L. Esserman et al., POTENTIALLY INEFFECTIVE CARE - A NEW OUTCOME TO ASSESS THE LIMITS OF CRITICAL CARE, JAMA, the journal of the American Medical Association, 274(19), 1995, pp. 1544-1551
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.