Volume 17 No. 1
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Volume 17 No. 1 January/February 2010
EDITORIAL
HEALTH CARE REFORM, HEALTH ECONOMICS AND INTENSIVE CARE
When President Obama was inaugurated as President of the United States, many in the USA felt certain that health care reform would soon come to pass and finally change the way that health care was financed and delivered. “Obamacare”, to use the term coined by the media, many thought would at last begin the process – or at least the dialogue – of eliminating the glaring inconsistencies that all too often have characterized American health care such as excessive cost, stifling barriers to access, misaligned incentives, and suboptimal outcomes for certain interventions.
A year later, it is safe to say that the electoral landscape has shifted and the optimism that accompanied the new administration has been replaced by a return to the usual political cynicism and squabbles that frequently make headlines but rarely lead to legislation and change. As such, the passage of health care reform that many believed to be a fait accompli only a few months earlier is now a real question, not only with respect to “when” but also with respect “if at all”.
While one may remain in doubt as to how health care reform in the USA will unfold, one should be certain that a major reason why reform is so prominent in the political agenda and the national consciousness is largely due to the paralyzingly high and rising cost of care. Americans devote a greater percentage of their gross domestic product (GDP) to health care, yet by most accepted crude metrics of effectiveness, have a relatively lower level of health status in comparison to other developed nations. One can therefore safely posit that America does not have a health care crisis but rather, possesses a crisis of health and medical care cost-effectiveness.
In other words, the value obtained for the resources expended is frequently suspect and thus, the general question arises whether the population’s health and the overall national interest could be better served by a reordered set of priorities and a different approach to funding, financing, reimbursement, and ultimately delivery.
These issues may be highlighted in the USA because of the current political climate and the seemingly burlesque nature of the American Congressional process that surrounds and frames health care reform and its associated debate. However, the issue of the high cost of health care and uncertain value for the resources that are expended, are just as real for all health care systems and practitioners in the world, because whilst most other health care systems do not have the extremes in costs and coverage of the US, all have their own unique problems and no system is blessed with infinite resources. To this end, many proactive, perhaps even enlightened, systems explicitly recognize that medical care – to paraphrase Garrett Hardin – shares a community commons1, and thus any new health care endeavour must be subject to objective evaluation of its ultimate societal value from both a clinical and an economic standpoint prior to approval, to ensure that scarce resources are put to their best (or at least better) possible use. In short, while health economics and methods such as cost-effectiveness and cost-utility analysis may seem to be out of the physician’s domain, when properly approached and applied are nevertheless very real, especially since the findings and interpretations of such studies may help to determine certain aspects of health care policy, including the number of ICUs, the number of unit beds, and what interventions and procedures are ultimately sanctioned.
As intensivists, we all – quite understandably given our scientific inklings and inherent dedication to provide our patients with the very best – marvel at the new medical technologies, a wonder that often manifests itself in a desire to work in centres that have the “latest and greatest” gizmos, gadgets, and genomics. However, since we live and practice in a world where we are forced to reckon with the concept of “the finite”, we must slow down the rush to blindly “expend and apply” without careful objective assessment of the economic impact in concert with clinical benefit. Fortunately, one sees strong signs of such a consciousness in the scientific community in critical care as the number of published health economic studies has grown significantly over the years. Since critical care medicine is often the locus of some of the most advanced yet expensive health care interventions, it should also serve as a natural intellectual home for economic, cost-effectiveness, and related outcomes research investigations. A key challenge is to hasten the leap from the arcane to the practical, so that cost-effectiveness analyses and other health economic studies can serve the dual interest of informing the clinician and driving effective, efficient, and even ethical health care policy.
Donald B. Chalfin, MD, MS, FCCM
Visiting Associate Professor of Epidemiology and Population Medicine,
Albert Einstein College of Medicine, New York, USA.
Reference:
1. Hardin G, Tragedy of the Commons. Science 1968; 162: 1243-1248.
Content
CARDIOVASCULAR
The following paper has been extracted and commented upon:
Lederle FA, Freischlag JA, Kyriakides TC et al. Outcomes following endovascular vs open repair of abdominal aortic aneurysm: a randomized trial.JAMA 2009;302:1535–1542.
‘Hot’ topic
Evidence Level: III
ETHICS
The following paper has been extracted and commented upon:
White DB, Evans LR, Bautista CA, Luce JM, Lo B. Are physicians’ recommend-ations to limit life support beneficial or burdensome? Am J Respir Crit Care Med 2009;180:320–325.
Evidence Level: III
HAEMATOLOGY
The following paper has been extracted and commented upon:
Spinella PC, Carroll CL, Staff I et al. Duration of red blood cell storage is associated with increased incidence of deep vein thrombosis and in hospital mortality in patients with traumatic injuries. Critical Care 2009;13: R151 (doi:10.1186/cc8050)
Could change clinical practice
Evidence Level: IV
ICM RECOMMENDED REVIEW PAPER
Sihler KC, Napolitano LM. Massive transfusion. Chest 2009;136; 1654-1667. 81 references.
HEPATOLOGY
ICM RECOMMENDED REVIEW PAPER
Stravitz RT, Kramer DJ. Management of acute liver failure. Nat Rev Gastroenterol Hepatol 2009;6:542-553. 115 references.
OUTCOME
The following papers have been extracted and commented upon:
Cuthbertson BH, Rattray J, Campbell MK et al. The PRaCTICaL study of nurse led, intensive care follow-up programmes for improving long term outcomes from critical illness: a pragmatic randomised controlled trial. BMJ 2009;339:b3723 (doi:10.1136/bmj.b3723)
‘Hot’ topic
Evidence Level: II
Steinberg JP, Braun BI, Hellinger WC et al. Timing of antimicrobial prophylaxis and the risk of surgical site infections. Ann Surg 2009;250:10–16.
Evidence Level: IV
PAEDIATRIC
The following paper has been extracted and commented upon:
Choong K, Bohn D, Fraser DD et al. Vasopressin in pediatric vasodilatory shock: a multicenter randomized controlled trial. Am J Respir Crit Care Med 2009;180:632–639.
Evidence Level: II
RENAL
The following papers have been extracted and commented upon:
The RENAL Replacement Therapy Study Investigators. Intensity of continuous renal-replacement therapy in critically ill patients. N Engl J Med 2009;361:1627–1638.
Evidence Level: II
Vesconi S, Cruz DN, Fumagalli R et al. Delivered dose of renal replacement therapy and mortality in critically ill patients with acute kidney injury. Crit Care 2009;13:R57 (doi: 10.1186/cc7784).
Evidence Level: III
Li AMMY, Gomersall CD, Choi G, Tian Q, Joynt GM, Lipman J. A systematic review of antibiotic dosing regimens for septic patients receiving continuous renal replacement therapy: do current studies supply sufficient data? J Antimicrob Chemother 2009;64:929–937.
Bright idea
Evidence Level: I
ICM RECOMMENDED REVIEW PAPER
Rodriguez-Capote K, Balion CM,Hill S, Cleve R, Yang L, El Sharif A. Utility of urine myoglobin for the prediction of acute renal failure in subjects where rhabdomyolysis is suspected: a systematic review. Clin Chem 2009 doi:10.1373/clinchem.2009.128546. 65 references.
RESPIRATORY
The following paper has been extracted and commented upon:
Hejblum G, Chalumeau-Lemaine L, Ioos V et al. Comparison of routine and on-demand prescription of chest radiographs in mechanically ventilated adults: a multicentre, cluster-randomised, two-period crossover study. Lancet 2009;374:1687–1693.
Could change clinical practice
Evidence Level: II
ICM RECOMMENDED REVIEW PAPER
Meduri GU, Annane D, Chrousos GP, Marik PE, Sinclair SE. Activation and regulation of systemic inflammation in ARDS: Rationale for prolonged glucocorticoid therapy. Chest 2009; 136:1631-1643. 101 references.
SEPSIS
The following papers have been extracted and commented upon:
Vincent JL, Rello J, Marshall J et al., for the EPIC II Group of Investigators. International study of the prevalence and outcomes of infection in intensive care units. JAMA 2009; 302: 2323–2329.
Evidence Level: IV
Raad I, Kassar R, Ghannam D, Chaftari AM, Hachem R, Jiang Y. Management of the catheter in documented catheter- related coagulase-negative staphylococcal bacteremia: remove or retain? Clin Infect Dis 2009;49:1187–1194.
Evidence Level: IV
ICM RECOMMENDED REVIEW PAPERS
Giamarellou H, Poulakou G. Multidrug-resistant Gram-negative infections: What are the treatment options?
Drugs 2009; 69; 1879-1901. 163 references.
Hunter JD, Doddi M. Sepsis and the heart. Br J Anaesth 2010;104:3-11. 111 references.
Melsen WG, Rovers MM, Bonten MJM. Ventilator-associated pneumonia and mortality: A systematic review of observational studies. Crit Care Med 2009;37:27092718. 65 references.
Tleyjeh IM, Kashour T, Hakim FA et al. Statins for the prevention and treatment of infections. A systematic review and meta-analysis. Arch Intern Med 2009;169:1658-1667. 64 references.
TRAUMA
The following paper has been extracted and commented upon:
Dolton M, Xu H, Cheong E et al. Vancomycin pharmacokinetics in patients with severe burn injuries. Burns 2009; doi:10.1016/j.burns.2009.08.010.
Bright idea
Evidence Level: III
Questions
1. Antibiotic dosing in renal failure:
a. The initial dose of most renally excreted drugs should be reduced in patients with acute renal failure.
b. Volume of distribution is one determinant of the appropriate initial dose.
c. The appropriate dosing interval for maintenance doses is dependent on the volume of distribution.
d. A paper reviewed in this issue of the journal demonstrates that appropriate doses can be calculated for most antibiotics using published data.
2. Coagulase negative staphylococci are an important cause of the following infections:
a. urinary tract infection in middle aged women.
b. community acquired pneumonia.
c. prosthetic valve endocarditis.
d. a paper reviewed in this issue of the Monitor suggests that it is unnecessary to remove the catheter in patients with catheter related bloodstream infection due to coagulase negative staphylococci.
3. Abdominal aortic aneurysm (AAA) repair:
a. The absolute difference in incidence of renal failure following open supra-renal and infra-renal AAA repair is large.
b. Colonic ischaemia is a recognized complication of AAA repair.
c. Cholesterol embolization is a rare complication.
d. A paper reviewed in this issue of the Monitor demonstrates that outcomes following open repair are similar to endovascular repair.
4. Storage of red cells:
a. Concentrations of 2-3 diphosphoglycerate fall within 2 weeks.
b. Is associated with decreased red cell deformability.
c. Transfusion of red cells stored for > 2 weeks is associated with increase post operative mortality and morbidity in cardiac surgical patients.
d. A paper reviewed in this issue of the Monitor found no relationship between duration of storage and outcome in critically ill patients.
Answers
Answers to questions featured in Intensive Care Monitor Vol. 17 No. 1 January/February 2010:
1. Antibiotic dosing in renal failure: FTFF
2. Coagulase negative staphylococci are an important cause of the following infections: TFTF
3. Abdominal aortic aneurysm (AAA) repair: FTFT
4. Storage of red cells: TTTF
