Topic: Retrospective or Prospective Cohort Study or Case Series
D'Egidio, Gianni1; Kyeremanteng, Kwadwo1; Neilipovitz, David1; Schouela, Nicholas2
1Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Canada; 2Department of Emergency Medicine, University of Ottawa, Ottawa, Canada
Introduction
Critical care involves the ability to invasively treat and monitor patients with life-threatening illness. However, it is also a finite resource that not every patient condition will benefit from, and costs on average 3 times more per day than a general ward [1]. There are some health states that critical care should not be used to perpetuate, such as when there is no hope of recovery, the patient will not benefit, or it may cause harm. Situations such as those described here are considered non-beneficial, inappropriate or futile care [2,3,4]. These can be difficult and divisive topics to address, and there may be instances when physicians and patients or their substitute decision makers disagree despite all efforts at communication and second opinions. These situations can potentially lead to the delivery of non-beneficial care. Physicians may consider an application to the Consent and Capacity Board of Ontario (CCB) when they believe care is inappropriate. There are few studies that have looked at the frequency or cost of non-beneficial intensive care [5,6,7], none of which are Canadian.
Objectives
In this case series we describe the hospital length of stay (LOS), intensive care unit (ICU) LOS, cost, and long-term outcomes of 12 cases that have been, or were considered for, adjudication by the CCB.
Methods
A single centre chart review was undertaken to identify patients admitted to the ICU, where critical care was considered non-beneficial, and in which their cases were considered for or brought before the CCB. Costs for each of these admissions were determined using the case-costing system of The Ottawa Hospital Data Warehouse, a standardized methodology developed by the Ontario Case Costing Initiative [8]. These costs were then broken down into “direct” and “indirect” components. Direct costs included all expenses to the hospital through fee codes linked to the patient chart, including salaries, equipment, and materials. Indirect costs included any overhead operational fees associated with the service being provided to the patient. Costs were then indexed using consumer price indices, as performed previously [9,10,11].
Results
Twelve patients were selected as a case series for economic analysis of their hospital admission. The median age at the time of admission was 83.5. All 12 patients had a LOS at greater than 120 days, with the longest being 704 days. No patient included in the study was discharged to an independent living situation. Seven patients died in hospital, while 5 were transferred. Two of the transferred patients went to long term care facilities, while the other 3 were sent to other hospitals where they ultimately died. The mean direct costs were $500,000 (total: $6,001,000) and average indirect costs were $158,000 (total: $1,896,000), equating to a total cost of $7,897,000 for the 12 selected patients.
Conclusion
There is a significant economic cost to providing resource-intensive critical care to patients in which these treatments are considered non-beneficial. Allowing patients and families to decide which complex treatments are appropriate would be an unfair use of healthcare resources. We as clinicians should carefully consider the allocation of these valuable and finite resources in order to utilize them in a way that actually benefits patients.
- Canadian Institute for Health Information, Care in Canadian ICUs, Canadian Institute for Health Information, Toronto, ON, Canada, 2016.
- Downar J, You JJ, Bagshaw SM, et al. Nonbeneficial treatment Canada: definitions, causes, and potential solutions from the perspective of healthcare practitioners*. Crit Care Med2015;43:270–81.
- Wilkinson D, Savulescu J. Knowing when to stop: futility in the intensive care unit. Current opinion in anaesthesiology 2011;24:160–5.
- Bosslet GT, Pope TM, Rubenfeld GD, et al. An Official ATS/AACN/ACCP/ESICM/SCCM Policy Statement: Responding to Requests for Potentially Inappropriate Treatments in Intensive Care Units. Am J Respir Crit Care Med 2015;191:1318–30.
- Huynh TN, Kleerup EC, Wiley JF, et al. The frequency and cost of treatment perceived to be futile in critical care. JAMA Intern Med2013;173:1887–94.
- Carter HE, Winch S, Barnett AG et al. Incidence, duration and cost of futile treatment in end-of-life hospital admissions to three Australian public-sector tertiary hospitals: a retrospective multicentre cohort study. BMJ Open. 2017;7(10):e017661.
- Sachdeva RC, Jefferson LS, Coss-Bu J, et al. Resource consumption and the extent of futile care among patients in a pediatric intensive care unit setting. J Pediatr 1996;128:742–7.
- Ronksley PE, McKay JA, Kobewka DM, et al: Patterns of health care use in a high-cost inpatient population in Ottawa, Ontario: A retrospective observational study. CMAJ Open 2015; 3:E111–E118
- Kyeremanteng K, Wan C, D'Egidio G, et al: Approach to economic analysis in critical care. J Crit Care 2016; 36:92–96
- Chin-Yee N, D'Egidio G, Thavorn K, et al: Cost analysis of the very elderly admitted to intensive care units. Crit Care 2017; 21:109
- Chaudhuri D, Tanuseputro P, Herritt B, et al: Critical care at the end of life: A population-level cohort study of cost and outcomes. Crit Care 2017; 21:124
Topic: Retrospective or Prospective Cohort Study or Case Series
D'Egidio, Gianni1; Kyeremanteng, Kwadwo1; Neilipovitz, David1; Schouela, Nicholas2
1Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Canada; 2Department of Emergency Medicine, University of Ottawa, Ottawa, Canada
Introduction
Critical care involves the ability to invasively treat and monitor patients with life-threatening illness. However, it is also a finite resource that not every patient condition will benefit from, and costs on average 3 times more per day than a general ward [1]. There are some health states that critical care should not be used to perpetuate, such as when there is no hope of recovery, the patient will not benefit, or it may cause harm. Situations such as those described here are considered non-beneficial, inappropriate or futile care [2,3,4]. These can be difficult and divisive topics to address, and there may be instances when physicians and patients or their substitute decision makers disagree despite all efforts at communication and second opinions. These situations can potentially lead to the delivery of non-beneficial care. Physicians may consider an application to the Consent and Capacity Board of Ontario (CCB) when they believe care is inappropriate. There are few studies that have looked at the frequency or cost of non-beneficial intensive care [5,6,7], none of which are Canadian.
Objectives
In this case series we describe the hospital length of stay (LOS), intensive care unit (ICU) LOS, cost, and long-term outcomes of 12 cases that have been, or were considered for, adjudication by the CCB.
Methods
A single centre chart review was undertaken to identify patients admitted to the ICU, where critical care was considered non-beneficial, and in which their cases were considered for or brought before the CCB. Costs for each of these admissions were determined using the case-costing system of The Ottawa Hospital Data Warehouse, a standardized methodology developed by the Ontario Case Costing Initiative [8]. These costs were then broken down into “direct” and “indirect” components. Direct costs included all expenses to the hospital through fee codes linked to the patient chart, including salaries, equipment, and materials. Indirect costs included any overhead operational fees associated with the service being provided to the patient. Costs were then indexed using consumer price indices, as performed previously [9,10,11].
Results
Twelve patients were selected as a case series for economic analysis of their hospital admission. The median age at the time of admission was 83.5. All 12 patients had a LOS at greater than 120 days, with the longest being 704 days. No patient included in the study was discharged to an independent living situation. Seven patients died in hospital, while 5 were transferred. Two of the transferred patients went to long term care facilities, while the other 3 were sent to other hospitals where they ultimately died. The mean direct costs were $500,000 (total: $6,001,000) and average indirect costs were $158,000 (total: $1,896,000), equating to a total cost of $7,897,000 for the 12 selected patients.
Conclusion
There is a significant economic cost to providing resource-intensive critical care to patients in which these treatments are considered non-beneficial. Allowing patients and families to decide which complex treatments are appropriate would be an unfair use of healthcare resources. We as clinicians should carefully consider the allocation of these valuable and finite resources in order to utilize them in a way that actually benefits patients.
- Canadian Institute for Health Information, Care in Canadian ICUs, Canadian Institute for Health Information, Toronto, ON, Canada, 2016.
- Downar J, You JJ, Bagshaw SM, et al. Nonbeneficial treatment Canada: definitions, causes, and potential solutions from the perspective of healthcare practitioners*. Crit Care Med2015;43:270–81.
- Wilkinson D, Savulescu J. Knowing when to stop: futility in the intensive care unit. Current opinion in anaesthesiology 2011;24:160–5.
- Bosslet GT, Pope TM, Rubenfeld GD, et al. An Official ATS/AACN/ACCP/ESICM/SCCM Policy Statement: Responding to Requests for Potentially Inappropriate Treatments in Intensive Care Units. Am J Respir Crit Care Med 2015;191:1318–30.
- Huynh TN, Kleerup EC, Wiley JF, et al. The frequency and cost of treatment perceived to be futile in critical care. JAMA Intern Med2013;173:1887–94.
- Carter HE, Winch S, Barnett AG et al. Incidence, duration and cost of futile treatment in end-of-life hospital admissions to three Australian public-sector tertiary hospitals: a retrospective multicentre cohort study. BMJ Open. 2017;7(10):e017661.
- Sachdeva RC, Jefferson LS, Coss-Bu J, et al. Resource consumption and the extent of futile care among patients in a pediatric intensive care unit setting. J Pediatr 1996;128:742–7.
- Ronksley PE, McKay JA, Kobewka DM, et al: Patterns of health care use in a high-cost inpatient population in Ottawa, Ontario: A retrospective observational study. CMAJ Open 2015; 3:E111–E118
- Kyeremanteng K, Wan C, D'Egidio G, et al: Approach to economic analysis in critical care. J Crit Care 2016; 36:92–96
- Chin-Yee N, D'Egidio G, Thavorn K, et al: Cost analysis of the very elderly admitted to intensive care units. Crit Care 2017; 21:109
- Chaudhuri D, Tanuseputro P, Herritt B, et al: Critical care at the end of life: A population-level cohort study of cost and outcomes. Crit Care 2017; 21:124
University of Ottawa
Topic: Retrospective or Prospective Cohort Study or Case Series
D'Egidio, Gianni1; Kyeremanteng, Kwadwo1; Neilipovitz, David1; Schouela, Nicholas2
1Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Canada; 2Department of Emergency Medicine, University of Ottawa, Ottawa, Canada
Introduction
Critical care involves the ability to invasively treat and monitor patients with life-threatening illness. However, it is also a finite resource that not every patient condition will benefit from, and costs on average 3 times more per day than a general ward [1]. There are some health states that critical care should not be used to perpetuate, such as when there is no hope of recovery, the patient will not benefit, or it may cause harm. Situations such as those described here are considered non-beneficial, inappropriate or futile care [2,3,4]. These can be difficult and divisive topics to address, and there may be instances when physicians and patients or their substitute decision makers disagree despite all efforts at communication and second opinions. These situations can potentially lead to the delivery of non-beneficial care. Physicians may consider an application to the Consent and Capacity Board of Ontario (CCB) when they believe care is inappropriate. There are few studies that have looked at the frequency or cost of non-beneficial intensive care [5,6,7], none of which are Canadian.
Objectives
In this case series we describe the hospital length of stay (LOS), intensive care unit (ICU) LOS, cost, and long-term outcomes of 12 cases that have been, or were considered for, adjudication by the CCB.
Methods
A single centre chart review was undertaken to identify patients admitted to the ICU, where critical care was considered non-beneficial, and in which their cases were considered for or brought before the CCB. Costs for each of these admissions were determined using the case-costing system of The Ottawa Hospital Data Warehouse, a standardized methodology developed by the Ontario Case Costing Initiative [8]. These costs were then broken down into “direct” and “indirect” components. Direct costs included all expenses to the hospital through fee codes linked to the patient chart, including salaries, equipment, and materials. Indirect costs included any overhead operational fees associated with the service being provided to the patient. Costs were then indexed using consumer price indices, as performed previously [9,10,11].
Results
Twelve patients were selected as a case series for economic analysis of their hospital admission. The median age at the time of admission was 83.5. All 12 patients had a LOS at greater than 120 days, with the longest being 704 days. No patient included in the study was discharged to an independent living situation. Seven patients died in hospital, while 5 were transferred. Two of the transferred patients went to long term care facilities, while the other 3 were sent to other hospitals where they ultimately died. The mean direct costs were $500,000 (total: $6,001,000) and average indirect costs were $158,000 (total: $1,896,000), equating to a total cost of $7,897,000 for the 12 selected patients.
Conclusion
There is a significant economic cost to providing resource-intensive critical care to patients in which these treatments are considered non-beneficial. Allowing patients and families to decide which complex treatments are appropriate would be an unfair use of healthcare resources. We as clinicians should carefully consider the allocation of these valuable and finite resources in order to utilize them in a way that actually benefits patients.
- Canadian Institute for Health Information, Care in Canadian ICUs, Canadian Institute for Health Information, Toronto, ON, Canada, 2016.
- Downar J, You JJ, Bagshaw SM, et al. Nonbeneficial treatment Canada: definitions, causes, and potential solutions from the perspective of healthcare practitioners*. Crit Care Med2015;43:270–81.
- Wilkinson D, Savulescu J. Knowing when to stop: futility in the intensive care unit. Current opinion in anaesthesiology 2011;24:160–5.
- Bosslet GT, Pope TM, Rubenfeld GD, et al. An Official ATS/AACN/ACCP/ESICM/SCCM Policy Statement: Responding to Requests for Potentially Inappropriate Treatments in Intensive Care Units. Am J Respir Crit Care Med 2015;191:1318–30.
- Huynh TN, Kleerup EC, Wiley JF, et al. The frequency and cost of treatment perceived to be futile in critical care. JAMA Intern Med2013;173:1887–94.
- Carter HE, Winch S, Barnett AG et al. Incidence, duration and cost of futile treatment in end-of-life hospital admissions to three Australian public-sector tertiary hospitals: a retrospective multicentre cohort study. BMJ Open. 2017;7(10):e017661.
- Sachdeva RC, Jefferson LS, Coss-Bu J, et al. Resource consumption and the extent of futile care among patients in a pediatric intensive care unit setting. J Pediatr 1996;128:742–7.
- Ronksley PE, McKay JA, Kobewka DM, et al: Patterns of health care use in a high-cost inpatient population in Ottawa, Ontario: A retrospective observational study. CMAJ Open 2015; 3:E111–E118
- Kyeremanteng K, Wan C, D'Egidio G, et al: Approach to economic analysis in critical care. J Crit Care 2016; 36:92–96
- Chin-Yee N, D'Egidio G, Thavorn K, et al: Cost analysis of the very elderly admitted to intensive care units. Crit Care 2017; 21:109
- Chaudhuri D, Tanuseputro P, Herritt B, et al: Critical care at the end of life: A population-level cohort study of cost and outcomes. Crit Care 2017; 21:124
Topic: Retrospective or Prospective Cohort Study or Case Series
D'Egidio, Gianni1; Kyeremanteng, Kwadwo1; Neilipovitz, David1; Schouela, Nicholas2
1Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Canada; 2Department of Emergency Medicine, University of Ottawa, Ottawa, Canada
Introduction
Critical care involves the ability to invasively treat and monitor patients with life-threatening illness. However, it is also a finite resource that not every patient condition will benefit from, and costs on average 3 times more per day than a general ward [1]. There are some health states that critical care should not be used to perpetuate, such as when there is no hope of recovery, the patient will not benefit, or it may cause harm. Situations such as those described here are considered non-beneficial, inappropriate or futile care [2,3,4]. These can be difficult and divisive topics to address, and there may be instances when physicians and patients or their substitute decision makers disagree despite all efforts at communication and second opinions. These situations can potentially lead to the delivery of non-beneficial care. Physicians may consider an application to the Consent and Capacity Board of Ontario (CCB) when they believe care is inappropriate. There are few studies that have looked at the frequency or cost of non-beneficial intensive care [5,6,7], none of which are Canadian.
Objectives
In this case series we describe the hospital length of stay (LOS), intensive care unit (ICU) LOS, cost, and long-term outcomes of 12 cases that have been, or were considered for, adjudication by the CCB.
Methods
A single centre chart review was undertaken to identify patients admitted to the ICU, where critical care was considered non-beneficial, and in which their cases were considered for or brought before the CCB. Costs for each of these admissions were determined using the case-costing system of The Ottawa Hospital Data Warehouse, a standardized methodology developed by the Ontario Case Costing Initiative [8]. These costs were then broken down into “direct” and “indirect” components. Direct costs included all expenses to the hospital through fee codes linked to the patient chart, including salaries, equipment, and materials. Indirect costs included any overhead operational fees associated with the service being provided to the patient. Costs were then indexed using consumer price indices, as performed previously [9,10,11].
Results
Twelve patients were selected as a case series for economic analysis of their hospital admission. The median age at the time of admission was 83.5. All 12 patients had a LOS at greater than 120 days, with the longest being 704 days. No patient included in the study was discharged to an independent living situation. Seven patients died in hospital, while 5 were transferred. Two of the transferred patients went to long term care facilities, while the other 3 were sent to other hospitals where they ultimately died. The mean direct costs were $500,000 (total: $6,001,000) and average indirect costs were $158,000 (total: $1,896,000), equating to a total cost of $7,897,000 for the 12 selected patients.
Conclusion
There is a significant economic cost to providing resource-intensive critical care to patients in which these treatments are considered non-beneficial. Allowing patients and families to decide which complex treatments are appropriate would be an unfair use of healthcare resources. We as clinicians should carefully consider the allocation of these valuable and finite resources in order to utilize them in a way that actually benefits patients.
- Canadian Institute for Health Information, Care in Canadian ICUs, Canadian Institute for Health Information, Toronto, ON, Canada, 2016.
- Downar J, You JJ, Bagshaw SM, et al. Nonbeneficial treatment Canada: definitions, causes, and potential solutions from the perspective of healthcare practitioners*. Crit Care Med2015;43:270–81.
- Wilkinson D, Savulescu J. Knowing when to stop: futility in the intensive care unit. Current opinion in anaesthesiology 2011;24:160–5.
- Bosslet GT, Pope TM, Rubenfeld GD, et al. An Official ATS/AACN/ACCP/ESICM/SCCM Policy Statement: Responding to Requests for Potentially Inappropriate Treatments in Intensive Care Units. Am J Respir Crit Care Med 2015;191:1318–30.
- Huynh TN, Kleerup EC, Wiley JF, et al. The frequency and cost of treatment perceived to be futile in critical care. JAMA Intern Med2013;173:1887–94.
- Carter HE, Winch S, Barnett AG et al. Incidence, duration and cost of futile treatment in end-of-life hospital admissions to three Australian public-sector tertiary hospitals: a retrospective multicentre cohort study. BMJ Open. 2017;7(10):e017661.
- Sachdeva RC, Jefferson LS, Coss-Bu J, et al. Resource consumption and the extent of futile care among patients in a pediatric intensive care unit setting. J Pediatr 1996;128:742–7.
- Ronksley PE, McKay JA, Kobewka DM, et al: Patterns of health care use in a high-cost inpatient population in Ottawa, Ontario: A retrospective observational study. CMAJ Open 2015; 3:E111–E118
- Kyeremanteng K, Wan C, D'Egidio G, et al: Approach to economic analysis in critical care. J Crit Care 2016; 36:92–96
- Chin-Yee N, D'Egidio G, Thavorn K, et al: Cost analysis of the very elderly admitted to intensive care units. Crit Care 2017; 21:109
- Chaudhuri D, Tanuseputro P, Herritt B, et al: Critical care at the end of life: A population-level cohort study of cost and outcomes. Crit Care 2017; 21:124
