Healthcare-related costs in very elderly intensive care patients

Introduction

The long-term outcome of “very old intensive care unit patients” (VOPs; ≥?80 years) is often disappointing. Little is known about the healthcare costs of these VOPs in comparison to younger ICU patients and the very elderly in the general population not admitted to the ICU.

Methods

Data from a national health insurance claims database and a national quality registry for ICUs were combined. Costs of VOPs admitted to the ICU in 2013 were compared with costs of younger ICU patients (two groups, respectively 18–65 and 65–80 years old) and a matched control group of very elderly subjects who were not admitted to the ICU. We compared median costs and median costs per day alive in the year before ICU admission (2012), the year of ICU admission (2013) and the year after ICU admission (2014).

Results

A total of 9272 VOPs were included and compared to three equally sized study groups. Median costs for VOPs in 2012, 2013 and 2014 (€5944, €35,653 and €12,565) are higher compared to the ICU 18–65 population (€3022, €30,223 and €5052, all p?<?0.001) and the very elderly control population (€3590, €4238 and €4723, all p?<?0.001). Compared to the ICU 65–80 population, costs of VOPs are higher in the year before and after ICU admission (€4323 and €6750, both p?<?0.001), but not in the year of ICU admission (€34,448, p?=?0.950). The median healthcare costs per day alive in the year before, the year of and the year after ICU admission are all higher for VOPs than for the other groups (p?<?0.001).

Conclusions

VOPs required more healthcare resources in the year before, the year of and the year after ICU admission compared to younger ICU patients and the very elderly control population, except compared to the ICU 65–80 population in the year of ICU admission. Healthcare costs per day alive, however, are substantially higher for VOPs than for all other study groups in all three studied years.

     

Acute kidney injury in elderly intensive care patients: a review

The elderly are at high risk for acute kidney injury (AKI). With the aging of the population, the demand for intensive care unit (ICU) admission from older patients will continue to rise, and this clinical entity will likely become increasingly common. In this article we review the relevant literature, discuss the age-related changes that render older people prone to AKI development, and examine the most frequent etiologies for renal impairment in these patients. We also consider the difficulties in achieving an early diagnosis in the elderly ICU patient, the particularities related to AKI treatment in this age group, and the data available on differences in renal recovery and mortality between the young and the old with renal injury. More importantly, we highlight the methods for prevention of AKI development or worsening in the elderly critically ill patient.     

Identification of high-risk subgroups in very elderly intensive care unit patients

Introduction  

Current prognostic models for intensive care unit (ICU) patients have not been specifically developed or validated in the very elderly. The aim of this study was to develop a prognostic model for ICU patients 80 years old or older to predict in-hospital mortality by means of data obtained within 24 hours after ICU admission. Aside from having good overall performance, the model was designed to reliably and specifically identify subgroups at very high risk of dying.     

Pediatric intensive care: factors that influence outcome

Four hundred sixty-one consecutive admissions to the Pediatric Intensive Care Unit (PICU) were evaluated using the Therapeutic Intervention Scoring System (TISS). Patients requiring an increased level of care, defined as TISS points greater than or equal to 10, accounted for 75% of patient days in the ICU. Within this group, the primary reason for admission to the ICU was congenital heart disease, trauma, malignancy, respiratory failure, and sepsis. Survival was inversely related to TISS points, through TISS itself could not differentiate between survivors and nonsurvivors. The mortality rates for children who had a congenital malformation, a cardiac arrest before admission, or who developed acute failure secondary to other disease processes were significantly increased. Comparison of critically ill children and adults using TISS showed mortality rates that were similar. Assuming that the cost of intensive care is related to both seriousness of illness (assessed by TISS) and length of hospitalization, in this pediatric population the cost of hospitalization was not disproportionately high for nonsurvivors compared to survivors. Reduction in mortality rates in a PICU population will be dependent on factors largely uncontrollable buy ICU practitioners. This will come about by reduction in the numbers of congenital malformations and the prevention of childhood trauma.     

Emotional outcome after intensive care: literature review

Title. Emotional outcome after intensive care: literature review. Aim. This paper is a report of a literature review to identify (a) the prevalence of emotional and psychological problems after intensive care, (b) associated factors and (c) interventions that might improve this aspect of recovery. Background. Being a patient in intensive care has been linked to both short‐ and long‐term emotional and psychological consequences. Data sources. The literature search was conducted during 2006. Relevant journals and databases were searched, i.e. Medline and CINAHL, between the years 1995 and 2006. Review methods. The search terms were ‘anxiety’, ‘depression’, posttraumatic stress’, ‘posttraumatic stress disorder’ and ‘intensive care’. Results. Fifteen papers were reviewed representing research studies of anxiety, depression and posttraumatic stress, and seven that represented intensive care follow‐up clinics and patient diaries. Being in intensive care can result in significant emotional and psychological problems for a number of patients. For the majority of patients, symptoms of distress will decrease over time but for a number these will endure for some years. Current evidence indicates that emotional problems after intensive care are related to both subjective and objective indicators of a patient’s intensive care experience. Evidence suggests some benefit in an early rehabilitation programme, daily sedation withdrawal and the use of patient diaries. However, additional research is required to support such findings. Conclusion. Our understanding of the consequences of intensive care is improving. Psychological care for intensive care patients has lagged behind care for physical problems. We now need to focus on developing and evaluating appropriate interventions to improve psychological outcome in this patient group.     

Intensive care unit outcome in the very elderly.

OBJECTIVES: To determine if age, previous functional status, or acute severity of illness affect the acute and long-term mortality rates and functional status of the very elderly (> or = 85 yrs) after an ICU admission. DESIGN: Cohort study (retrospective entry for the first year of the study and prospective entry thereafter with prospective follow-up throughout). SETTING: An ICU in a community teaching hospital with follow-up at home or at a skilled nursing facility. PATIENTS: All (n = 105) patients > or = 85 yrs admitted to the ICU over a 2-yr period. MAIN OUTCOME MEASURES: ICU, 30-day posthospital discharge, and 1-yr mortality rates, activities of daily living scores, organ system failure score at the time of ICU admission. RESULTS: The ICU, 30-day posthospital discharge, and the 1-yr mortality rates were 30%, 43%, and 64%, respectively. Mortality rates significantly increased between the ICU stay or 30 days posthospital discharge and 1-yr follow-up periods. Of those patients who lived up to 6 months after hospital discharge, 86% survived to 1 yr with little change in functional status from baseline. In the patients with > or = 2 organ system failures, there were 88% 30-day posthospital discharge and 100% 1-yr mortality rates. Severity of illness, as measured by the number of organ system failures, was associated with increased ICU (odds ratio 3.38; 95% confidence interval, 1.51 to 7.60; p < .005) and 1 yr (odds ratio 5.76; 95% confidence interval, 2.49 to 13.29; p < .0001) mortality rates, while age within this group and preadmission functional status were not. CONCLUSIONS: Within the very elderly population, acute severity of illness is the most significant predictor of mortality after an ICU admission. For most very elderly patients, surviving 1 yr after an ICU admission, there is little change in functional status.     

Short-term and long-term mortality in very elderly patients admitted to an intensive care unit

Objective To report short-term and long-term mortality of very elderly ICU patients and to determine independent risk factors for short-term and long-term mortalityDesign and setting Retrospective cohort study in the medical/surgical ICU of a tertiary university teaching hospital.Patients 578 consecutive ICU patients aged 80 years or older.Results Demographic, physiological, and laboratory values derived from the first 24 h after ICU admission. ICU mortality of unplanned surgical (34.0%) and medical patients (37.7%) was higher than that of planned surgical patients (10.6%), as was post-ICU hospital mortality (26.5% and 29.7% vs. 4.4%). Mortality 12 months after hospital discharge, including ICU and hospital mortality, was 62.1% in unplanned surgical and 69.2% in medical patients vs. 21.6% in planned patients. Only median survival of planned surgical patients did not differ from survival in the age- and gender-matched general population. Independent risk factors for ICU mortality were lower Glasgow Coma Scale score, higher SAPS II score, the lowest urine output over 8 h, abnormal body temperature, low plasma bicarbonate levels, and higher oxygen fraction of inspired air. High urea concentrations and admission type were risk factors for hospital mortality, and high creatinine concentration was an independent risk factor for 12-month mortality.Conclusion Mortality in very elderly patients after unplanned surgical or medical ICU admission is higher than after planned admission. The most important factors independently associated with ICU mortality were related to the severity of illness at admission. Long-term mortality was associated with renal function.This article is discussed in the editorial available at:     

Factors that influence intensive care admission decisions for older people: A systematic review

BackgroundThe population worldwide is rapidly ageing, and demand for intensive care is increasing. People aged 85 years and above, known as the oldest old, are particularly vulnerable to critical illness owing to the physiological effects of ageing. Evidence surrounding admission of the oldest old to the intensive care is limited.ObjectiveThe objective of this study was to systematically and comprehensively review and synthesise the published research investigating factors that influence decisions to admit the oldest old to the intensive care unit.MethodThis was a systematic review and narrative synthesis. Following a comprehensive search of CINAHL, Embase, and Medline databases, peer-reviewed primary research articles examining factors associated with admission or refusal to admit the oldest old to intensive care were selected. Data were extracted into tables and narratively synthesised.ResultsSix studies met the inclusion criteria. Three studies identified factors associated with admission such as greater premorbid self-sufficiency, patient preferences, alignment between patient and physicians’ goals of treatment, age less than 85 years, and absence of cancer, or previous intensive care admission. Factors associated with refusal to admit were identified in all six studies and included limited or no bed availability, level of ICU physician experience, patients being deemed too ill or too well to benefit, and older age.ConclusionsPublished research investigating decision-making about admission or refusal to admit the oldest old to the intensive care unit is scant. The ageing population and increasing demand for intensive care unit resources has amplified the need for greater understanding of factors that influence decisions to admit or refuse admission of the oldest old to the intensive care unit. Such knowledge may inform guidelines regarding complex practice decisions about admission of the oldest old to an intensive care unit. Such guidelines would ensure the specialty needs of this population are considered and would reduce admission decisions that might disadvantage older people.     

Optimal sedation in pediatric intensive care patients: a systematic review

Purpose

Sedatives administered to critically ill children should be titrated to effect, because both under- and oversedation may have negative effects. We conducted a systematic review to examine reported incidences of under-, optimal, and oversedation in critically ill children receiving intensive care.

Methods

A systematic literature search using predefined criteria was performed in PubMed and Embase to identify all articles evaluating level of sedation in PICU patients receiving continuous sedation. Two authors independently recorded: study objective, study design, sample size, age range, details of study intervention (if applicable), sedatives used, length of sedation, sedation scale used, and incidences of optimal, under-, and oversedation as defined in the studies.

Results

Twenty-five studies were included. Two studies evaluated sedation level as primary study outcome; the other 23 as secondary outcomes. Together, these studies investigated 1,163 children; age range, 0–18 years. Across studies, children received many different sedative agents and sedation level was assessed with 12 different sedation scales. Optimal sedation was ascertained in 57.6 % of the observations, under sedation in 10.6 %, and oversedation in 31.8 %.

Conclusions

This study suggests that sedation in the PICU is often suboptimal and seldom systematically evaluated. Oversedation is more common than undersedation. As oversedation may lead to longer hospitalization, tolerance, and withdrawal, preventing oversedation in pediatric intensive care deserves greater attention.     

Development of demographics and outcome of very old critically ill patients admitted to intensive care units

Purpose  

To evaluate the development of demographics and outcome of very old (>80 years) critically ill patients admitted to intensive care units.     

Clinical review: fever in intensive care unit patients

Fever is a common response to sepsis in critically ill patients. Fever occurs when either exogenous or endogenous pyrogens affect the synthesis of prostaglandin E2 in the pre-optic nucleus. Prostaglandin E2 slows the rate of firing of warm sensitive neurons and results in increased body temperature. The febrile response is well preserved across the animal kingdom, and experimental evidence suggests it may be a beneficial response to infection. Fever, however, is commonly treated in critically ill patients, usually with antipyretics, without good data to support such a practice. Fever induces the production of heat shock proteins (HSPs), a class of proteins critical for cellular survival during stress. HSPs act as molecular chaperones, and new data suggest they may also have an anti-inflammatory role. HSPs and the heat shock response appear to inhibit the activation of NF-kappabeta, thus decreasing the levels of proinflammatory cytokines. The anti-inflammatory effects of HSPs, coupled with improved survival of animal models with fever and infection, call into question the routine practice of treating fever in critically ill patients.     

Clinical review: Fever in intensive care unit patients

Fever is a common response to sepsis in critically ill patients. Fever occurs when either exogenous or endogenous pyrogens affect the synthesis of prostaglandin E₂ in the pre-optic nucleus. Prostaglandin E₂ slows the rate of firing of warm sensitive neurons and results in increased body temperature. The febrile response is well preserved across the animal kingdom, and experimental evidence suggests it may be a beneficial response to infection. Fever, however, is commonly treated in critically ill patients, usually with antipyretics, without good data to support such a practice. Fever induces the production of heat shock proteins (HSPs), a class of proteins critical for cellular survival during stress. HSPs act as molecular chaperones, and new data suggest they may also have an anti-inflammatory role. HSPs and the heat shock response appear to inhibit the activation of NF-κβ, thus decreasing the levels of proinflammatory cytokines. The anti-inflammatory effects of HSPs, coupled with improved survival of animal models with fever and infection, call into question the routine practice of treating fever in critically ill patients.     

Risk factors to predict outcome in critically ill cancer patients receiving chemotherapy in the intensive care unit

Objective  

The decision to start chemotherapy in critically ill cancer patients is extremely complex in the intensive care unit (ICU). Therefore, this study evaluated the outcomes and prognostic factors in critically ill cancer patients receiving chemotherapy in the ICU.     

Mortality in very long-stay pediatric intensive care unit patients and incidence of withdrawal of treatment

Background

The mortality for children with prolonged stay in pediatric intensive care units (PICU) is much higher than overall mortality. The incidence of withdrawal or limitation of therapy in this group is unknown.

Purpose

To assess mortality and characteristics of children admitted for ≥28 days to our ICU, and to describe the extent to which limitations of care were involved in the terminal phase preceding death.

Methods

For the period 2003 to 2005 clinical data were collected retrospectively for children with prolonged stay (defined as ≥28 days) in a medical/surgical PICU of a university children’s hospital.

Results

In the PICU, 4.4% of the children (116/2,607, equal gender, mean age 29 days) had a prolonged stay. Median (range) stay was 56 (28–546) days. These children accounted for 3% of total admissions and occupied 63% of total admission days. Mortality during admission for this group was five times higher (22%) than the average PICU mortality rate of 4.6%. Withdrawal or limitation of therapy preceded 70% of deaths.

Conclusions

Children with prolonged stay in the PICU have a significantly high risk of mortality. Death is typically preceded by limitation of care.