Provision of critical care for the elderly in Europe: a retrospective comparison of national healthcare frameworks in intensive care units

Abstract

ObjectivesIn Europe, there is a distinction between two different healthcare organisation systems, the tax-based healthcare system (THS) and the social health insurance system (SHI). Our aim was to investigate whether the characteristics, treatment and mortality of older, critically ill patients in the intensive care unit (ICU) differed between THS and SHI.SettingICUs in 16 European countries.ParticipantsIn total, 7817 critically ill older (≥80 years) patients were included in this study, 4941 in THS and 2876 in the SHI systems.Primary and secondary outcomes measuresWe chose generalised estimation equations with robust standard errors to produce population average adjusted OR (aOR). We adjusted for patient-specific variables, health economic data, including gross domestic product (GDP) and human development index (HDI), and treatment strategies.ResultsIn SHI systems, there were higher rates of frail patients (Clinical Frailty Scale>4; 46% vs 41%; p<0.001), longer length of ICU stays (90±162 vs 72±134 hours; p<0.001) and increased levels of organ support. The ICU mortality (aOR 1.50, 95% CI 1.09 to 2.06; p=0.01) was consistently higher in the SHI; however, the 30-day mortality (aOR 0.89, 95% CI 0.66 to 1.21; p=0.47) was similar between THS and SHI. In a sensitivity analysis stratifying for the health economic data, the 30-day mortality was higher in SHI, in low GDP per capita (aOR 2.17, 95% CI 1.42 to 3.58) and low HDI (aOR 1.22, 95% CI 1.64 to 2.20) settings.ConclusionsThe 30-day mortality was similar in both systems. Patients in SHI were older, sicker and frailer at baseline, which could be interpreted as a sign for a more liberal admission policy in SHI. We believe that the observed trend towards ICU excess mortality in SHI results mainly from a more liberal admission policy and an increase in treatment limitations.Trial registration numbersNCT03134807 and NCT03370692.

Comparison of Clinical Characteristics and Outcomes of Younger and Elderly Patients with Severe COVID-19 in Korea: A Retrospective Multicenter Study

“…Hence, some details could have been missing. Third, patients' economic status was not assessed even though inferior economic conditions are associated with poor outcomes [36,37]. Nevertheless, in Korea, the National Health Insurance provides free COVID-19 treatment.…”

The effect of socioeconomic status, insurance status, and insurance coverage benefits on mortality in critically ill patients admitted to the intensive care unit

“…Wernly et al[5] performed a retrospective post-hoc analysis of data from 16 European countries, analyzing critically ill patients >80 years of age admitted to the ICU. They evaluated 4,941 patients with THS and 2,876 with SHI from the previous Very elderly Intensive Patient (VIP)1 and VIP2 studies [5] and found that the associated 30-day mortality rate was similar between both systems; however, patients with SHI were older, sicker, and frailer at baseline. They interpreted their findings as being indicative that a liberal admission policy and an increase in treatment limitations resulted in a trend of ICU excess mortality among patients with SHI [5].In South Korea, Oh et al [6] conducted a retrospective observational study of adults aged >20 years admitted to the ICU.…”

“…They evaluated 4,941 patients with THS and 2,876 with SHI from the previous Very elderly Intensive Patient (VIP)1 and VIP2 studies [5] and found that the associated 30-day mortality rate was similar between both systems; however, patients with SHI were older, sicker, and frailer at baseline. They interpreted their findings as being indicative that a liberal admission policy and an increase in treatment limitations resulted in a trend of ICU excess mortality among patients with SHI [5].In South Korea, Oh et al [6] conducted a retrospective observational study of adults aged >20 years admitted to the ICU. They included 6,008 patients and found that socioeconomic status was not associated with 30-day mortality in the Korean National Health Insurance (NHI) coverage system.…”

“…In Europe, two different health care systems exist, specifically the tax-based health care system (THS) and the social health insurance system (SHI). Wernly et al [ 5 ] performed a retrospective post-hoc analysis of data from 16 European countries, analyzing critically ill patients >80 years of age admitted to the ICU. They evaluated 4,941 patients with THS and 2,876 with SHI from the previous Very elderly Intensive Patient (VIP)1 and VIP2 studies [ 5 ] and found that the associated 30-day mortality rate was similar between both systems; however, patients with SHI were older, sicker, and frailer at baseline.…”

“…They evaluated 4,941 patients with THS and 2,876 with SHI from the previous Very elderly Intensive Patient (VIP)1 and VIP2 studies [ 5 ] and found that the associated 30-day mortality rate was similar between both systems; however, patients with SHI were older, sicker, and frailer at baseline. They interpreted their findings as being indicative that a liberal admission policy and an increase in treatment limitations resulted in a trend of ICU excess mortality among patients with SHI [ 5 ].…”