The ongoing mystery of ARDS.
Explore the source record for details and available documents.
Critical Care↗
Biomedical subjects
W A Knaus
Publications and source records attributed to W A Knaus.
Application of the APACHE III prognostic system in Brazilian intensive care units: a prospective multicenter study.
OBJECTIVE: To compare patients and their outcomes at ten Brazilian intensive care units (ICUs) with those reported from the United States. DESIGN: Prospective multicenter inception cohort study. SETTING: Ten Brazilian adult medical-surgical ICUs. PATIENTS: 1734 consecutive adult ICU admissions. MEASUREMENTS AND RESULTS: We used demographic, clinical and physiologic information and the APACHE III prognostic system to predict risk of hospital death for 1734 ICU admissions. We then divided the observed by the predicted hospital death rate to calculate standardized mortality ratios (SMRs) for patient groups and each ICU. Hospital mortality for Brazilian patients (34%) was double that found in the United States (17%, p < 0.01). Discrimination of survivors from non-survivors using APACHE III was good (area under a receiver operating characteristic curve = 0.82), but the predicted risk of death was significantly (p < 0.0001) lower than observed outcome (SMR = 1.67). Three of the ten Brazilian ICUs, however, had SMRs of 1.01 to 1.1 and no significant difference between observed and predicted outcomes; the remaining seven ICUs had significantly higher SMRs, ranging from 1.50 to 2.30. CONCLUSION: The APACHE III prognostic system was a good discriminator of hospital mortality for ICU admissions at 10 Brazilian ICUs. There was substantial and significant variation, however, in SMRs among the Brazilian ICUs, which suggests that further evaluations of international differences in intensive care using a common risk assessment system should be performed and factors associated with variations in risk-adjusted mortality scrutinized.
APACHE↗
The importance of technology for achieving superior outcomes from intensive care. Brazil APACHE III Study Group.
OBJECTIVE: To test the hypothesis that technology availability, staffing, and diagnostic diversity in an intensive care unit (ICU) are associated with the ability to decrease hospital mortality. DESIGN: Prospective multicenter descriptive cohort study. SETTING: Ten Brazilian medical-surgical ICUs. PATIENTS: 1734 consecutive adult ICU admissions. MEASUREMENTS AND RESULTS: We recorded the amount of technology, number of diagnoses, and availability of nurses at each ICU. We also used demographic, clinical and physiologic information for an average of 173 admissions to each ICU to calculate standardized mortality ratios (SMRs) for each ICU. The mean SMR for the ten ICUs was 1.67 (range 1.01-2.30). A greater availability of ICU equipment and services was significantly (p < 0.001) associated with a lower SMR. CONCLUSION: The ability of Brazilian ICUs to reduce hospital mortality is associated with the amount of technology available in these units.
Adult↗
International comparisons of intensive care: meeting the challenges of different worlds of intensive care.
Explore the source record for details and available documents.
Clinical Trials as Topic↗
Severity stratification and outcome prediction for multisystem organ failure and dysfunction.
Multiple organ system failure or dysfunction (MOSF/MODS) remains a major cause of morbidity and mortality in hospitalized adults. Among intensive care unit (ICU) patients the extent of physiologic derangement, the type of associated disease or injury, increasing age, and life-threatening comorbid conditions are the major determinants of risk for developing MOSF and for survival during the 1980s. Hospital mortality for patients with a single organ system failure (OSF) lasting more than 1 day approached 40%; and for those with two OSFs hospital mortality increased to 60%. These outcomes did not change over the decade. For patients with three or more OSFs persisting after 3 days of OSF, however, data suggest that between 1982 and 1990 the mortality has been reduced from 98% to 84% (p = 0.0003). Because of variations in the types and combinations of OSFs, associated disease, and extent of physiologic derangement, it is difficult to interpret variations in mortality among patients with one or more OSFs defined using categorical criteria. For this and other reasons, outcome prediction based on a comprehensive assessment of patient risk factors is a more sensitive, specific, useful approach to quantifying MODS than a simple count of the number and duration of OSFs. Because repeated assessment of risk factors during subsequent ICU days reflects complications and response to therapy, daily outcome predictions are even more precise than estimates at ICU admission. The ability to more accurately predict survival from MODS/MOSF can improve our ability to test new therapies, evaluate how outcome has changed over time, and assess the efficacy of supportive therapy for individuals.
Adult↗
Use of predicted risk of mortality to evaluate the efficacy of anticytokine therapy in sepsis. The rhIL-1ra Phase III Sepsis Syndrome Study Group.
OBJECTIVES: To investigate a novel anticytokine therapy in patients with sepsis syndrome, and the relationship between a patient's baseline mortality risk and survival benefit. DESIGN: Data from a recent phase III, double-blind, placebo-controlled, multicenter clinical trial with patients randomized to three treatment arms: an intravenous loading dose of recombinant human interleukin-1-receptor antagonist (rhIL-1ra) or placebo, followed by a continuous infusion of rhIL-1ra (1.0 mg/kg/hr, or 2.0 mg/kg/hr), or placebo for 72 hrs. SETTING: Sixty-three investigative centers in eight countries. PATIENTS: The study population consisted of 893 patients: 302 placebo patients; 298 patients treated with 1.0 mg/kg/hr of rhIL-1ra; and 293 patients treated with 2.0 mg/kg/hr of rhIL-1ra. MEASUREMENTS AND MAIN RESULTS: An independent, sepsis-specific, log-normal regression model that predicts the risk of mortality over 28 days was applied to all patients enrolled into the rhIL-1ra sepsis study. The ability of the Predicted Risk of Mortality model to predict 28-day mortality in the placebo patients was determined and the relationship between mortality risk and efficacy of rhIL-1ra was investigated. The trial data were also analyzed using two other risk-assessment models for comparison with Predicted Risk of Mortality. A significant increase in survival time was demonstrated for all patients treated with rhIL-1ra (n = 893, p < .02 Predicted Risk of Mortality log-normal), but patients with a Predicted Risk of Mortality of < 24% derived little benefit. Retrospective examination of time-to-death data demonstrated that rhIL-1ra reduced risk of death in the first 2 days for patients with > or = 24% Predicted Risk of Mortality (n = 580, p < .005 Predicted Risk of Mortality log-normal). This same effect was not present in patients with a Predicted Risk of Mortality of < 24% on entry into the study. The Predicted Risk of Mortality model predicted a 28-day mortality rate of 35% for placebo patients compared with 34% observed and accurately stratified patients along the full range of risks. There was a wide distribution of individual patient risks for 28-day mortality for all patients, as well as within categorical subgroups, such as shock and organ system dysfunction. Two alternate risk models were assessed and the Acute Physiology Score of Acute Physiology and Chronic Health Evaluation III also demonstrated a statistically significant survival benefit for rhIL-1ra (p = .04 Predicted Risk of Mortality log-normal) for all patients treated. CONCLUSIONS: Using an appropriate analytic model, a statistically significant increase in survival time from rhIL-1ra was measured. A direct relationship was found between a patient's Predicted Risk of Mortality at study entry to efficacy of rhIL-1ra. Individual risk or severity assessment may be a useful tool for evaluating the clinical benefit of new therapeutic approaches to sepsis and for monitoring outcomes at the bedside.
APACHE↗
Does selective decontamination of the digestive tract reduce mortality for severely ill patients?
OBJECTIVE: To investigate the relationship between baseline risk of death and reduced mortality after selective decontamination of the digestive tract in intensive care unit patients. DESIGN: Analysis of data from a meta-analysis of 23 randomized, controlled trials. PATIENTS: A total of 4,142 adult intensive care unit patients from the 23 trials. MEASUREMENTS AND MAIN RESULTS: Mortality for patients receiving selective decontamination of the digestive tract treatment was analyzed as a function of baseline risk of death at study entry, using weighted least squares regression across all 23 trials. In testing whether the slope of the regression is different than 1.0, the observed t value is 3.32 (p < .004), suggesting that the efficacy of selective decontamination of the digestive tract in reducing mortality is significantly better in populations at high mortality risk at study entry. CONCLUSIONS: Mortality reduction from selective decontamination of the digestive tract appears related to the mortality risk of patients at the time of study entry. Future trials should consider using baseline risk assessment as part of trial design and outcome analysis.
Adult↗
Planning patient services for intermediate care units: insights based on care for intensive care unit low-risk monitor admissions.
OBJECTIVE: To describe the technology and nursing services that would be required to care for intensive care unit (ICU) low-risk monitor admissions in an intermediate unit. DESIGN: Prospective, multicenter, inception cohort analysis. SETTING: Forty U.S. hospitals with > 200 beds, including 26 hospitals that were randomly selected and 14 that volunteered for the study. PATIENTS: A sample of 8,040 ICU patients admitted to the ICU for monitoring, who received no active life-support treatment on ICU day 1. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Demographic, physiologic, and treatment information were obtained during ICU days 1 to 7. A previously validated multivariate equation was used to identify 6,180 monitor admissions at low (< 10%) risk for receiving active treatment during their entire ICU stay. We used daily Therapeutic intervention Scoring System (TISS) data to identify the equipment, type and amount of nursing care, and the types of active treatment that would have been used had these ICU patients been admitted to an intermediate care unit. Mean day-1 ICU TISS scores were as follows: 16.4 for all patients; 18.3 for surgical patients; and 13.5 for medical admissions. Concentrated nursing care accounted for 89% and technologic monitoring for 11% of day-1 TISS points. Surgical admissions had a 2.8-day mean ICU length of stay and received an average of 16.5 TISS points per patient per day. Medical admissions had a 2.7-day mean ICU length of stay and received an average of 12.3 TISS points per patient per day. Subsequent active life-support therapy was received by 4.4% of these ICU low-risk monitor admissions. CONCLUSIONS: The services received by ICU low-risk monitor admissions provide insight regarding the equipment and nursing care that might be required, and the kinds of emergencies that might occur, if these patients were cared for in medical and surgical intermediate care units. Our data suggest that if ICU low-risk monitor patients were admitted to an intermediate care unit, they would mainly require concentrated nursing care (nurse/patient ratio of 1:3 to 1:4) and limited technologic monitoring.
APACHE↗
A comparison of risks and outcomes for patients with organ system failure: 1982-1990.
OBJECTIVES: To compare the outcomes for patients with one or more organ system failures treated in 1988 to 1990 with those outcomes from 1979 to 1982; to document risk factors for developing organ system failure; and investigate the relationship of these factors to hospital survival. DESIGN: Prospective, multicenter, inception cohort analysis. SETTING: Sixty intensive care units (ICUs) at 53 U.S. hospitals. PATIENTS: A total of 17,440 ICU admissions treated in 1988 to 1990 and 5,677 ICU admissions treated in 1979 to 1982. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: At the time of organ system failure, patients were classified by demographic, physiologic, and diagnostic information. The type and number of organ system failures and physiologic responses were recorded for < or = 7 days of ICU treatment, and all patients were followed for status at hospital discharge. Hospital survival and the prognostic value of assessing the number of organ system failures were compared with risk assessment, based on use of a prognostic scoring system that estimated the patient's probability of hospital mortality. The incidence of organ system failure (48%) among patients treated in 1988 to 1990 was similar (44%) to the occurrence rate in patients in 1979 to 1982; and an identical proportion (14%) developed multiple organ system failure. There was a significant (p < .0003) improvement in hospital mortality for patients with three or more organ system failures on day 4 or later of organ system failure. However, overall hospital mortality rates from multiple organ system failure were not different over this 8-yr period. The most important predictor of hospital mortality was the severity of physiologic disturbance on the initial day of failure. Discrimination of patients by risk of hospital mortality was better using the prognostic scoring system on day 1 of organ system failure (receiver operating characteristic curve = 0.88) than using a model based on the number of organ system failures (receiver operating characteristic curve = 0.68). CONCLUSIONS: Organ system failure remains a major contributor to death in patients in ICUs. The incidence and overall outcome have not significantly changed over the past 8 yrs, but there has been significant improvement in survival for patients with persistent severe organ system failure. A continuous measure of individual patient severity of illness is a more sensitive and accurate method for describing patients and estimating outcome than counting the number of organ system failures.
APACHE↗
Outcomes following acute exacerbation of severe chronic obstructive lung disease. The SUPPORT investigators (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments)
In order to describe the outcomes of patients hospitalized with an acute exacerbation of severe chronic obstructive pulmonary disease (COPD) and determine the relationship between patient characteristics and length of survival, we studied a prospective cohort of 1,016 adult patients from five hospitals who were admitted with an exacerbation of COPD and a PaCO2 of 50 mm Hg or more. Patient characteristics and acute physiology were determined. Outcomes were evaluated over a 6 mo period. Although only 11% of the patients died during the index hospital stay, the 60-d, 180-d, 1-yr, and 2-yr mortality was high (20%, 33%, 43%, and 49%, respectively). The median cost of the index hospital stay was $7,100 ($4,100 to $16,000; interquartile range). The median length of the index hospital stay was 9 d (5 to 15 d). After discharge, 446 patients were readmitted 754 times in the next 6 mo. At 6 mo, only 26% of the cohort were both alive and able to report a good, very good, or excellent quality of life. Survival time was independently related to severity of illness, body mass index (BMI), age, prior functional status, PaO2/FI(O2), congestive heart failure, serum albumin, and the presence of cor pulmonale. Patients and caregivers should be aware of the likelihood of poor outcomes following hospitalization for exacerbation of COPD associated with hypercarbia.
APACHE↗
Predicting the duration of mechanical ventilation. The importance of disease and patient characteristics.
STUDY OBJECTIVE: To analyze the determinants of an individual patient's duration of mechanical ventilation and assess interhospital variations for average durations of ventilation. DESIGN: Prospective, multicenter, inception, cohort study. SETTING: Forty-two ICUs at 40 US hospitals. PATIENTS: A total of 5,915 patients undergoing mechanical ventilation on ICU day 1 selected from the acute physiology and chronic health evaluation (APACHE) III database of 17,440 admissions. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Utilizing APACHE III data collected on the 5,915 patients, multivariate regression analysis was performed on selected patients and disease characteristics to determine which variables were significantly associated with the duration of mechanical ventilation. An equation predicting duration of ventilation was then developed using the significant predictor variables and its accuracy was evaluated. Variables significantly associated with duration of ventilation included primary reason for ICU admission, day 1 acute physiology score (APS) of APACHE III, age, prior patient location and hospital length of stay, activity limits due to respiratory disease, serum albumin, respiratory rate, and PaO2/FIo2 measurements. Using an equation derived from these variables, predicted durations of ventilation were then calculated and compared with actual observed durations for each of the 42 ICUs. Average duration of ventilation for the 42 ICUs ranged from 2.6 to 7.9 days, but 60% of this variation was accounted for by differences in patient characteristics. CONCLUSIONS: For patients admitted to the ICU and ventilated on day 1, total duration of ventilation is primarily determined by admitting diagnosis and degree of physiologic derangement as measured by APS. An equation developed using multivariate regression techniques can accurately predict average duration of ventilation for groups of ICU patients, and we believe this equation will be useful for comparing ventilator practices between ICUs, controlling for patient differences in clinical trials of new therapies or weaning techniques, and as a quality improvement mechanism.
APACHE↗
Variations in the use of do-not-resuscitate orders in ICUS. Findings from a national study.
STUDY OBJECTIVES: To describe the variation in frequency of do-not-resuscitate (DNR) orders in 42 US ICUs and to examine the relationship between published guidelines and qualitative observations about terminal care in 9 ICUs. DESIGN: Prospective inception cohort. SETTING: Forty-two ICUs in 40 US hospitals with more than 200 beds: 26 randomly selected and 14 large tertiary-care volunteers. PARTICIPANTS: A consecutive sample of 17,440 ICU admissions during 1988 to 1990. MEASUREMENTS AND RESULTS: We used age, race, comorbid conditions, disease, functional status, and acute physiology score on ICU day 1 to predict the likelihood of a DNR order for each patient. A cross-validated model was then used to predict variations in the risk of an ICU DNR order from 0 to 45% (area under receiver operating characteristic curve = 0.9). The model was then used to compare aggregate observed with predicted frequency of ICU DNR orders. Finally, we compared observations of DNR practices by a team of clinical and organizational researchers at 9 of the 42 ICUs with published guidelines and risk-adjusted DNR frequency: 1,577 admissions (9%) had DNR orders written in the ICU (range, 1.5 to 22%). The ICU site was a significant (p < 0.0001) predictor of variance in the patient level model. DNR orders were written significantly (p < 0.05) less frequently than predicted in 5 and more frequently than predicted in 3 of 42 ICUs. Nonwhite patients had significantly (p = 0.0001) fewer DNR orders after adjustment. The research team's implicit judgments following on-site analysis failed to distinguish ICUs with more or less DNR orders than predicted. Site-visited ICUs exhibited practices to emulate and practice to avoid. CONCLUSIONS: The frequency of ICU DNR orders can be predicted based on individual risk factors for groups of ICU patients. After adjusting for differences in patient characteristics, there is significant variation in the frequency of DNR orders in a national sample of ICUs. These variations may be due to unmeasured differences in patient characteristics such as treatment preferences, religious affiliation, educational level, or physician practices. We found no relationship between risk-adjusted DNR order frequency and adherence to published guidelines.
APACHE↗
Outcome of mechanical ventilation for adults with hematologic malignancy.
BACKGROUND: Patients with hematologic malignancy who develop respiratory failure generally have a very poor prognosis. A few such patients, however, enjoy long-term survival. The objective of this study was to identify clinical characteristics of patients with hematologic malignancy and respiratory failure that are predictive of outcome. METHODS: We performed a retrospective chart review of all patients who required mechanical ventilation for acute respiratory failure while on the leukemia or bone marrow transplantation units at the Johns Hopkins Oncology Center between January 1985 and October 1991 (n = 157). RESULTS: Overall hospital mortality was 83%. Major organ system dysfunction, as measured by the acute physiology score (APS) of the APACHE III prognostic system, was significantly (P < 0.05) related to hospital mortality. Three disease-specific clinical characteristics were predictive of mortality: 1) stage beyond first complete remission, 2) duration of neutropenia greater than 30 days, and 3) treatment with bone marrow transplantation, especially if HLA-mismatched. None of the 15 (10%) patients with neutropenia greater than 30 days or the four patients who underwent HLA-mismatched transplantation survived to discharge. Age was also a significant predictor of hospital mortality. CONCLUSIONS: Overall outcome of patients with hematologic malignancy and acute respiratory failure is poor. A larger prospective study will be required to confirm the relative value of disease-specific variables identified in this study when combined with established predictive variables. In the future, it may be possible to develop a predictive instrument that is specifically tailored for patients with hematologic malignancy who develop respiratory failure.
APACHE↗
Hospital and 1-year survival of patients admitted to intensive care units with acute exacerbation of chronic obstructive pulmonary disease.
OBJECTIVE: To describe outcomes and identify variables associated with hospital and 1-year survival for patients admitted to an intensive care unit (ICU) with an acute exacerbation of chronic obstructive pulmonary disease (COPD). DESIGN: Prospective, multicenter, inception cohort study. SETTING: Forty-two ICUs at 40 US hospitals. PATIENTS: A total of 362 admissions for COPD exacerbation selected from the Acute Physiology and Chronic Health Evaluation (APACHE) III database of 17,440 ICU admissions. MEASUREMENTS AND RESULTS: Hospital mortality for the 362 admissions was 24%. For the 167 patients aged 65 years or older, mortality was 30% at hospital discharge, 41% at 90 days, 47% at 180 days, and 59% at 1 year. Median survival for all patients was 224 days, and median survival for the patients who died within 1 year was 30.5 days. On multiple regression analysis, variables associated with hospital mortality included age, severity of respiratory and nonrespiratory organ system dysfunction, and hospital length of stay before ICU admission. Development of nonrespiratory organ system dysfunction was the major predictor of hospital mortality (60% of total explanatory power) and 180-day outcomes (54% of explanatory power). Respiratory physiological variables (respiratory rate, serum pH, PaCO2, PaO2, and alveolar-arterial difference in partial pressure of oxygen [PAO2-PaO2]) indicative of advanced dysfunction were more strongly associated with 180-day mortality rates (22% of explanatory power) than hospital death rates (4% of explanatory power). After controlling for severity of illness, mechanical ventilation at ICU admission was not associated with either hospital mortality or subsequent survival. CONCLUSIONS: Patients with COPD admitted to an ICU for an acute exacerbation have a substantial hospital mortality (24%). For patients aged 65 years or older, mortality doubles in 1 year from 30% to 59%. Hospital and longer-term mortality is closely associated with development of nonrespiratory organ system dysfunction; severity of the underlying respiratory function substantially influences mortality following hospital discharge. The need for mechanical ventilation at ICU admission did not influence either short- or long-term outcomes. Physicians should be aware of these relationships when making treatment decisions or evaluating new therapies.
APACHE↗
Predicting future functional status for seriously ill hospitalized adults. The SUPPORT prognostic model.
OBJECTIVE: To develop a model estimating the probability of an adult patient having severe functional limitations 2 months after being hospitalized with one of nine serious illnesses. DESIGN: Prospective cohort study. SETTING: Five teaching hospitals in the United States. PARTICIPANTS: 1746 patients (model development) who survived 2 months and completed an interview, selected from 4301 patients in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT); independent validation sample of 2478 patients. MEASUREMENTS AND MAIN OUTCOMES: Patient function 2 months after admission categorized as absence or presence of severe functional limitations (defined as Sickness Impact Profile scores > or = 30 or as activities of daily living scores > or = 4 [levels that require near-constant personal assistance]). A logistic regression model was constructed to predict severe functional limitation. RESULTS: One third (n = 590) of patients who were interviewed at 2 months had severe functional limitations. Changes in functional status were common: Of those with no baseline dependencies (not dependent on personal assistance), 21% were severely limited at 2 months; of those with 4 or more baseline limitations, 30% had improved. The patient's ability to do activities of daily living was the most important predictor of functional status. Physiologic abnormalities, diagnosis, days in hospital, age, quality of life, and previous exercise capacity also contributed substantially. Model performance, assessed using receiver-operating characteristic curves, was 0.79 for the development sample and 0.75 for the validation sample. The model was well calibrated for the entire risk range. CONCLUSIONS: Functional outcome varied substantially after hospitalization for a serious illness. A small amount of readily available clinical information can estimate the probability of severe functional limitations.
Activities of Daily Living↗
The SUPPORT prognostic model. Objective estimates of survival for seriously ill hospitalized adults. Study to understand prognoses and preferences for outcomes and risks of treatments.
OBJECTIVE: To develop and validate a prognostic model that estimates survival over a 180-day period for seriously ill hospitalized adults (phase I of SUPPORT [Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments]) and to compare this model's predictions with those of an existing prognostic system and with physicians' independent estimates (SUPPORT phase II). DESIGN: Prospective cohort study. SETTING: 5 tertiary care academic centers in the United States. PARTICIPANTS: 4301 hospitalized adults were selected for phase I according to diagnosis and severity of illness; 4028 patients were evaluated from phase II. MEASUREMENTS: A survival model was developed using the following predictor variables: diagnosis, age, number of days in the hospital before study entry, presence of cancer, neurologic function, and 11 physiologic measures recorded on day 3 after study entry. Physicians were interviewed on day 3. Patients were followed for survival for 180 days after study entry. RESULTS: The area under the receiver-operating characteristics (ROC) curve for prediction of surviving 180 days was 0.79 in phase I, 0.78 in the phase II independent validation, and 0.78 when the acute physiology score from the APACHE (Acute Physiology, Age, Chronic Health Evaluation) III prognostic scoring system was substituted for the SUPPORT physiology score. For phase II patients, the SUPPORT model had equal discrimination and slightly improved calibration compared with physician's estimates. Combining the SUPPORT model with physician's estimates improved both predictive accuracy (ROC curve area = 0.82) and the ability to identify patients with high probabilities of survival or death. CONCLUSIONS: A limited amount of readily available clinical information can provide a foundation for long-term survival estimates that are as accurate as physicians' estimates. The best survival estimates combine an objective prognosis with a physician's clinical estimate.
APACHE↗
Preferences for cardiopulmonary resuscitation: physician-patient agreement and hospital resource use. The SUPPORT Investigators.
OBJECTIVE: To describe the association between hospital resource utilization and physicians' knowledge of patient preferences for cardiopulmonary resuscitation (CPR) among seriously ill hospitalized adult patients. DESIGN: Prospective cohort study. SETTING: Five U.S. academic medical center, 1989-1991. PATIENTS: A sample of 2,636 patients with self- or surrogate interviews and matching physician interviews describing patient preferences for CPR, from a cohort of 4,301 patients with life-threatening illnesses enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). MEASURES: Patient, surrogate, and physician reports of preferences for resuscitation, and resource use derived from the Therapeutic Intensity Scoring System and hospital length of stay, converted into 1990 dollars. RESULTS: Nearly one-third of the patients preferred to forego resuscitation. Of the 2,636 paired physician-patient answers, nearly one-third did not agree about preferences for resuscitation. The physicians' views of the patients' preferences and those preferences themselves were both associated with resource use. Standardized adjusted hospital resource consumption, expressed as average cost in dollars during the enrollment hospitalization, was lowest when the physician agreed with the patient preference for a do-not-resuscitate order ($20,527), and highest when the patient did not have a preference and the physician believed the patient wanted resuscitation in the case of a cardiopulmonary arrest ($34,829). Hospital resource use was intermediate when patient-physician pairs evidenced either lack of agreement or communication, or awareness of options about resuscitation. CONCLUSIONS: Both physician and patient preferences for CPR influence total hospital resource consumption. Physician misunderstanding of patient preferences to forego CPR was associated with increased use of hospital resources, and could have led to a course of care at odds with patients' expressed preferences in the event of cardiac arrest. Increasing physicians' knowledge of patient preferences, and increasing communication to help patients understand that options for medical care that include foregoing resuscitation efforts, might reduce hospital expenditures for the seriously ill.
Academic Medical Centers↗
African-American and white patients admitted to the intensive care unit: is there a difference in therapy and outcome?
OBJECTIVE: To evaluate variations in patient characteristics, hospital mortality, intensive care unit (ICU) length of stay, and treatment among African-American and white patients admitted to the ICU. DESIGN: Prospective, inception cohort study. SETTING: Forty-two ICUs at 40 U.S. hospitals, including 26 hospitals that were randomly selected and 14 volunteer institutions, primarily large university or tertiary care centers. PATIENTS: A consecutive sample of 17,440 ICU admissions. MEASUREMENTS AND MAIN RESULTS: Selected demographic, physiologic, and treatment information for an average of 415 admissions at each ICU, and payor information at 36 of 40 hospitals. Outcomes were compared using the ratio of observed to risk-adjusted predicted hospital mortality rate, ICU length of stay, and resource use during ICU day 1 and the first seven ICU days. Compared with 14,006 white patients admitted to the ICU, 2,450 African-American patient admissions were significantly (p < .0001) younger, had a higher mean severity of disease, and a greater proportion of nonoperative and emergency department admissions. African-Americans had fewer life-threatening Acute Physiology and Chronic Health Evaluation III (APACHE III) comorbidities, but a higher prevalence of severe compromise in activities of daily living, diabetes mellitus, chronic renal disease, and intravenous drug abuse. There was no significant racial difference in risk-adjusted hospital mortality rate. For African-Americans, adjusted ICU length of stay was significantly (p < .0003) shorter, and the first 7 days of resource use was significantly (p < .0004) lower, but the differences were small (3% to 4%). CONCLUSIONS: After adjusting for variations in patient characteristics at ICU admission, race has no significant effect on hospital survival. The small but statistically significant differences in adjusted ICU length of stay and resource use could indicate undertreatment for African-Americans or overtreatment for whites.
APACHE↗