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

Title: Implications of ICU triage decisions on patient mortality: a cost-effectiveness analysis
Authors: Edbrooke, DL
Minelli, C
Mills, GH
Iapichino, G
Pezzi, A
Corbella, D
Jacobs, P
Lippert, A
Wiis, J
Pesenti, A
Patroniti, N
Pirracchio, R
Payen, D
Gurman, G
Bakker, J
Kesecioglu, J
Hargreaves, C
Cohen, SL
Baras, M
Artigas, A
Sprung, CL
Item Type: Journal Article
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.
Issue Date: 9-Feb-2011
Date of Acceptance: 9-Feb-2011
ISSN: 1364-8535
Publisher: BioMed Central
Journal / Book Title: Critical Care
Volume: 15
Copyright Statement: © Edbrooke et al. 2011. This article is published under license to BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Keywords: Adult
Cost-Benefit Analysis
Health Resources
Hospital Mortality
Intensive Care Units
Middle Aged
Patient Admission
Patients' Rooms
Risk Assessment
Treatment Outcome
Emergency & Critical Care Medicine
11 Medical And Health Sciences
Publication Status: Published
Article Number: R56
Appears in Collections:Infectious Disease Epidemiology
National Heart and Lung Institute
Faculty of Medicine

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