Implications of ICU triage decisions on patient mortality: a cost effectiveness analysis.
Crit Care. 2011 Feb 9;15(1):R56
Authors: Edbrooke DL, Minelli C, Mills GH, Iapichino G, Pezzi A, Corbella D, Jacobs P, Lippert A, Wiis J, Pesenti A, Patroniti N, Pirrachio R, Payen D, Gurman G, Bakker J, Kesecioglu J, Hargreaves C, Cohen SL, Baras M, Artigas A, Sprung CL
ABSTRACT: INTRODUCTION: Intensive care is generally regarded as expensive, and as a result beds are limited, which has raised serious questions about rationing when there are insufficient beds for all those referred. However, the evidence for the cost effectiveness of intensive care is weak and the work that does exist usually assumes that those who are not admitted do not survive, which is not always the case. Randomised studies of the effectiveness of intensive care are difficult to justify on ethical grounds; therefore this observational study examined the cost effectiveness of ICU admission by comparing patients who were accepted into ICU after ICU triage versus those who were not accepted, whilst attempting to adjust such comparison for confounding factors. METHODS: This multi-centre observational cohort study involved 11 hospitals in 7 EU countries and was designed to assess the cost effectiveness of admission to intensive care after ICU triage. 7,659 consecutive patients referred to the intensive care unit (ICU) were divided into those accepted for admission and those not accepted. The two groups were compared in terms of cost and mortality using multilevel regression models to account for differences across centres, and after adjusting for age, Karnofsky score and indication for ICU admission. The analyses were also stratified by categories of SAPS II predicted mortality (<5%, 5%-40% and >40%). Cost-effectiveness was evaluated as cost per life saved and cost per life-year saved. RESULTS: Admission to ICU produced a relative reduction in mortality risk, expressed as odds ratio, of 0.70 (0.52-0.94) at 28 days. When stratified by predicted mortality, the odds ratio was 1.49 (0.79 to 2.81), 0.7 (0.51-0.97) and 0.55 (0.37-0.83) for <5%, 5%-40% and >40% predicted mortality, respectively. Average cost per life saved for all patients was $103,771 (EUR 82,358) and cost per life year saved was $7,065 (EUR 5,607). These figures decreased substantially for patients with predicted mortality higher than 40%, $60,046 (EUR 47,656) and $4,088 ( EUR 3,244), respectively. Results were very similar when considering 3-month mortality. Sensitivity analyses performed to assess the robustness of the results provided findings similar to the main analyses. CONCLUSIONS: Not only does ICU appear to produce an improvement in survival, but the cost per life saved falls for patients with greater severity of illness. This suggests that intensive care is similarly cost-effective to other therapies that are generally regarded as essential.
PMID: 21306645 [PubMed - as supplied by publisher]