Three new articles in Critical Care add to an expanding body of information on the epidemiology of severe sepsis. Although there have been a range of approaches to estimate the incidence of severe ...sepsis, most studies report severe sepsis in about 10 +/- 4% of ICU patients with a population incidence of 1 +/- 0.5 cases per 1000. Importantly, the availability of ICU services may well determine the number of treated cases of severe sepsis, and it seems clear that these studies are reporting the treated incidence, not the incidence, of severe sepsis. In the future, we must focus on whether all severe sepsis should be treated, and, consequently, what level of ICU services is optimal.
Summary
Drotrecogin alfa (activated) is licensed in Europe for the treatment of severe sepsis in patients with multiple organ failure. We constructed a model to assess the cost effectiveness of ...drotrecogin alfa (activated) from the perspective of the UK National Health Service when used in adult intensive care units. Patient outcomes from a 28‐day international clinical trial (PROWESS) and a subsequent follow‐up study (EVBI) were supplemented with UK data. Cost effectiveness was assessed as incremental cost per life year and per quality adjusted life year saved compared to placebo alongside best usual care. Applying the 28‐day mortality outcomes of the PROWESS study, the model produced a cost per life year saved of £4608 and cost per quality adjusted life year saved of £6679. Equivalent results using actual hospital outcomes were £7625 per life year and £11 051 per quality adjusted life year. Drotrecogin alfa (activated) appears cost effective in treating severe sepsis in UK intensive care units.
OBJECTIVES:To describe the organization and distribution of intensive care unit (ICU) patients and services in the United States and to determine ICU physician staffing before the publication and ...dissemination of the Leapfrog Group ICU physician staffing recommendations.
DESIGN AND SETTING:Stratified, weighted survey of ICU directors in the United States, performed as part of the Committee on Manpower for the Pulmonary and Critical Care Societies (COMPACCS) study. Using lenient definitions, we defined an ICU as “high intensity” if ≥80% of patients were cared for by a critical care physician (intensivist) and defined an ICU as compliant with Leapfrog if it was both high-intensity and providing some form of in-house physician coverage during all hours.
SUBJECTS:Three hundred ninety-three ICU directors.
INTERVENTIONS:None.
MEASUREMENTS AND MAIN RESULTS:We obtained a 33.5% response rate (393/1,173). We estimated there were 5,980 ICUs in the United States, caring for approximately 55,000 patients per day, with at least one ICU in all acute care hospitals. The predominant reasons for admission were respiratory insufficiency, postoperative care, and heart failure. Most ICUs were combined medical-surgical ICUs (n = 3,865; 65%), were located in nonteaching, community hospitals (n = 4,245; 71%), and were in hospitals of <300 beds (n = 3,710; 62%). One in four ICUs were high-intensity (n = 1,578; 26%), half had no intensivist coverage (n = 3,183; 53%), and the remainder had at least some intensivist presence (n = 1,219; 20%). High-intensity units were more common in larger hospitals (p = .001) and in teaching hospitals (p < .001) and more likely to be surgical (p < .001) or trauma ICUs (p < .001). Few ICUs had any in-house physician coverage outside weekday daylight hours (20% during weekend days, 12% during weeknights, and 10% during weekend nights). Only 4% (n = 255) of all adult ICUs in the United States appeared to meet the full Leapfrog standards (a high-intensity ICU staffing pattern plus dedicated attending coverage during daytime plus dedicated coverage by any physician during nighttime).
CONCLUSIONS:ICU services are widely distributed but heterogeneously organized in the United States. Although high-intensity ICUs have been associated previously with improved outcomes, they were infrequent in our study, especially in smaller hospitals, and virtually no ICU met the Leapfrog standards before their dissemination. These findings highlight the considerable challenge to any efforts designed to promote either 24-hr physician coverage or high-intensity model organization.
Our goal was to describe disease‐specific survival and the clinical variables that predict survival in a large national cohort of adult liver transplant recipients. Data on 17,044 adult patients who ...received an initial orthotopic liver transplant between 1990 and 1996 with follow‐up through 1999 was obtained from the United Network for Organ Sharing (UNOS). Disease‐specific Kaplan‐Meier survival plots and Cox Proportional Hazards models were estimated, and differences in the clinical characteristics of patients at the time of transplantation by disease were examined. Overall posttransplant survival currently exceeds 85% in the first year and is approaching 75% at 5 years. Unadjusted Kaplan‐Meier survival is improved for recipients who are younger, female, and in better clinical condition. Survival is a function of disease and level of illness: cancer, fulminant liver failure, alcoholic liver disease, and the hepatitidies have the poorest prognosis, while primary billiary cirrohsis and sclerosing cholangitis have the best. Recipients who were outpatients before transplantation have longer survival than those transplanted from the hospital or intensive care unit. Although the model for end‐stage liver disease (MELD) score was designed to predict pretransplant survival, patients with higher MELD scores have poorer posttransplant survival, but the MELD score is less predictive than the specific disease. Differences in disease‐specific survival are partially explained by differences in disease severity at the time of transplantation. In conclusion, Disease‐specific survival models indicate that there remains tremendous variability in survival as a function of underlying liver disease. However, a significant portion of the difference in survival between diseases arises from differences in clinical characteristics at the time of transplantation. (Liver Transpl 2004;10:886–897.)
Dissociative seizures are paroxysmal events resembling epilepsy or syncope with characteristic features that allow them to be distinguished from other medical conditions. We aimed to compare the ...effectiveness of cognitive behavioural therapy (CBT) plus standardised medical care with standardised medical care alone for the reduction of dissociative seizure frequency.
In this pragmatic, parallel-arm, multicentre randomised controlled trial, we initially recruited participants at 27 neurology or epilepsy services in England, Scotland, and Wales. Adults (≥18 years) who had dissociative seizures in the previous 8 weeks and no epileptic seizures in the previous 12 months were subsequently randomly assigned (1:1) from 17 liaison or neuropsychiatry services following psychiatric assessment, to receive standardised medical care or CBT plus standardised medical care, using a web-based system. Randomisation was stratified by neuropsychiatry or liaison psychiatry recruitment site. The trial manager, chief investigator, all treating clinicians, and patients were aware of treatment allocation, but outcome data collectors and trial statisticians were unaware of treatment allocation. Patients were followed up 6 months and 12 months after randomisation. The primary outcome was monthly dissociative seizure frequency (ie, frequency in the previous 4 weeks) assessed at 12 months. Secondary outcomes assessed at 12 months were: seizure severity (intensity) and bothersomeness; longest period of seizure freedom in the previous 6 months; complete seizure freedom in the previous 3 months; a greater than 50% reduction in seizure frequency relative to baseline; changes in dissociative seizures (rated by others); health-related quality of life; psychosocial functioning; psychiatric symptoms, psychological distress, and somatic symptom burden; and clinical impression of improvement and satisfaction. p values and statistical significance for outcomes were reported without correction for multiple comparisons as per our protocol. Primary and secondary outcomes were assessed in the intention-to-treat population with multiple imputation for missing observations. This trial is registered with the International Standard Randomised Controlled Trial registry, ISRCTN05681227, and ClinicalTrials.gov, NCT02325544.
Between Jan 16, 2015, and May 31, 2017, we randomly assigned 368 patients to receive CBT plus standardised medical care (n=186) or standardised medical care alone (n=182); of whom 313 had primary outcome data at 12 months (156 84% of 186 patients in the CBT plus standardised medical care group and 157 86% of 182 patients in the standardised medical care group). At 12 months, no significant difference in monthly dissociative seizure frequency was identified between the groups (median 4 seizures IQR 0–20 in the CBT plus standardised medical care group vs 7 seizures 1–35 in the standardised medical care group; estimated incidence rate ratio IRR 0·78 95% CI 0·56–1·09; p=0·144). Dissociative seizures were rated as less bothersome in the CBT plus standardised medical care group than the standardised medical care group (estimated mean difference −0·53 95% CI −0·97 to −0·08; p=0·020). The CBT plus standardised medical care group had a longer period of dissociative seizure freedom in the previous 6 months (estimated IRR 1·64 95% CI 1·22 to 2·20; p=0·001), reported better health-related quality of life on the EuroQoL-5 Dimensions-5 Level Health Today visual analogue scale (estimated mean difference 6·16 95% CI 1·48 to 10·84; p=0·010), less impairment in psychosocial functioning on the Work and Social Adjustment Scale (estimated mean difference −4·12 95% CI −6·35 to −1·89; p<0·001), less overall psychological distress than the standardised medical care group on the Clinical Outcomes in Routine Evaluation-10 scale (estimated mean difference −1·65 95% CI −2·96 to −0·35; p=0·013), and fewer somatic symptoms on the modified Patient Health Questionnaire-15 scale (estimated mean difference −1·67 95% CI −2·90 to −0·44; p=0·008). Clinical improvement at 12 months was greater in the CBT plus standardised medical care group than the standardised medical care alone group as reported by patients (estimated mean difference 0·66 95% CI 0·26 to 1·04; p=0·001) and by clinicians (estimated mean difference 0·47 95% CI 0·21 to 0·73; p<0·001), and the CBT plus standardised medical care group had greater satisfaction with treatment than did the standardised medical care group (estimated mean difference 0·90 95% CI 0·48 to 1·31; p<0·001). No significant differences in patient-reported seizure severity (estimated mean difference −0·11 95% CI −0·50 to 0·29; p=0·593) or seizure freedom in the last 3 months of the study (estimated odds ratio OR 1·77 95% CI 0·93 to 3·37; p=0·083) were identified between the groups. Furthermore, no significant differences were identified in the proportion of patients who had a more than 50% reduction in dissociative seizure frequency compared with baseline (OR 1·27 95% CI 0·80 to 2·02; p=0·313). Additionally, the 12-item Short Form survey–version 2 scores (estimated mean difference for the Physical Component Summary score 1·78 95% CI −0·37 to 3·92; p=0·105; estimated mean difference for the Mental Component Summary score 2·22 95% CI −0·30 to 4·75; p=0·084), the Generalised Anxiety Disorder-7 scale score (estimated mean difference −1·09 95% CI −2·27 to 0·09; p=0·069), and the Patient Health Questionnaire-9 scale depression score (estimated mean difference −1·10 95% CI −2·41 to 0·21; p=0·099) did not differ significantly between groups. Changes in dissociative seizures (rated by others) could not be assessed due to insufficient data. During the 12-month period, the number of adverse events was similar between the groups: 57 (31%) of 186 participants in the CBT plus standardised medical care group reported 97 adverse events and 53 (29%) of 182 participants in the standardised medical care group reported 79 adverse events.
CBT plus standardised medical care had no statistically significant advantage compared with standardised medical care alone for the reduction of monthly seizures. However, improvements were observed in a number of clinically relevant secondary outcomes following CBT plus standardised medical care when compared with standardised medical care alone. Thus, adults with dissociative seizures might benefit from the addition of dissociative seizure-specific CBT to specialist care from neurologists and psychiatrists. Future work is needed to identify patients who would benefit most from a dissociative seizure-specific CBT approach.
National Institute for Health Research, Health Technology Assessment programme.
CONTEXT Intensive care unit (ICU) physician staffing varies widely, and its
association with patient outcomes remains unclear. OBJECTIVE To evaluate the association between ICU physician staffing and ...patient
outcomes. DATA SOURCES We searched MEDLINE (January 1, 1965, through September 30, 2001) for
the following medical subject heading (MeSH) terms: intensive
care units, ICU, health resources/utilization, hospitalization, medical staff,
hospital organization and administration, personnel staffing and scheduling,
length of stay, and LOS. We also used the
following text words: staffing, intensivist, critical, care, and specialist. To identify observational
studies, we added the MeSH terms case-control study and retrospective study. Although we searched for non–English-language
citations, we reviewed only English-language articles. We also searched EMBASE,
HealthStar (Health Services, Technology, Administration, and Research), and
HSRPROJ (Health Services Research Projects in Progress) via Internet Grateful
Med and The Cochrane Library and hand searched abstract proceedings from intensive
care national scientific meetings (January 1, 1994, through December 31, 2001). STUDY SELECTION We selected randomized and observational controlled trials of critically
ill adults or children. Studies examined ICU attending physician staffing
strategies and the outcomes of hospital and ICU mortality and length of stay
(LOS). Studies were selected and critiqued by 2 reviewers. We reviewed 2590
abstracts and identified 26 relevant observational studies (of which 1 included
2 comparisons), resulting in 27 comparisons of alternative staffing strategies.
Twenty studies focused on a single ICU. DATA SYNTHESIS We grouped ICU physician staffing into low-intensity (no intensivist
or elective intensivist consultation) or high-intensity (mandatory intensivist
consultation or closed ICU all care directed by intensivist) groups. High-intensity
staffing was associated with lower hospital mortality in 16 of 17 studies
(94%) and with a pooled estimate of the relative risk for hospital mortality
of 0.71 (95% confidence interval CI, 0.62-0.82). High-intensity staffing
was associated with a lower ICU mortality in 14 of 15 studies (93%) and with
a pooled estimate of the relative risk for ICU mortality of 0.61 (95% CI,
0.50-0.75). High-intensity staffing reduced hospital LOS in 10 of 13 studies
and reduced ICU LOS in 14 of 18 studies without case-mix adjustment. High-intensity
staffing was associated with reduced hospital LOS in 2 of 4 studies and ICU
LOS in both studies that adjusted for case mix. No study found increased LOS
with high-intensity staffing after case-mix adjustment. CONCLUSIONS High-intensity vs low-intensity ICU physician staffing is associated
with reduced hospital and ICU mortality and hospital and ICU LOS.
Community-acquired pneumonia (CAP) is a frequent cause of hospital admission and death among elderly patients, but there is little information on age- and sex-specific incidence, patterns of care ...(intensive care unit admission and mechanical ventilation), resource use (length of stay and hospital costs), and outcome (mortality). We conducted an observational cohort study of all Medicare recipients, aged 65 years or older, hospitalized in nonfederal U.S. hospitals in 1997, who met ICD-9-CM-based criteria for CAP. We identified 623,718 hospital admissions for CAP (18.3 per 1,000 population > or = 65 years), of which 26,476 (4.3%) were from nursing homes and of which 66,045 (10.6%) died. The incidence rose five-fold and mortality doubled as age increased from 65-69 to older than 90 years. Men had a higher mortality, both unadjusted (odds ratio OR: 1.21 95% CI: 1.19-1.23) and adjusted for age, location before admission, underlying comorbidity, and microbiologic etiology (OR: 1.15 95% CI: 1.13-1.17). Mean hospital length of stay and costs per hospital admission were 7.6 days and $6,949. For those admitted to the intensive care unit (22.4%) and for those receiving mechanical ventilation (7.2%), mean length of stay and costs were 11.3 days and $14,294, and 15.7 days and $23,961, respectively. Overall hospital costs were $4.4 billion (6.3% of the expenditure in the elderly for acute hospital care), of which $2.1 billion was incurred by cases managed in intensive care units. We conclude that in the hospitalized elderly, CAP is a common and frequently fatal disease that often requires intensive care unit admission and mechanical ventilation and consumes considerable health care resources. The sex differences are of concern and require further investigation.
Abstract Background Alcohol-related trauma remains high among underserved patients despite ongoing preventive measures. Geographic variability in prevalence of alcohol-related injury has prompted ...reexamination of this burden across different regions. We sought to elucidate demographic and socioeconomic factors influencing the prevalence of alcohol-related trauma among underserved patients and determine alcohol effects on selected outcomes. Methods A retrospective analysis examined whether patients admitted to a suburban trauma center differed according to their blood alcohol concentration (BAC) on admission. Patients were stratified based on their BAC into four categories (undetectable BAC, BAC 1–99 mg/dL, BAC 100–199 mg/dL, and BAC ≥ 200 mg/dL). T-tests and X2 tests were used to detect differences between BAC categories in terms of patient demographics and clinical outcomes. Multivariate linear and logistic regressions were used to investigate the association between patient variables and selected outcomes while controlling for confounders. Results One third of 738 patients analyzed were BAC-positive, mean (SD) BAC was 211.4 (118.9) mg/dL, 80% of BAC-positive patients had levels ≥ 100 mg/dL. After risk adjustments, the following patient characteristics were predictive of having highly elevated BAC (≥ 200 mg/dL) upon admission to the Trauma Center; Hispanic patients (adjusted odds ratio (OR) = 1.91, 95% confidence interval (CI): 1.14–3.21), unemployment (OR = 1.74, 95% CI: 1.09–2.78), Medicaid beneficiaries (OR = 3.59, 95% CI: 1.96–6.59), and uninsured patients (OR = 2.86, 95% CI: 1.60–5.13). Patients with BAC of 100–199 mg/dL were likely to be more severely injured ( P = 0.016) compared to undetectable-BAC patients. There was no association between being intoxicated, and being ICU–admitted or having differences in length of ICU or hospital stay. Conclusion Demographic and socioeconomic factors underlie disparities in the prevalence of alcohol-related trauma among underserved patients. These findings may guide targeted interventions toward specific populations to help reduce the burden of alcohol-related injury.
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