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By Betty Tran, MD, MSc
Assistant Professor of Medicine, Pulmonary and Critical Care Medicine, Rush University Medical Center, Chicago
Dr. Tran reports no financial relationships relevant to this field of study.
SYNOPSIS: The authors of a study randomizing U.S. critical care physicians to analyze hypothetical patient vignettes found that estimates of whether a patient would benefit from ICU care were widely dissimilar among those surveyed and influenced by factors unrelated to severity of illness.
SOURCE: Valley TS, et al. Estimating ICU benefit: A randomized study of physicians. Crit Care Med 2019;47:62-68.
Appropriate allocation of ICU resources is vital for most settings where the demand for ICU beds exceeds the supply. But it is also important to avoid deleterious effects associated with ICU overuse, including higher costs, more iatrogenic complications, and overaggressive care at the end of life.1 Current Society of Critical Care Medicine (SCCM) guidelines recommend that patients be admitted strictly on their potential to benefit from ICU care. However, identifying the benefit of critical care for different patient populations remains elusive.2
Valley et al recruited volunteer members of SCCM to participate in a study which they were randomized to eight online vignettes of hypothetical patients with pneumonia. Each vignette included a randomized single patient factor related to severity of illness (blood pressure, mental status, oxygen requirement, respiratory rate) or hospital factor (patient age, patient race/ethnicity, presence of patient’s family at bedside, number of available ICU beds). Vignettes were designed so that clear indications for ICU admission (e.g., on mechanical ventilation or vasopressors) were avoided. The primary outcome was an estimate of ICU benefit in the form of the question, “Would this patient receive the most benefit from admission to the general ward or the ICU?” A secondary outcome was the difficulty in assessing ICU benefit in the form of the question, “How difficult was this decision for you?” Responses used a 4-point Likert-type scale (e.g., “definitely general ward” to “definitely ICU”). There was a 14% recruitment rate, and 913 physicians ultimately completed all eight vignettes (75% completion rate). The average age of participants was 42 years. Most were male (65%), most were white (61%), and most worked in an academic clinical setting (73.1%) or academic hospital (66.7%). Among physicians reviewing the exact same vignette, there was poor consensus (mean intraclass correlation coefficient, 0.06; standard deviation, 0.08; range, 0-0.18). Greater estimated benefit of ICU care was seen for increasing respiratory rate or oxygen requirement, decreasing blood pressure, and patient confusion. Physicians believed ICU care was more beneficial if they were told one ICU bed was available (compared to ICU bed availability not mentioned). Still, Valley et al observed no difference in estimated ICU benefit if physicians knew that five ICU beds were available.
Physicians believed ICU care was less beneficial if family was present than if family presence was not mentioned and if the patient was younger. Race/ethnicity had no significant effect. Physicians reported it was easier to estimate ICU benefit when the patient was hypotensive, but more difficult when the patient was confused or when the patient’s wife was crying at bedside.
In general, for industrialized countries, for every increase of 100 hospital beds per 100,000 population, there are an extra 3.5 ICU beds.3 However, the United States is an outlier, spending more resources (and more money on healthcare overall) on ICU beds per capita than its counterparts with similar outcomes.3,4 These observations shine a light on ICU overuse and call for ideas to both reduce ICU demand while improving the quality of ICU care.
Although current societal guidelines acknowledge the need to triage ICU admissions based on a number of criteria, including specific patient needs, condition, prognosis, and bed availability, there are no benchmarks to delineate the “potential for the patient to benefit from interventions.”2 Valley et al demonstrated that even among a community of critical care colleagues, there is little consensus that defines which types of patients benefit from ICU admission. Surprisingly, the investigators found that their results conflicted with other studies in that ICU bed availability did not affect ICU admission decisions and that older age did not negatively affect ICU admission. Although the study design was randomized and has been shown to simulate clinical behavior, limitations included a low recruitment rate and sampling biases, as the study participants were more likely to be younger, male, and white compared to the SCCM population as a whole. In addition, one-third of the participants had been in practice for four years or less and one-fifth practiced in surgery or anesthesia, suggesting they may be less experienced treating the patient population presented in the vignettes. Regardless, this study, especially when considered with prior work, demonstrates that clinicians allocate ICU resources inconsistently based on individual patient presentations. Generating a group of explicit “criteria” to allow or deny ICU admission may be impractical, not to mention fraught with ethical and legal concerns over the concept of explicit “rationing” of ICU care. Furthermore, a single set of decision rules would unlikely function well across hospitals in different communities and of varying capabilities.
How can healthcare workers reduce ICU overuse? In an opinion piece, Kahn and Rubenfeld argued for implicit “rationing” through efforts to reduce the relative number of ICU beds. They called for introducing certificate of need laws at the state level to slow growth and incentivizing safe and effective triage by physicians, all with close monitoring to ensure no worsening effects on quality, adverse events, or health disparities.5 Ultimately, it will take thoughtful approaches to slow an unsustainable rate of healthcare consumption in the United States while improving quality of care for patients, regardless of whether they receive it in the ICU.
Internal Medicine Alert’s Physician Editor Stephen Brunton, MD, is a retained consultant for Abbott, Acadia, Allergan, AstraZeneca, Avadel, Boehringer Ingelheim, GlaxoSmithKline, Janssen, Mylan, and Salix; he serves on the speakers bureau of AstraZeneca, Boehringer Ingelheim, Janssen, Lilly, and Novo Nordisk. Peer Reviewer Gerald Roberts, MD; Editor Jonathan Springston; Editorial Group Manager Leslie Coplin; and Accreditations Manager Amy M. Johnson, MSN, RN, CPN, report no financial relationships relevant to this field of study.