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November 15, 1995, Vol 274, No. 19 >
Concepts in Emergency and Critical Care | November 15, 1995

Potentially Ineffective Care: Title and subTitle BreakA New Outcome to Assess the Limits of Critical Care

Laura Esserman, MD, MBA; Jeffrey Belkora, MS; Leslie Lenert, MD, MS
[+] Author Affiliations

Reprint requests to UCSF-Mount Zion Medical Center, Department of Surgery, Box 1610.74, San Francisco, CA 94143-1610.74 (Dr Esserman).


From the Departments of Surgery (Dr Esserman) and Medicine (Dr Lenert), Stanford University School of Medicine; the Department of Engineering Economic Systems, Stanford University (Mr Belkora); and the Stanford University Graduate School of Business (Dr Esserman), Stanford, Calif.


JAMA. 1995;274(19):1544-1551. doi:10.1001/jama.1995.03530190058034
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Article
References

Objective.  —To examine the limits of the effectiveness of critical care through the study of patients for whom it was ineffective.

Design.  —We studied the relationship between resource use and long-term outcome (2-year follow-up) in 402 consecutively admitted critical care patients to develop a benchmark for ineffective applications of critical care. We defined an outcome called potentially ineffective care (PIC), developed and evaluated a model with an independent data set to predict PIC from a patient's response to treatment, and estimated the economic effects of limiting care after a prediction of PIC.

Setting.  —The combined medical and surgical intensive care unit at a 600-bed university teaching hospital.

Patients.  —Two groups of 402 consecutively admitted critical care patients, one from 1989, the other from 1991.

Main Outcome Measures and Results.  —Based on observations from a two-dimensional plot of resource use vs benefit for 402 critical care patients, PIC was defined as resource use in the upper 25th percentile and survival for less than 100 days after discharge. Thirteen percent of the patients fell into the PIC category and used 32% of the resources. A product of the APACHE risk estimates on days 1 and 5 of at least 0.35 predicted 37% of PIC outcomes with a specificity of 98%. In a second data set, PIC outcome prediction had a sensitivity of 43% and a specificity of 94%, and a positive predictive value of 80%. For the hospital studied, reduction of intensity of treatment after a prediction of a PIC outcome would result in a reduction of hospital charges in the range of $1.8 million to $5 million per year.

Conclusion.  —Patients in the PIC category consumed a large portion of the resources devoted to critical care at an academic teaching hospital. We suggest a change in focus from assessment of the quality of critical care and risk-adjusted mortality to an assessment of ineffective care based on outcome and resource use and a patient's response to treatment over time.(JAMA. 1995;274:1544-1551)

REFERENCES

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Raffin TA, Shurkin JN, Sinkler WIII. Intensive Care: Facing the Critical Choices . New York, NY: WH Freeman & Co; 1988;.
2 +
Oye RK, Bellamy PE.  Patterns of resource consumption in medical intensive care. Chest . 1991;;99: 685-689.
3 +
Schapira DV, Studnicki J, Bradham DD, Wolff P, Jarrett A.  Intensive care, survival, and expense of treating critically ill cancer patients. JAMA . 1993;; 269:783-786.
4 +
Wachter RM, Luce JM, Hopewell PC.  Critical care of patients with AIDS. JAMA . 1992;;267:541-547.
5 +
Cohen IL, Lambrinos J, Fein IA.  Mechanical ventilation for the elderly patient in intensive care. JAMA . 1993;;269:1025-1029.
6 +
Knaus WA, Harrell FE, Lynne J, Goldman L, Phillips RS.  The SUPPORT prognostic model: objective estimates of survival for seriously ill hospitalized adults. Ann Intern Med . 1995;;122:191-203.
7 +
Rutledge R, Fakhry S, Rutherford E, Muakkassa F, Meyer A.  Comparison of APACHE II, Trauma Score, and Injury Severity Score as predictors of outcome in critically injured trauma patients. Am J Surg . 1993;;166:244-247.
8 +
McAnena OJ, Moore FA, Moore EE, Mattox KL, Marx JA, Pepe P.  Invalidation of the APACHE II scoring system for patients with acute trauma. J Trauma . 1992;;33:504-506.
9 +
Cheadle WG, Wilson M, Hershman MJ, Bergamini D, Richardson JD, Polk HJ.  Comparison of trauma assessment scores and their use in prediction of infection and death. Ann Surg . 1989;;209: 541-545.
10 +
Murray LS, Teasdale GM, Murray GD, et al.  Does prediction of outcome alter patient management? Lancet . 1993;;341:1487-1491.
11 +
Knaus WA, Draper EA, Wager DP, Zimmerman JE.  APACHE II: a severity of disease classification system. Crit Care Med . 1985;;13:818-829.
12 +
Chang RW, Jacobs S, Lee B, Pace N.  Predicting deaths among intensive care unit patients. Crit Care Med . 1988;;16:34-42.
13 +
Chang RW.  Individual outcome prediction models for intensive care units. Lancet . 1989;;2:143-146.
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Atkinson S, Mason R, Biari D.  Assessment of the Riyadh intensive care program in predicting fatal outcome in the intensive care unit. Crit Care Med . 1994;;22:A41.
15 +
Knaus WA, Wagner DP, Draper EA, et al.  The APACHE III prognostic system: risk prediction of hospital mortality for critically ill hospitalized adults. Chest . 1991;;100:1619-1636.
16 +
Knaus WA, Wagner DP, Lynn J.  Short-term mortality predictions for critically ill hospitalized adults: science and ethics. Science . 1991;;254:389-394.
17 +
Research TFMGoI.  Factors related to outcome in intensive care: French multicenter study. Crit Care Med . 1989;;17:305-308.
18 +
Le Gall JR, Lemeshow S, Saulnier F.  A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. JAMA . 1993;;270:2957-2963.
19 +
Knaus WA, Wagner DP, Zimmerman JE, Draper EA.  Variations in mortality and length of stay in intensive care units. Ann Intern Med . 1993;; 118:753-761.
20 +
Civetta JM, Hudson-Civetta J, Kirton O, Aragon C, Salas C.  Further appraisal of APACHE II limitations and potential. Surg Gynecol Obstet . 1992;; 175:195-203.
21 +
Detsky AS, Stricker SC, Mulley AG, Thibault GE.  Prognosis, survival, and the expenditure of hospital resources for patients in an intensive-care unit. N Engl J Med . 1981;;305:667-672.
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Civetta JM.  Determination of survival in the ICU.  In: Wilmore DW et al, eds. Care of the Surgical Patient: Care in the ICU . New York, NY: Scientific American Library; 1991;;2:1-14.
23 +
Bierman H, Bonini C, Hausman WH. Quantitative Analysis for Business Decisions . 8th ed. Homewood, Ill: RD Irwin Inc; 1991;.
24 +
Norton R.  Which offices or stores really perform best? a new tool tells. Fortune . (October 31) , 1994;;130:38.
25 +
Letsch SW, Maple BT, Cowan CA, Donham CS.  Health care indicators. Health Care Financ Rev . 1991;;13:129-153.
26 +
Rosner B. Fundamentals of Biostatistics . Boston, Mass: Duxbury Press; 1982;.
27 +
Breiman L, Freidman J, Olshen R, Stone C. Classification and Regression Trees . Monterey, Calif: Wadsworth & Brooks/Cole Advanced Books and Software; 1984;.
28 +
Dawson NW, Younger SJ, Connors AF.  Phase II: influencing decision making in SUPPORT. J Clin Epidemiol . 1990;;43( (suppl) ):1035-1085.
29 +
Garber AM, Fuch VR, Silverman JF.  Case mix, costs, and outcomes: differences between faculty and community services in a university hospital. N Engl J Med . 1984;;310:1231-1237.
30 +
Borlase BC, Baxter JT, Benotti PN, et al.  Surgical intensive care unit resource use in a specialty referral hospital. Surgery . 1990;;109:687-693.
31 +
Civetta JM, Hudson JA, Nelson LD.  Evaluation of APACHE II for cost containment and quality assurance. Ann Surg . 1990;;212:266-276.
32 +
Lemeshow S, Teres D, Avrunin JS, Gage RW.  Refining intensive care unit outcome prediction by changing probabilities of mortality. Crit Care Med . 1988;;16:470-477.
33 +
Robbins RA, Linder J, Stahl MG, et al.  Diffuse alveolar hemorrhage in autologous bone marrow transplant recipients. Am J Med . 1989;;87:511-518.
34 +
Crawford SW, Petersen FB.  Long-term survival from respiratory failure after marrow transplantation for malignancy. Am Rev Respir Dis . 1992;; 145:510-514.
35 +
Lantos JD, Singer PA, Walker RM, et al.  The illusion of futility in clinical practice. Am J Med . 1989;;87:81-84.
36 +
Rauss A, Knaus WA, Patois E, Le Gall JR, Loirat P.  Prognosis for recovery from multiple organ system failure: the accuracy of objective estimates of chances for survival. Med Decis Making . 1990;;10:155-162.
37 +
Danis M, Patrick DL, Southerland LI, Green ML.  Patients' and families' preferences for medical intensive care. JAMA . 1988;;260:797-802.
38 +
Ende J, Kazis L, Ash A, Moskowitz M.  Measuring patients' desire for autonomy: decision-making and information-seeking preferences among medical patients. J Gen Intern Med . 1989;;4:23-30.
39 +
Lidz CW, Meisel A.  Informed consent and the structure of medical care.  In: Making Healthcare Decisions: The Ethical and Legal Implications of Informed Consent in the Patient-Practitioner Relationship . Washington, DC: President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research; 1982;;2: 317-410.
40 +
Imbus SH, Zawacki BE.  Autonomy for burned patients when survival is unprecedented. N Engl J Med . 1977;;279:308-311.
41 +
Feller I, Tholen D, Cornell RG.  Improvements in burn care 1965 to 1979. JAMA . 1980;;224:2074-2078.
42 +
Rosenthal G, Harper D.  Cleveland Health Quality Choice: a model for collaborative community-based outcomes assessment. J Qual Improvement . 1994;;20:425-442.
43 +
Berwick DM.  Continuous improvement as an ideal in health care. N Engl J Med . 1989;;320:53-56.
44 +
Charlson M, Sax F, MacKenzie R, Braham R, Fields S, Douglas JRG.  Morbidity during hospitalization: can we predict it? J Chronic Dis . 1987;;40: 705-712.

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Raffin TA, Shurkin JN, Sinkler WIII. Intensive Care: Facing the Critical Choices . New York, NY: WH Freeman & Co; 1988;.
2 +
Oye RK, Bellamy PE.  Patterns of resource consumption in medical intensive care. Chest . 1991;;99: 685-689.
3 +
Schapira DV, Studnicki J, Bradham DD, Wolff P, Jarrett A.  Intensive care, survival, and expense of treating critically ill cancer patients. JAMA . 1993;; 269:783-786.
4 +
Wachter RM, Luce JM, Hopewell PC.  Critical care of patients with AIDS. JAMA . 1992;;267:541-547.
5 +
Cohen IL, Lambrinos J, Fein IA.  Mechanical ventilation for the elderly patient in intensive care. JAMA . 1993;;269:1025-1029.
6 +
Knaus WA, Harrell FE, Lynne J, Goldman L, Phillips RS.  The SUPPORT prognostic model: objective estimates of survival for seriously ill hospitalized adults. Ann Intern Med . 1995;;122:191-203.
7 +
Rutledge R, Fakhry S, Rutherford E, Muakkassa F, Meyer A.  Comparison of APACHE II, Trauma Score, and Injury Severity Score as predictors of outcome in critically injured trauma patients. Am J Surg . 1993;;166:244-247.
8 +
McAnena OJ, Moore FA, Moore EE, Mattox KL, Marx JA, Pepe P.  Invalidation of the APACHE II scoring system for patients with acute trauma. J Trauma . 1992;;33:504-506.
9 +
Cheadle WG, Wilson M, Hershman MJ, Bergamini D, Richardson JD, Polk HJ.  Comparison of trauma assessment scores and their use in prediction of infection and death. Ann Surg . 1989;;209: 541-545.
10 +
Murray LS, Teasdale GM, Murray GD, et al.  Does prediction of outcome alter patient management? Lancet . 1993;;341:1487-1491.
11 +
Knaus WA, Draper EA, Wager DP, Zimmerman JE.  APACHE II: a severity of disease classification system. Crit Care Med . 1985;;13:818-829.
12 +
Chang RW, Jacobs S, Lee B, Pace N.  Predicting deaths among intensive care unit patients. Crit Care Med . 1988;;16:34-42.
13 +
Chang RW.  Individual outcome prediction models for intensive care units. Lancet . 1989;;2:143-146.
14 +
Atkinson S, Mason R, Biari D.  Assessment of the Riyadh intensive care program in predicting fatal outcome in the intensive care unit. Crit Care Med . 1994;;22:A41.
15 +
Knaus WA, Wagner DP, Draper EA, et al.  The APACHE III prognostic system: risk prediction of hospital mortality for critically ill hospitalized adults. Chest . 1991;;100:1619-1636.
16 +
Knaus WA, Wagner DP, Lynn J.  Short-term mortality predictions for critically ill hospitalized adults: science and ethics. Science . 1991;;254:389-394.
17 +
Research TFMGoI.  Factors related to outcome in intensive care: French multicenter study. Crit Care Med . 1989;;17:305-308.
18 +
Le Gall JR, Lemeshow S, Saulnier F.  A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. JAMA . 1993;;270:2957-2963.
19 +
Knaus WA, Wagner DP, Zimmerman JE, Draper EA.  Variations in mortality and length of stay in intensive care units. Ann Intern Med . 1993;; 118:753-761.
20 +
Civetta JM, Hudson-Civetta J, Kirton O, Aragon C, Salas C.  Further appraisal of APACHE II limitations and potential. Surg Gynecol Obstet . 1992;; 175:195-203.
21 +
Detsky AS, Stricker SC, Mulley AG, Thibault GE.  Prognosis, survival, and the expenditure of hospital resources for patients in an intensive-care unit. N Engl J Med . 1981;;305:667-672.
22 +
Civetta JM.  Determination of survival in the ICU.  In: Wilmore DW et al, eds. Care of the Surgical Patient: Care in the ICU . New York, NY: Scientific American Library; 1991;;2:1-14.
23 +
Bierman H, Bonini C, Hausman WH. Quantitative Analysis for Business Decisions . 8th ed. Homewood, Ill: RD Irwin Inc; 1991;.
24 +
Norton R.  Which offices or stores really perform best? a new tool tells. Fortune . (October 31) , 1994;;130:38.
25 +
Letsch SW, Maple BT, Cowan CA, Donham CS.  Health care indicators. Health Care Financ Rev . 1991;;13:129-153.
26 +
Rosner B. Fundamentals of Biostatistics . Boston, Mass: Duxbury Press; 1982;.
27 +
Breiman L, Freidman J, Olshen R, Stone C. Classification and Regression Trees . Monterey, Calif: Wadsworth & Brooks/Cole Advanced Books and Software; 1984;.
28 +
Dawson NW, Younger SJ, Connors AF.  Phase II: influencing decision making in SUPPORT. J Clin Epidemiol . 1990;;43( (suppl) ):1035-1085.
29 +
Garber AM, Fuch VR, Silverman JF.  Case mix, costs, and outcomes: differences between faculty and community services in a university hospital. N Engl J Med . 1984;;310:1231-1237.
30 +
Borlase BC, Baxter JT, Benotti PN, et al.  Surgical intensive care unit resource use in a specialty referral hospital. Surgery . 1990;;109:687-693.
31 +
Civetta JM, Hudson JA, Nelson LD.  Evaluation of APACHE II for cost containment and quality assurance. Ann Surg . 1990;;212:266-276.
32 +
Lemeshow S, Teres D, Avrunin JS, Gage RW.  Refining intensive care unit outcome prediction by changing probabilities of mortality. Crit Care Med . 1988;;16:470-477.
33 +
Robbins RA, Linder J, Stahl MG, et al.  Diffuse alveolar hemorrhage in autologous bone marrow transplant recipients. Am J Med . 1989;;87:511-518.
34 +
Crawford SW, Petersen FB.  Long-term survival from respiratory failure after marrow transplantation for malignancy. Am Rev Respir Dis . 1992;; 145:510-514.
35 +
Lantos JD, Singer PA, Walker RM, et al.  The illusion of futility in clinical practice. Am J Med . 1989;;87:81-84.
36 +
Rauss A, Knaus WA, Patois E, Le Gall JR, Loirat P.  Prognosis for recovery from multiple organ system failure: the accuracy of objective estimates of chances for survival. Med Decis Making . 1990;;10:155-162.
37 +
Danis M, Patrick DL, Southerland LI, Green ML.  Patients' and families' preferences for medical intensive care. JAMA . 1988;;260:797-802.
38 +
Ende J, Kazis L, Ash A, Moskowitz M.  Measuring patients' desire for autonomy: decision-making and information-seeking preferences among medical patients. J Gen Intern Med . 1989;;4:23-30.
39 +
Lidz CW, Meisel A.  Informed consent and the structure of medical care.  In: Making Healthcare Decisions: The Ethical and Legal Implications of Informed Consent in the Patient-Practitioner Relationship . Washington, DC: President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research; 1982;;2: 317-410.
40 +
Imbus SH, Zawacki BE.  Autonomy for burned patients when survival is unprecedented. N Engl J Med . 1977;;279:308-311.
41 +
Feller I, Tholen D, Cornell RG.  Improvements in burn care 1965 to 1979. JAMA . 1980;;224:2074-2078.
42 +
Rosenthal G, Harper D.  Cleveland Health Quality Choice: a model for collaborative community-based outcomes assessment. J Qual Improvement . 1994;;20:425-442.
43 +
Berwick DM.  Continuous improvement as an ideal in health care. N Engl J Med . 1989;;320:53-56.
44 +
Charlson M, Sax F, MacKenzie R, Braham R, Fields S, Douglas JRG.  Morbidity during hospitalization: can we predict it? J Chronic Dis . 1987;;40: 705-712.

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