospitals had a greater severity of illness (mean predicted risk of in-hospital death, 15.1%+/-21.9% vs. 11.2%+/-19.0%; p < .01) than patients at the 23 other hospitals. Patients at major teaching hospitals also had higher mean intervention scores (3.5+/-4.9 vs. 2.3+/-3.7; p < .01). Differences in intervention scores persisted after controlling for severity of illness, admission diagnosis, and admission source. However, scores varied among the major teaching hospitals. When examined individually, only three of the five major teaching hospitals had higher (p < .05) interventions scores, compared with other hospitals, whereas one had a lower (p < .05) intervention score. CONCLUSIONS: Patients in ICUs at major teaching hospitals were, in aggregate, more likely to receive diagnostic and therapeutic interventions than patients at other hospitals. Variation among major teaching hospitals suggests that factors other than teaching status also affect the use of these interventions.

Who goes to the ICU postoperatively?

OBJECTIVE: To describe changes in ICU postoperative management strategies utilized for patients undergoing cardiac surgery. The treatment of these patients serves as a useful illustration of the changing patterns of ICU utilization and care associated with contemporary surgery. DESIGN: Evidence-based review of the clinical literature following a MEDLINE search, direct observation of rapid recovery programs following surgery, and informal inquiry of others utilizing similar approaches to postoperative cardiac surgery care. SETTING AND PATIENTS: The reports reviewed are from a diverse set of hospitals providing cardiac surgery services in both Europe and the United States. Most reports focus efforts on patients undergoing coronary artery revascularization. MEASUREMENTS: Outcome measures used to gauge the effectiveness of postoperative ICU care typically include time to extubation, ICU and hospital length of stay, postoperative complications including reintubation and ICU readmission, patient satisfaction, and health resource savings. MAIN RESULTS: The literature regarding current practice for postoperative ICU management in cardiac surgery consists primarily of grade 2 and 3 literature. CONCLUSIONS: Despite the paucity of controlled data, rapid recovery, extubation, and discharge from the ICU following cardiac surgery is an approach to care that is growing in acceptance. The goals include reduction in the utilization of resources and costs associated with cardiac surgery and maintenance of quality of care and patient satisfaction. Assessment of outcomes requires a program to monitor outcomes. Success does not appear to be linked to preoperative risk for most patients but does relate directly to the anesthetic management delivered in the operating room. Few adverse consequences from this approach have been reported. Experience to date suggests that programs designed to truncate ICU admission following cardiac surgery can be implemented with the cooperation between the health delivery team including surgeon, anesthesiologist, intensivist where available, nursing, respiratory care, and patient and family. These programs can serve as useful models for reassessing the utilization and role of the ICU in the postoperative treatment of routine surgical patients.

Are readmissions to the intensive care unit a useful measure of hospital performance?

BACKGROUND: Although patients readmitted to intensive care units (ICUs) typically have poor outcomes, ICU readmission rates have not been studied as a measure of hospital performance. OBJECTIVES: To determine variation in ICU readmission rates across hospitals and associations of readmission rates with other ICU-based measures of hospital performance. RESEARCH DESIGN: Observational cohort study. SUBJECTS: One hundred three thousand nine hundred eighty four consecutive ICU patients who were admitted to twenty eight hospitals who were then transferred to a hospital ward in those 28 hospitals. MEASURES: Predicted risk of in-hospital death and ICU length of stay (LOS) were determined by a validated method based on age, ICU admission source, diagnosis, comorbidity, and physiologic abnormalities. Severity-adjusted mortality rates, LOS, and readmission rates were determined for each hospital. RESULTS: One or more ICU readmissions occurred in 5.8% patients who were initially classified as postoperative and in 6.4% patients who were initially classified as nonoperative. In-hospital mortality rate was 24.7% in patients who were readmitted as compared with 4.0% in other patients (P < 0.001). After adjusting for predicted risk of death, the odds of death remained 7.5 times higher (OR 7.5, 95% CI, 6.8-8.3). Readmitted patients also had longer (P < 0.001) ICU LOS (5.2 vs. 3.7 days) and hospital LOS (29.3 vs. 11.7 days). Severity-adjusted readmission rates varied across hospitals from 4.2% to 7.6%. Readmission rates were not correlated with severity-adjusted hospital mortality, ICU LOS, or hospital LOS. CONCLUSIONS: ICU patients who were subsequently readmitted have a higher risk of death and longer LOS after adjusting for severity of illness. However, readmission rates were not associated with severity-adjusted mortality or LOS. Those data indicate that ICU readmission may capture other aspects of hospital performance and may be complementary to these measures.

Community-wide assessment of intensive care outcomes using a physiologically based prognostic measure: implications for critical care delivery from Cleveland Health Quality Choice.

STUDY OBJECTIVES: To examine the applicability of a previously developed intensive care prognostic measure to a community-based sample of hospitals, and assess variations in severity-adjusted mortality across a major metropolitan region. DESIGN: Retrospective cohort study. SETTING: Twenty-eight hospitals with 38 ICUs participating in a community-wide initiative to measure performance supported by the business community, hospitals, and physicians. PATIENTS: Included in the study were 116,340 consecutive eligible patients admitted to medical, surgical, neurologic, and mixed medical/surgical ICUs between March 1, 1991, and March 31, 1995. MAIN OUTCOME MEASURES: The risk of hospital mortality was assessed using a previous risk prediction equation that was developed in a national sample, and a reestimated logistic regression model fit to the current sample. The standardized mortality ratio (SMR) (actual/predicted mortality) was used to describe hospital performance. RESULTS: Although discrimination of the previous national risk equation in the current sample was high (receiver operating characteristic [ROC] curve area = 0.90), the equation systematically overestimated the risk of death and was not as well calibrated (Hosmer-Lemeshow statistic, 2407.6, 8 df, p < 0.001). The locally derived equation had similar discrimination (ROC curve area = 0.91), but had improved calibration across all ranges of severity (Hosmer-Lemeshow statistic = 13.5, 8 df, p = 0.10). Hospital SMRs ranged from 0.85 to 1.21, and four hospitals had SMRs that were higher or lower (p < 0.01) than 1.0. Variation in SMRs tended to be greatest during the first year of data collection. SMRs also tended to decline over the 4 years (1.06, 1.02, 0.98, and 0.94 in years 1 to 4, respectively), as did mean hospital length of stay (13.0, 12.4, 11.6, and 11.1 days in years 1 to 4; p < 0.001). However, excluding the increasing (p < 0.001) number of patients discharged to skilled nursing facilities attenuated much of the decline in standardized mortality over time. CONCLUSIONS: A previously validated physiologically based prognostic measure successfully stratified patients in a large community-based sample by their risk of death. However, such methods may require recalibration when applied to new samples and to reflect changes in practice over time. Moreover, although significant variations in hospital standardized mortality were observed, changing hospital discharge practices suggest that in-hospital mortality may no longer be an adequate measure of ICU performance. Community-wide efforts with broad-based support from business, hospitals, and physicians can be sustained over time to assess outcomes associated with ICU care. Such efforts may provide important information about variations in patient outcomes and changes in practice patterns over time. Future efforts should assess the impact of such community-wide initiatives on health-care purchasing and institutional quality improvement programs.

Use of intensive care units for patients with low severity of illness.

OBJECTIVE: To determine variations among hospitals in use of intensive care units (ICUs) for patients with low severity of illness. DESIGN: Retrospective cohort study. SETTING: Twenty-eight hospitals with 44 ICUs in a large metropolitan region. PATIENTS: Consecutive eligible patients (N=104,487) admitted to medical, surgical, neurological, or mixed medical-surgical ICUs from March 1, 1991, to March 31, 1995. OUTCOME MEASURES: The predicted risk of in-hospital death for each patient was assessed using a validated method that is based on age, ICU admission source, diagnosis, severe comorbid conditions, and abnormalities in 17 physiologic variables. Admissions were classified as low severity if the patient's predicted risk of death was less than 1%. In a subset of 12,929 consecutive patients, use of 19 specific interventions typically delivered in ICUs was examined. RESULTS: Twenty thousand four hundred fifty-one admissions (19.6%) were categorized as low severity, including 23.6% of postoperative and 16.9% of nonoperative admissions. Alcohol and other drug overdoses accounted for 40.2% of nonoperative low-severity admissions; laminectomy and carotid endarterectomy accounted for 52.3% of postoperative low-severity admissions. Mortality among patients with low-severity illness was 0.3%, and only 28.6% received an ICU-specific intervention during the first ICU day. Although mean ICU length of stay was shorter (P<.001) in low-severity admissions (2.2 vs 4.7 days in nonoperative and 2.4 vs 4.2 days in postoperative admissions), low-severity admissions accounted for 11.1% of total ICU bed days. Rates of low-severity admissions varied (P<.001) across hospitals, ranging from 5% to 27% for nonoperative and 9% to 68% for postoperative admissions. CONCLUSIONS: A large proportion of patients admitted to the ICU have a low probability of death and do not receive ICU-specific interventions. Rates of low-severity admissions varied among hospitals. The development and implementation of protocols to target ICU care to patients most likely to benefit may decrease the number of low-severity ICU admissions and improve the cost-effectiveness of ICU care.

International comparisons of critical care outcome and resource consumption.

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 dictate that the optimal critical care delivery system is different for different countries. With the increasing availability of large patient databases, however, it will be more feasible in the future to design and conduct assessments of critical care delivery systems between countries taking appropriate account of the choice of study design, definition of at-risk populations, and choice of valuable measures of output and cost. The results of such assessments will hopefully drive wiser decision making in the design and management of critical care delivery systems worldwide.

The effect of managed care on ICU length of stay: implications for medicare.

OBJECTIVE: To determine whether insurance status (managed care vs traditional commercial and Medicare) influences resource consumption (as measured by length of stay [LOS]) in the intensive care unit (ICU). DESIGN: Retrospective analysis of the 1992 Massachusetts state hospital discharge database, using prospectively developed and validated risk-stratification models. SETTING: All nonfederal hospitals in Massachusetts. SUBJECTS: Of all adult hospitalizations where an ICU stay was incurred (n=104270), we selected those covered by 1 of 4 payer groups (n=88050): (1) commercial fee-for-service (patients aged <65 years); (2) commercial managed care (patients aged <65 years); (3) traditional Medicare (patients aged >/=65 years); and (4) Medicare-sponsored managed care (patients aged >/=65 years). MAIN OUTCOME MEASURE: Mean ICU LOS. ANALYSIS: The ICU LOS regression models were constructed using split-halves validation to adjust for differences in age, sex, severity of illness, diagnosis, discharge status, and payer. Separate models were constructed for those younger than 65 years and those aged 65 years or older. Robustness of the models was explored using goodness of fit and correlation. The effect of payer on hospital mortality was also explored using logistic regression. Observed minus predicted mean ICU LOS and mortality rates were correlated with managed care penetration at the hospital level. RESULTS: The ICU LOS models performed well (R2=0.84 and R2L [likelihood ratio statistic]=0.92 for the development set, and R2=0.83 and R2L=0.89 for the validation set). Significant covariables affecting LOS included age, severity of principal illness, comorbidity, reason for admission, and discharge status (P<.001 for each). Among the cohort younger than 65 years (n=27805), although unadjusted mean ICU LOS was shorter (2.9 vs 3.43 days; P<.05) for those covered by managed care organizations, payer status had no independent effect on ICU LOS (P=.48). Among those older than 65 years, there was neither a difference in unadjusted ICU LOS (3.94 vs 3.88 days; P>/=.05) nor an independent effect of payer on ICU LOS (P=.35). Unadjusted mortality was lower among managed care patients (3.9% vs 5.1% in patients aged <65 years [P<.05] and 8.7% vs 12.1% in patients aged > or = 65 years [P<.05]). Age, severity of principal diagnosis, comorbidity, and reason for admission significantly influenced mortality (P<.001). After controlling for these factors with the mortality model (R2L=0.92 and 0.89, C statistic [12 df]=8.45 and 17.58, and P=.75 and .13 [where a large P reflects good agreement] for the development and validation sets, respectively), payer continued to have a small but significant effect on mortality (odds ratios ranging from 1.67 at 0.1% probability of death to 1.11 at 30% probability of death.) Managed care penetration among the commercially insured varied across hospitals (n=82) from 0% to 68%. There was no correlation between managed care penetration and either ICU LOS (R2=0.04; P=.09) or mortality (R2=0.0; P=.88). CONCLUSIONS: Though patients covered under managed care consume fewer ICU resources, this appears to be primarily attributable to a difference in patient-related factors. Thus, as managed care case mix changes in the future to include sicker and older patients, the initial advantages of reduced resource consumption may diminish.

Evaluating outcomes in cardiac care and developing consensus for action: the Pennsylvania Health Care Cost Containment Council experience.

Sophisticated tools can be applied to patient data accurately reflecting patient severity of illness for individuals diagnosed with an acute myocardial infarction or undergoing coronary artery bypass graft surgery. These tools have been utilized in northern New England, New York, and Pennsylvania to assess the impact of care on outcomes for patients undergoing coronary revascularization for atherosclerotic heart disease. Results confirm there is wide variation in outcome associated with surgical volume and hospital processes. Traditionally, efforts to assess the clinical performance of individual physicians have been met by the profession with resistance. The Pennsylvania Health Care Cost Containment Council has recently undertaken an extensive analysis of patient outcomes for patients admitted to hospital with acute myocardial infarction in 1993. The process by which the Council developed consensus between business, labor, and the medical community to bring about this effort was noteworthy in its collaborative underpinnings and can serve as a model for public efforts to scrutinize health care outcomes.

Designing the Optimal Health Assessment System: the Cleveland Quality Choice (CHQC) example.

Cleveland Health Quality Choice (CHQC) is an ongoing collaborative partnership between business, hospitals, and physicians designed to assess the performance of health care institutions in the greater Cleveland metropolitan area. CHQC coordinates the collection of data for analysis of intensive care unit outcomes; general medical, surgical and obstetric outcomes; and patient satisfaction. CHQC has documented improved outcomes in all measured spheres over a 4-year period. Its success can be attributed to a leadership strategy focused on providing rigorously tested analytic tools and a shared vision regarding the value of outcome information in assessing institutional performance. CHQC can serve as a model for communities interested in creating joint programs between purchasers and providers of health care to measure health outcomes.

Public reporting of clinical outcomes--the data needs of health care stakeholders.

The Pennsylvania Health Care Cost Containment Council (PHC4) was created by the Pennsylvania legislature to promote cost constraint and assure quality of care by providing public information about the performance of health care providers. Today the Council is challenged by the information needs of multiple users including business, labor, insurers, managed care organizations, hospitals, physicians, and the public. Each of these interest groups has different priorities for the types of activities and reports of the Council. PHC4 must carefully balance the information needs of each of these stakeholders. All stakeholders believe that an assessment of the impact of changes currently underway within the delivery system must occur. PHC4 must continue to provide meaningful and more timely outcomes information and also find an appropriate role to augment data from other sources regarding the implications of the movement toward managed care.

The expanding role of ICU medical directors: from patient management to unit management.

Over the past three decades the focus of physicians delivering intensive care has been on patient management whereas the management of critical care units has been done primarily by nurses. This article reviews existing literature and the arguments supporting a more active role for physicians in the management of critical care units.

Trial of nurse practitioners in intensive care.

As public concern for quality control of medical care at the beginning of this century forced regulations on medical licensing of physicians, the forces of change in health care are again substantial, this time driven by concerns for cost and access. Our experience at the University of Pittsburgh Medical Center leads us to believe that well-trained physician extenders will play a valuable role in improving efficiency and effectiveness in the care of critically ill patients. We have developed a method for training and supervision. Graded practice supervision, with physician-led professional review, is considered a reasonable goal. We propose that the appropriate degree of supervision in any given area can be determined by: a) careful development of training programs; b) careful assessment of the individual's practice with the target patient population; and c) application of a review process that is sensitive in that population. Issues surrounding the independent practice and reimbursement of acute care nurse practitioners (ACNPs) are not resolved. These issues should be addressed by joint position statements that are based on objective documentation of the safe, effective performance of ACNPs, and on the incorporation of routine performance measurements with continued medical or joint evaluation of the quality review system. Guidelines regarding the evolving roles of ACNPs should be established by professional associations and state or national boards of both nursing and medical practice. Critical care physician and nursing leaders should lead such initiatives.

Cleveland Health Quality Choice (CHQC)--an ongoing collaborative, community-based outcomes assessment program.

Cleveland Health Quality Choice (CHQC) is a unique community-based program designed to provide more efficient delivery of healthcare services through routine collection and dissemination of selected patient interventions and outcomes. This effort, coordinated by a consortium of business, hospital, and medical leaders, provides comparative public data on hospital performance. In the ICU, this effort involves collection of Acute Physiology and Chronic Health Evaluation (APACHE) III, as well as severity and prognostic data. To date, results suggest that a higher percentage of patients admitted to the ICU are at low risk of death or adverse outcome when compared with a national benchmark using APACHE III. Risk-adjusted mortality rates are lower and length of stay is shorter than predicted. CHQC demonstrates that cooperative public efforts, undertaken by groups with often divergent interests and using objective risk estimates, can provide useful data for hospital quality improvement activities and market-based health reform efforts.

Cost containment: the Pacific. Japan.

The Japanese healthcare system is structured to provide universal healthcare access to the entire Japanese population via a constitutional guarantee. Increasing costs within the Japanese healthcare system are largely attributable to the country's rapidly aging population. Intensive care services are provided primarily in large tertiary care hospitals by a relatively small cadre of dedicated critical care physicians. Triage pressure is high in many Japanese hospitals due to a relatively small proportion of ICU beds. As a result, few patients are admitted to the ICU at low risk of adverse outcome or monitoring. Costs associated with providing critical care are poorly understood because of current hospital cost accounting systems. Critical care costs have only recently become an area of concern. Nevertheless, critical care physicians are taking steps to more fully understand severity of illness, clinical outcome, and utilization of resources in order to effectively guide healthcare policy and resource allocation decisions impacting Japanese critical care.