Long-Term Outcomes After ICU Admission Triage in Octogenarians

Andersen, Finn H.; Flaatten, Hans; Klepstad, Pål; Follestad, Turid; Strand, Kristian; Krüger, Andreas; Hahn, Michael; Buskop, Christian; Rime, Anne-Karin; Kvåle, Reidar

doi:10.1097/ccm.0000000000002098

Cited by 47 publications

(45 citation statements)

References 32 publications

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“…1 where the absolute short-term survival benefit (Fig. 1 and Additional file 2 ) [ 21 , 37 ]: a) increases with SAPS II, and indirectly with age since SAPS II is age-weighted; b) peaks around mid- to high-range SAPS II; c) diminishes in each end of the SAPS II range, i.e. if too well or too sick to benefit, respectively; and d) can differ between patients too well and too sick to benefit, i.e.…”

Section: Methodsmentioning

confidence: 99%

“…For a patient admitted to the ICU, we calculated the expected LOS ICU as the weighted sum of sampled LOS of individuals of the same age group (age ±5 years) and the same type of admission from three categories in NIR: those who died in the ICU (66% of the non-survivors), died in the ward (34% of the non-survivors), or survived hospital (weighted by the patient’s probability of dying or surviving the hospital stay given by calibrated SAPS II; Tables 1 and 2 ). The expected number of ward days following ICU discharge (LOS ward) was estimated based on available references from Norway and a European multi-centre study of ICU triage [ 37 , 45 , 46 ]. For ICU decedents, we set LOS ward to 0 days, and for those who died in the ward after ICU discharge we sampled LOS ward from a distribution of possible values (mean 2.5 days).…”

Section: Methodsmentioning

confidence: 99%

See 1 more Smart Citation

Costs and expected gain in lifetime health from intensive care versus general ward care of 30,712 individual patients: a distribution-weighted cost-effectiveness analysis

Haaland¹,

Kvåle²,

Norheim³

et al. 2017

Crit Care

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BackgroundClinicians, hospital managers, policy makers, and researchers are concerned about high costs, increased demand, and variation in priorities in the intensive care unit (ICU). The objectives of this modelling study are to describe the extra costs and expected health gains associated with admission to the ICU versus the general ward for 30,712 patients and the variation in cost-effectiveness estimates among subgroups and individuals, and to perform a distribution-weighted economic evaluation incorporating extra weighting to patients with high severity of disease.MethodsWe used a decision-analytic model that estimates the incremental cost per quality-adjusted life year (QALY) gained (ICER) from ICU admission compared with general ward care using Norwegian registry data from 2008 to 2010. We assigned increasing weights to health gains for those with higher severity of disease, defined as less expected lifetime health if not admitted. The study has inherent uncertainty of findings because a randomized clinical trial comparing patients admitted or rejected to the ICU has never been performed. Uncertainty is explored in probabilistic sensitivity analysis.ResultsThe mean cost-effectiveness of ICU admission versus ward care was €11,600/QALY, with 1.6 QALYs gained and an incremental cost of €18,700 per patient. The probability (p) of cost-effectiveness was 95% at a threshold of €22,000/QALY. The mean ICER for medical admissions was €10,700/QALY (p = 97%), €12,300/QALY (p = 93%) for admissions after acute surgery, and €14,700/QALY (p = 84%) after planned surgery. For individualized ICERs, there was a 50% probability that ICU admission was cost-effective for 85% of the patients at a threshold of €64,000/QALY, leaving 15% of the admissions not cost-effective. In the distributional evaluation, 8% of all patients had distribution-weighted ICERs (higher weights to gains for more severe conditions) above €64,000/QALY. High-severity admissions gained the most, and were more cost-effective.ConclusionsOn average, ICU admission versus general ward care was cost-effective at a threshold of €22,000/QALY (p = 95%). According to the individualized cost-effectiveness information, one in six ICU admissions was not cost-effective at a threshold of €64,000/QALY. Almost half of these admissions that were not cost-effective can be regarded as acceptable when weighted by severity of disease in terms of expected lifetime health. Overall, existing ICU services represent reasonable resource use, but considerable uncertainty becomes evident when disaggregating into individualized results.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-017-1792-0) contains supplementary material, which is available to authorized users.

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Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Costs and expected gain in lifetime health from intensive care versus general ward care of 30,712 individual patients: a distribution-weighted cost-effectiveness analysis

Haaland¹,

Kvåle²,

Norheim³

et al. 2017

Crit Care

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“…It is, however, still unclear if there might be a risk of overtreatment or undertreatment of older patients in the setting of a critical illness. This multicentre study will provide the characterization of older patients and the identification of end of life trajectories providing clinicians with predictor tools including specific multidimensional geriatric evaluation to support the daily clinical decisions appeared useful to guide triage decisions prior to ICU admission of VOPs [51]. While both have potential, neither scoring system has been clinically or externally evaluated.…”

Section: Severity Of Disease Models and The Elderlymentioning

confidence: 99%

The status of intensive care medicine research and a future agenda for very old patients in the ICU

Flaatten¹,

Lange²,

Artigas³

et al. 2017

Intensive Care Med

200

196

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The "very old intensive care patients" (abbreviated to VOPs; greater than 80 years old) are probably the fastest expanding subgroup of all intensive care unit (ICU) patients. Up until recently most ICU physicians have been reluctant to admit these VOPs. The general consensus was that there was little survival to gain and the incremental life expectancy of ICU admission was considered too small. Several publications have questioned this belief, but others have confirmed the poor long-term mortality rates in VOPs. More appropriate triage (resource limitation enforced decisions), admission decisions based on shared decision-making and improved prediction models are also needed for this particular patient group. Here, an expert panel proposes a research agenda for VOPs for the coming years.

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“…Triage is in many ICUs a daily challenge, and reports on patients who are triaged before ICU admission vary a lot. [5][6][7] In the ICE-CUB1 (Intensive Care Elderly-College des Utilisateurs de Base de données 1) study, 8 details of the trajectories of patients proposed to be admitted or not to an ICU are shown in ►Table 2. Apart from those considered too well, the patients admitted to an ICU had lower mortality than those not admitted.…”

Section: Triage and Limitation Of Carementioning

confidence: 99%

Elderly Patients in the Intensive Care Unit

Beil

Guidet

2020

Semin Respir Crit Care Med

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Very old intensive care unit (ICU) patients, aged ≥ 80 years, are by no mean newcomers, but during the last decades their impact on ICU admissions has grown in parallel with the increase in the number of elderly persons in the community. Hence, from being a “rarity,” they have now become common and constitute one of the largest subgroups within intensive care, and may easily be the largest group in 20 years and make up 30 to 40% of all ICU admissions. Obviously, they are not admitted because they are old but because they are with various diseases and problems like any other ICU patient. However, their age and the presence of common geriatric syndromes such as frailty, cognitive decline, reduced activity of daily life, and several comorbid conditions makes this group particularly challenging, with a high mortality rate. In this review, we will highlight aspects of current and future epidemiology and current knowledge on outcomes, and describe the effects of the aforementioned geriatric syndromes. The major challenge for the coming decades will be the question of whom to treat and the quest for better triage criteria not based on age alone. Challenges with the level of care during the ICU stay will also be discussed. A stronger relationship with geriatricians should be promoted to create a better and more holistic care and aftercare for survivors.

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Long-Term Outcomes After ICU Admission Triage in Octogenarians

Cited by 47 publications

References 32 publications

Costs and expected gain in lifetime health from intensive care versus general ward care of 30,712 individual patients: a distribution-weighted cost-effectiveness analysis

Costs and expected gain in lifetime health from intensive care versus general ward care of 30,712 individual patients: a distribution-weighted cost-effectiveness analysis

The status of intensive care medicine research and a future agenda for very old patients in the ICU

Elderly Patients in the Intensive Care Unit

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