POTENTIALLY INEFFECTIVE CARE - A NEW OUTCOME TO ASSESS THE LIMITS OF CRITICAL CARE

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 (PIG), deve loped and evaluated a model with an independent data set to predict PI C from a patient's response to treatment, and estimated the economic e ffects of limiting care after a prediction of PIC. Setting.-The combin ed medical and surgical intensive care unit at a 600-bed university te aching hospital. Patients.-Two groups of 402 consecutively admitted cr itical care patients, one from 1989, the other from 1991. Main Outcome Measures and Results.-Based on observations from a two-dimensional pl ot 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 f ell 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 3 7% of PIC outcomes with a specificity of 98%. In a second data set, PI C outcome prediction had a sensitivity of 43% and a specificity of 94% , and a positive predictive value of 80%. For the hospital studied, re duction 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 m illion to $5 million per year. Conclusion.-Patients in the PIC categor y consumed a large portion of the resources devoted to critical care a t an academic teaching hospital. We suggest a change in focus from ass essment of the quality of critical care and risk-adjusted mortality to an assessment of ineffective care based on outcome and resource use a nd a patient's response to treatment over time.