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Implications of ICU triage decisions on patient mortality: a cost-effectiveness analysis

David L Edbrooke12, Cosetta Minelli23, Gary H Mills24*, Gaetano Iapichino5, Angelo Pezzi5, Davide Corbella5, Philip Jacobs6, Anne Lippert7, Joergen Wiis7, Antonio Pesenti8, Nicolo Patroniti8, Romain Pirracchio9, Didier Payen9, Gabriel Gurman10, Jan Bakker11, Jozef Kesecioglu12, Chris Hargreaves13, Simon L Cohen14, Mario Baras15, Antonio Artigas16 and Charles L Sprung17

Author Affiliations

1 Faculty of Health and Wellbeing, Sheffield Hallam University, City Campus, Howard Street, Sheffield, S1 1WB, UK

2 Medical and Economics Research Centre (MERCS) Sheffield, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Trust, Glossop Road, Sheffield S10 2JF, UK

3 EURAC research, Viale Druso 1, 39100, Bolzano, Italy

4 Critical Care, Anaesthesia and Operating Services, and Medical and Economics Research Centre (MERCS), Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Trust, Glossop Road, Sheffield, S10 2JF, UK

5 Istituto di Anestesiologia e Rianimazione, Universita degli Studi di Milano, UO Anestesia e Rianimazione, Polo Universitario San Paolo via Di Rudini, 20142, Milano, Italy

6 Collaborations, Institute of Health Economics and Department of Medicine. University of Alberta, 1200 10405 Jasper Avenue, Edmonton, Alberta, T5J 3N4, Canada

7 Department of Anaesthesia, Herlev University Hospital, Herlev Ringvej 75, 2730 Herlev, Copenhagen, Denmark

8 San Gerardo Hospital, Università degli Studi Milano-Bicocca, Monza, Italy

9 Department of Anaesthesia, Lariboisiere Hospital, Rue Ambroise Pare 2, 75475, Paris, France

10 Soroka Medical Centre, Ben Gurion University of the Negev, Beer Sheva, 84141, Israel

11 Isala Hospital, GM Zwolle, 8000, Netherlands

12 University Medical Centre, Heidelberglaan 100, 3584CX, Utrecht, Netherlands

13 Intensive Care Unit, Whittington Hospital NHS Trust, London N19 5NF, UK

14 University College Hospital, Euston Rd, London, NW1 2BU, UK

15 The Hebrew University, Haddasah School of Public Health, Haddasah Medical Centre, Jerusalem, 91120, Israel

16 Critical Care Center Sabadell Hospital, CIBER Enfermedades Respiratorias, Corporacio Sanataria Parc Tauli, 08208, Sabadell, Spain

17 Department of Anesthesiology and Critical Care, Hadassah Hebrew University Medical Centre, Jerusalem, 91120, Israel

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Critical Care 2011, 15:R56  doi:10.1186/cc10029

Published: 9 February 2011

Abstract

Introduction

Intensive care is generally regarded as expensive, and as a result beds are limited. This has raised serious questions about rationing when there are insufficient beds for all those referred. However, the evidence for the cost effectiveness of intensive care is weak and the work that does exist usually assumes that those who are not admitted do not survive, which is not always the case. Randomised studies of the effectiveness of intensive care are difficult to justify on ethical grounds; therefore, this observational study examined the cost effectiveness of ICU admission by comparing patients who were accepted into ICU after ICU triage to those who were not accepted, while attempting to adjust such comparison for confounding factors.

Methods

This multi-centre observational cohort study involved 11 hospitals in 7 EU countries and was designed to assess the cost effectiveness of admission to intensive care after ICU triage. A total of 7,659 consecutive patients referred to the intensive care unit (ICU) were divided into those accepted for admission and those not accepted. The two groups were compared in terms of cost and mortality using multilevel regression models to account for differences across centres, and after adjusting for age, Karnofsky score and indication for ICU admission. The analyses were also stratified by categories of Simplified Acute Physiology Score (SAPS) II predicted mortality (< 5%, 5% to 40% and >40%). Cost effectiveness was evaluated as cost per life saved and cost per life-year saved.

Results

Admission to ICU produced a relative reduction in mortality risk, expressed as odds ratio, of 0.70 (0.52 to 0.94) at 28 days. When stratified by predicted mortality, the odds ratio was 1.49 (0.79 to 2.81), 0.7 (0.51 to 0.97) and 0.55 (0.37 to 0.83) for <5%, 5% to 40% and >40% predicted mortality, respectively. Average cost per life saved for all patients was $103,771 (€82,358) and cost per life-year saved was $7,065 (€5,607). These figures decreased substantially for patients with predicted mortality higher than 40%, $60,046 (€47,656) and $4,088 (€3,244), respectively. Results were very similar when considering three-month mortality. Sensitivity analyses performed to assess the robustness of the results provided findings similar to the main analyses.

Conclusions

Not only does ICU appear to produce an improvement in survival, but the cost per life saved falls for patients with greater severity of illness. This suggests that intensive care is similarly cost effective to other therapies that are generally regarded as essential.