The accuracy of the signs and tests that clinicians use to diagnose ventilator-associated pneumonia (VAP) and initiate antibiotic treatment has not been well characterized. We sought to characterize ...and compare the accuracy of physical examination, chest radiography, endotracheal aspirate (ETA), bronchoscopic sampling cultures (protected specimen brush PSB and bronchoalveolar lavage BAL), and CPIS > 6 to diagnose VAP. We searched six databases from inception through September 2019 and selected English-language studies investigating accuracy of any of the above tests for VAP diagnosis. Reference standard was histopathological analysis. Two reviewers independently extracted data and assessed study quality. We included 25 studies (1639 patients). The pooled sensitivity and specificity of physical examination findings for VAP were poor: fever (66.4% 95% confidence interval CI: 40.7–85.0, 53.9% 95% CI 34.5–72.2) and purulent secretions (77.0% 95% CI 64.7–85.9, 39.0% 95% CI 25.8–54.0). Any infiltrate on chest radiography had a sensitivity of 88.9% (95% CI 73.9–95.8) and specificity of 26.1% (95% CI 15.1–41.4). ETA had a sensitivity of 75.7% (95% CI 51.5–90.1) and specificity of 67.9% (95% CI 40.5–86.8). Among bronchoscopic sampling methods, PSB had a sensitivity of 61.4% 95% CI 43.7–76.5 and specificity of 76.5% 95% CI 64.2–85.6; while BAL had a sensitivity of 71.1% 95% CI 49.9–85.9 and specificity of 79.6% 95% CI 66.2–85.9. CPIS > 6 had a sensitivity of 73.8% (95% CI 50.6–88.5) and specificity of 66.4% (95% CI 43.9–83.3). Classic clinical indicators had poor accuracy for diagnosis of VAP. Reliance upon these indicators in isolation may result in misdiagnosis and potentially unnecessary antimicrobial use.
Very elderly patients are often admitted to intensive care units (ICUs) despite poor outcomes and frequent preference to avoid unnecessary prolongation of life. We sought to determine the cost of ICU ...admission for the very elderly and the factors influencing this cost.
This prospective, observational cohort study included patients ≥80 years old admitted to 22 Canadian ICUs from 2009 to 2013. A subset of consenting individuals comprised a longitudinal cohort followed over 12 months. Costs were calculated from ICU length of stay and unit costs for ICU admission from a Canadian academic hospital. A generalized linear model was employed to identify cost-predictive variables.
In total, 1671 patients were included; 610 were enrolled in the longitudinal cohort. The average age was 85 years; median ICU length of stay was 4 days. Mortality was 35% (585/1671) in hospital and 41% (253/610) at 12 months. The average cost of ICU admission per patient was $31,679 ± 65,867. Estimated ICU costs were $48,744 per survivor to discharge and $61,783 per survivor at 1 year. For both decedents and survivors, preference for comfort measures over life support was an independent predictor for lower cost (P < 0.01).
Considering the poor clinical outcomes, and that many ICU admissions may be undesired by very elderly patients, ICU costs in this population are substantial. Our finding that a preference for comfort care predicted a lower cost independent of mortality reinforces the importance of early goals of care discussions to avoid both undesired and potentially non-beneficial interventions, consequently reducing costs.
ClinicalTrials.gov, NCT01293708 . Registered on 10 February 2011.
Up to 12% of the 800,000 patients who undergo mechanical ventilation in the United States every year require tracheostomies. A recent systematic review showed that early tracheostomy was associated ...with better outcomes: more ventilator-free days, shorter ICU stays, less sedation and reduced long-term mortality. However, the financial impact of early tracheostomies remain unknown.
To conduct a cost-analysis on the timing of tracheostomy in mechanically ventilated patients.
We extracted individual length of hospital stay and length of ICU stay data from the studies included in the systematic review from Hosokawa et al. We also searched for any recent randomized control trials on the topic that were published after this review. The weighted length of stay was estimated using a random effects model. Average daily hospital and ICU costs per patients were obtained from a cost study by Kahn et al. We estimated hospital and ICU costs by multiplying LOS with respective average daily cost per patient. We calculated difference in costs by subtracting hospital costs, ICU costs and total direct variable costs from early tracheotomy to late tracheotomy. 95% confidence intervals were estimated using bootstrap re-sampling procedures with 1000 iterations.
The average weighted cost of ICU stay in patients with an early tracheostomy was $4316 less when compared to patients with late tracheostomy (95% CI: 403–8229). Subgroup analysis revealed that very early tracheostomies (<4days) cost on average $3672 USD less than late tracheostomies (95% CI: –1309, 10,294) and that early tracheostomies (<10days but >4) cost on average $6385 USD less than late tracheostomies (95% CI: –4396–17,165).
This study shows that early tracheostomy can significantly reduce direct variable and likely total hospital costs in the intensive care unit based on length of stay alone. This is in addition to the already shown benefits of early tracheostomy in terms of ventilator dependent days, reduced length of stays, decreased pain, and improved communication. Further prospective studies on this topic are needed to prove the cost-effectiveness of early tracheostomy in the critically ill population.
•Early tracheostomy reduces ICU & hospital costs.•Early tracheostomy reduces ICU length of stay.•Findings are consistent after sensitivity analysis.
Background:
Palliative care aims to improve quality of life by relieving physical, emotional, and spiritual suffering. Health system planning can be informed by evaluating cost and effectiveness of ...health care delivery, including palliative care.
Aim:
The objectives of this article were to describe and critically appraise economic evaluations of palliative care models and to identify cost-effective models in improving patient-centered outcomes.
Design:
We conducted a systematic review and registered our protocol in PROSPERO (CRD42016053973).
Data sources:
A systematic search of nine medical and economic databases was conducted and extended with reference scanning and gray literature. Methodological quality was assessed using the Drummond checklist.
Results:
We identified 12,632 articles and 5 were included. We included two modeling studies from the United States and England, and three economic evaluations from England, Australia, and Italy. Two studies compared home-based palliative care models to usual care, and one compared home-based palliative care to no care. Effectiveness outcomes included hospital readmission prevented, days at home, and palliative care symptom severity. All studies concluded that palliative care was cost-effective compared to usual care. The methodological quality was good overall, but three out of five studies were based on small sample sizes.
Conclusion:
Applicability and generalizability of evidence is uncertain due to small sample sizes, short duration, and limited modeling of costs and effects. Further economic evaluations with larger sample sizes are needed, inclusive of the diversity and complexity of palliative care populations and using patient-centered outcomes.
Background:
Due to the COVID-19 pandemic, many community palliative healthcare providers shifted from providing care in a patient’s home to providing almost exclusively virtual palliative care, or a ...combination of in-person and virtual care. Research on virtual palliative care is thus needed to provide evidence-based recommendations aiming to enhance the delivery of palliative care during and beyond the pandemic.
Aim:
To explore the experiences and perceptions of community palliative care providers, patients and caregivers who delivered or received virtual palliative care as a component of home-based palliative care during the COVID-19 pandemic.
Design:
Qualitative study using phone and video-based semi-structured interviews. Data were analyzed using thematic analysis.
Setting/participants:
A total of 37 participants, including community palliative care patients/caregivers (n = 19) and healthcare providers (n = 18) recruited from sites in Ottawa and Toronto, Ontario, Canada.
Results:
Overall, participants preferred in-person palliative care compared to virtual care, but suggested virtual care could be a useful supplement to in-person care. The findings are presented in three main themes: (1) Impact of COVID-19 pandemic on community palliative care services; (2) Factors influencing transition from exclusively virtual model of care back to a blended model of care; and (3) Recommended uses and implementation of virtual palliative care
Conclusions:
Incorporating virtual palliative care into healthcare provider practice models (blended care models) may be the ideal model of care and standard practice moving forward beyond the COVID-19 pandemic, which has important implications toward organization and delivery of community palliative care services and funding of healthcare providers.
AbstractObjectiveTo analyse the association between survival from critical illness and suicide or self-harm after hospital discharge.DesignPopulation based cohort study using linked and validated ...provincial databases.SettingOntario, Canada between January 2009 and December 2017 (inclusive).ParticipantsConsecutive adult intensive care unit (ICU) survivors (≥18 years) were included. Linked administrative databases were used to compare ICU hospital survivors with hospital survivors who never required ICU admission (non-ICU hospital survivors). Patients were categorised based on their index hospital admission (ICU or non-ICU) during the study period.Main outcome measuresThe primary outcome was the composite of death by suicide (as noted in provincial death records) and deliberate self-harm events after discharge. Each outcome was also assessed independently. Incidence of suicide was evaluated while accounting for competing risk of death from other causes. Analyses were conducted by using overlap propensity score weighted, cause specific Cox proportional hazard models.Results423 060 consecutive ICU survivors (mean age 61.7 years, 39% women) were identified. During the study period, the crude incidence (per 100 000 person years) of suicide, self-harm, and the composite of suicide or self-harm among ICU survivors was 41.4, 327.9, and 361.0, respectively, compared with 16.8, 177.3, and 191.6 in non-ICU hospital survivors. Analysis using weighted models showed that ICU survivors (v non-ICU hospital survivors) had a higher risk of suicide (adjusted hazards ratio 1.22, 95% confidence interval 1.11 to 1.33) and self-harm (1.15, 1.12 to 1.19). Among ICU survivors, several factors were associated with suicide or self-harm: previous depression or anxiety (5.69, 5.38 to 6.02), previous post-traumatic stress disorder (1.87, 1.64 to 2.13), invasive mechanical ventilation (1.45, 1.38 to 1.54), and renal replacement therapy (1.35, 1.17 to 1.56).ConclusionsSurvivors of critical illness have increased risk of suicide and self-harm, and these outcomes were associated with pre-existing psychiatric illness and receipt of invasive life support. Knowledge of these prognostic factors might allow for earlier intervention to potentially reduce this important public health problem.
Despite the high cost associated with ICU use at the end of life, very little is known at a population level about the characteristics of users and their end of life experience. In this study, our ...goal was to characterize decedents who received intensive care near the end of life and examine their overall health care use prior to death.
This was a retrospective cohort study that examined all deaths in a 3-year period from April 2010 to March 2013 in Ontario, Canada. Using population-based health administrative databases, we examined healthcare use and cost in the last year of life.
There were 264,754 individuals included in the study, of whom 18% used the ICU in the last 90 days of life; 34.5% of these ICU users were older than 80 years of age and 53.0% had more than five chronic conditions. The average cost of stay for these decedents was CA$15,511 to CA$25,526 greater than for those who were not admitted to the ICU. These individuals also died more frequently in hospital (88.7% vs 36.2%), and spent more time in acute-care settings (18.7 days vs. 10.5 days).
We showed at a population level that a significant proportion of those with ICU use close to death are older, multi-morbid individuals who incur significantly greater costs and die largely in hospital, with higher rates of readmission, longer lengths of stay and higher rates of aggressive care.
New-onset atrial fibrillation (NOAF) is commonly encountered in critically ill adults. Evidence evaluating the association between NOAF and patient-important outcomes in this population is ...conflicting. Furthermore, little is known regarding the association between NOAF and resource use or hospital costs.
Retrospective analysis (2011-2016) of a prospectively collected registry from two Canadian hospitals of consecutive ICU patients aged ≥ 18 years. We excluded patients with a known history of AF prior to hospital admission. Any occurrence of atrial fibrillation (AF) was prospectively recorded by bedside nurses. The primary outcome was hospital mortality, and we used multivariable logistic regression to adjust for confounders. We used a generalized linear model to evaluate contributors to total cost.
We included 15,014 patients, and 1541 (10.3%) had NOAF during their ICU admission. While NOAF was not associated with increased odds of hospital death among the entire cohort (adjusted odds ratio aOR 1.02 95% confidence interval CI 0.97-1.08), an interaction was noted between NOAF and sepsis, and the presence of both was associated with higher odds of hospital mortality (aOR 1.28 95% CI 1.09-1.36) than either alone. Patients with NOAF had higher total costs (cost ratio CR 1.09 95% CI 1.02-1.20). Among patients with NOAF, treatment with a rhythm-control strategy was associated with higher costs (CR 1.24 95% CI 1.07-1.40).
While NOAF was not associated with death or requiring discharge to long-term care among critically ill patients, it was associated with increased length of stay in ICU and increased total costs.
Healthcare expenditure within the intensive care unit (ICU) is costly. A cost reduction strategy may be to target patients accounting for a disproportionate amount of healthcare spending, or ...high-cost users. This study aims to describe high-cost users in the ICU, including health outcomes and cost patterns.
We conducted a population-based retrospective cohort study of patients with ICU admissions in Ontario from 2011 to 2018. Patients with total healthcare costs in the year following ICU admission (including the admission itself) in the upper 10th percentile were defined as high-cost users. We compared characteristics and outcomes including length of stay, mortality, disposition, and costs between groups.
Among 370,061 patients included, 37,006 were high-cost users. High-cost users were 64.2 years old, 58.3% male, and had more comorbidities (41.2% had ≥3) when likened to non-high cost users (66.1 years old, 57.2% male, 27.9% had ≥3 comorbidities). ICU length of stay was four times greater for high-cost users compared to non-high cost users (22.4 days, 95% confidence interval CI 22.0-22.7 days vs. 5.56 days, 95% CI 5.54-5.57 days). High-cost users had lower in-hospital mortality (10.0% vs.14.2%), but increased dispositioning outside of home (77.4% vs. 42.2%) compared to non-high-cost users. Total healthcare costs were five-fold higher for high-cost users ($238,231, 95% CI $237,020-$239,442) compared to non-high-cost users ($45,155, 95% CI $45,046-$45,264). High-cost users accounted for 37.0% of total healthcare costs.
High-cost users have increased length of stay, lower in-hospital mortality, and higher total healthcare costs when compared to non-high-cost users. Further studies into cost patterns and predictors of high-cost users are necessary to identify methods of decreasing healthcare expenditure.
Following emergency department (ED) assessment, patients with infection may be directly admitted to the intensive care unit (ICU) or alternatively admitted to hospital wards or sent home. Those ...admitted to the hospital wards or sent home may experience future deterioration necessitating ICU admission.
We used a prospectively collected registry from two hospitals within a single tertiary care hospital network between 2011 and 2014. Patient information, outcomes, and costs were stored in the hospital data warehouse. Patients were categorized into three groups: (1) admitted directly from the ED to the ICU; (2) initially admitted to the hospital wards, with ICU admission within 72 hours of initial presentation; or (3) sent home from the ED, with ICU admission within 72 hours of initial presentation. Using multivariable logistic regression, we sought to compare outcomes and total costs between groups. Total costs were evaluated using a generalized linear model.
A total of 657 patients were included; of these, 338 (51.4%) were admitted directly from the ED to the ICU, 246 (37.4%) were initially admitted to the wards and then to the ICU, and 73 (11.1%) were initially sent home and then admitted to the ICU. In-hospital mortality was lowest among patients admitted directly to the ICU (29.5%), as compared with patients admitted to the ICU from wards (42.7%) or home (61.6%) (P < 0.001). As compared with direct ICU admission, disposition to the ward was associated with an adjusted OR of 1.75 (95% CI, 1.22-2.50; P < 0.01) for mortality, and disposition home was associated with an adjusted OR of 4.02 (95% CI, 2.32-6.98). Mean total costs were lowest among patients directly admitted to the ICU ($26,748), as compared with those admitted from the wards ($107,315) and those initially sent home ($71,492) (P < 0.001). Cost per survivor was lower among patients directly admitted to the ICU ($37,986) than either those initially admitted to the wards ($187,230) or those sent home ($186,390) (P < 0.001).
In comparison with direct admission to the ICU, patients with suspected infection admitted to the ICU who have previously been discharged home or admitted to the ward are associated with higher in-hospital mortality and costs.
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