Case-Mix and the Limitations of Standardized Mortality Ratios for ICU Performance and Benchmarking
Abstract
No abstract available.
Conflict of interest statement
Dr. Salluh is supported, in part, by individual research grants from Conselho Nacional de Desenvolvimento Científico e Tecnológico and Fundação Carlos Chagas Filho de Amparo à Pesquisa do Rio de Janeiro. The remaining authors have disclosed that they do not have any potential conflicts of interest.
ICU registries: From tracking to fostering better outcomes
DOI: 10.1016/j.jcrc.2023.154462
PMID: 37981535
Abstract
No abstract available.
Conflict Of Interest Statement
Declaration of Competing Interest Dr. Salluh is co-founder and shareholder of Epimed Solutions, a cloud-based analytics company. Dr. Pisani receives salary support from Wellcome. Dr. Quintairos has no conflicts of interest to declare.
National ICU Registries as Enablers of Clinical Research and Quality Improvement
Jorge I F Salluh 1 2, Amanda Quintairos 1 3, Dave A Dongelmans 4 5, Diptesh Aryal 6, Sean Bagshaw 7 8, Abigail Beane 9 10, Gaston Burghi 11, Maria Del Pilar Arias López 12 13, Stefano Finazzi 14 15, Bertrand Guidet 16, Satoru Hashimoto 17, Nao Ichihara 18, Edward Litton 19 20, Nazir I Lone 21 22, Vrindha Pari 23, Cornelius Sendagire 1 24, Bharath Kumar Tirupakuzhi Vijayaraghavan 25 26, Rashan Haniffa 9 27 28, Luigi Pisani 9, David Pilcher 29; Linking of Global Intensive Care (LOGIC) and Japanese Intensive care PAtient Database (JIPAD) Working Group
DOI: 10.1097/CCM.0000000000006050
PMID: 37698452
Abstract
Objectives: Clinical quality registries (CQRs) have been implemented worldwide by several medical specialties aiming to generate a better characterization of epidemiology, treatments, and outcomes of patients. National ICU registries were created almost 3 decades ago to improve the understanding of case-mix, resource use, and outcomes of critically ill patients. This narrative review describes the challenges, proposed solutions, and evidence generated by National ICU registries as facilitators for research and quality improvement.
Data sources: English language articles were identified in PubMed using phrases related to ICU registries, CQRs, outcomes, and case-mix.
Study selection: Original research, review articles, letters, and commentaries, were considered.
Data extraction: Data from relevant literature were identified, reviewed, and integrated into a concise narrative review.
Data synthesis: CQRs have been implemented worldwide by several medical specialties aiming to generate a better characterization of epidemiology, treatments, and outcomes of patients. National ICU registries were created almost 3 decades ago to improve the understanding of case-mix, resource use, and outcomes of critically ill patients. The initial experience in European countries and in Oceania ensured that through locally generated data, ICUs could assess their performances by using risk-adjusted measures and compare their results through fair and validated benchmarking metrics with other ICUs contributing to the CQR. The accomplishment of these initiatives, coupled with the increasing adoption of information technology, resulted in a broad geographic expansion of CQRs as well as their use in quality improvement studies, clinical trials as well as international comparisons, and benchmarking for ICUs.
Conclusions: ICU registries have provided increased knowledge of case-mix and outcomes of ICU patients based on real-world data and contributed to improve care delivery through quality improvement initiatives and trials. Recent increases in adoption of new technologies (i.e., cloud-based structures, artificial intelligence, machine learning) will ensure a broader and better use of data for epidemiology, healthcare policies, quality improvement, and clinical trials.
Copyright © 2023 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Conflict Of Interest Statement
Dr. Beane received support for article research from Wellcome Trust/Charity Open Access Fund (COAF). Drs. Pilcher and Litton are members of the Australian and New Zealand Intensive Care Society Centre for Outcome and Resources Evaluation management committee. Drs Salluh is co-founder and shareholder of Epimed Solutions, a healthcare cloud-based analytics company. He is also supported, in part, by individual research grants from the National Council for Scientific and Technological Development and Research Support Foundation of the State of Rio de Janeiro. Dr. Dongelmans is unpaid chair of National Intensive Care Evaluation Foundation. Dr. Ichihara’s primary affiliation is the Department of Healthcare Quality Assessment, which is a social collaboration department at the University of Tokyo supported by National Clinical Database, Johnson & Johnson K.K., and Nipro Corporation. Dr. Vijayaraghavan is the National Coordinator for the Indian Registry of IntenSive Care and is supported for 0.5 full-time equivalent hours by funding from the Wellcome Trust, U.K. Dr. Bagshaw received funding from Baxter and BioPorto. Dr. Hashimoto’s institution received funding from the Japanese Ministry of Health, Labour and Welfare for the Japanese Intensive care PAtient Database (JIPAD), the Japanese Society of Intensive Care Medicine, and JMS. Dr. Haniffa’s institution received funding from Wellcome Trust/COAF and UK Research and Innovation (UKRI); he disclosed that he is an honorary director of National Intensive Care Surveillance MORU. Dr. Pisani received funding from Wellcome Trust and The African Critical Care registry network funded by this UKRI MRC (grant MR/V030884/1). The remaining authors have disclosed that they do not have any potential conflicts of interest.
International Comparisons of ICU Performance: A Proposed Approach to Severity Scoring Systems
Crit Care Med. 2022 Nov 1;50(11):e799-e800. doi: 10.1097/CCM.0000000000005619. Epub 2022 Oct 13.
PMID: 36227050
Abstract
No abstract available
Conflict Of Interest Statement
Dr. Salluh is a shareholder of Epimed Solutions. Dr. Haniffa was a founding collaborator of the Global Open Source Severity of Illness Score initiative. Dr. Haniffa disclosed that he is the founding collaborator of Linking of Global Intensive Care, director of Crit Care Asia Network Registry, trustee of Network for Improving Critical Care Systems and Training, and co-lead of Critical Care Asia and Africa; received support for article research from the Wellcome Trust/Charity Open Access Fund. The remaining authors have disclosed that they do not have any potential conflicts of interest.
Four decades of prognostic scores in intensive care
Amanda Quintairos,1,2 David Pilcher,3,4 and Jorge I. F. Salluh
1,5
Intensive Care Med. 2022 Oct 31:1-3. doi: 10.1007/s00134-022-06914-8. Online ahead of print.
PMID: 36315260
Intensive care units (ICUs) are people- and technology-intensive environments where timely and wise use of advanced monitoring and life support is crucial to revert or avoid life-threatening conditions. From their inception, this highly complex environment has been confronted with a need to demonstrate its effectiveness to healthcare stakeholders [1]. In the 1970s and 80s, increasing costs of intensive care, associated with poor outcomes of patients with multi-organ failure, urged intensivists and healthcare managers to look for metrics could concisely express ‘severity of illness’ and, thus, allow measurement of risk-adjusted outcomes [2].
In the early 1980s, the Acute Physiology and Chronic Health Evaluation (APACHE) system was a milestone in the history of ICU outcome prediction. This scoring system translated domains of pre-morbid conditions (age and co-morbidities), diagnoses and early physiologic derangements (organ failures, laboratory and physiological abnormalities) into a numeric expression of illness severity. In addition to the absolute value of the score, the APACHE system provided an estimate of the risk of death for each individual patient. APACHE was soon followed by the development of the Mortality Prediction Model (MPM) in the United States and the Simplified Acute Physiology Score (SAPS) in Europe. As the technologies improved, new treatments and protocols of care were applied, and the case-mix of the ICU changed (more elderly, co-morbidities and immunocompromised), scores needed to be updated to remain valid predictors of outcomes. The pioneering early versions of APACHE, SAPS and MPM were updated, with SAPS3, APACHE IV, and MPM0-III published, respectively, in 2005, 2006, and 2007 [3]. One of the important differences among these scores relates to the time when they are calculated. SAPS3 and MPM0-III use data from the first hour of ICU admission; whereas, APACHE IV uses the “worst” measurements from the first 24 h. Therefore SAPS3/MPM0-III potentially reflects the early severity of the non-resuscitated patient. APACHE IV provides more time for data collection and less missing data.
Finally, dynamic scores may be applied in the ICU. The most commonly used is the Sequential Organ Failure Assessment (SOFA) which was developed to define the degree of organ failure, to stratify risk particularly in patients with sepsis, and to monitor response to treatment. Scoring systems, although useful for individual risk assessment, are not as applicable for mortality prediction and ICU performance monitoring. They are often used to complement more general mortality scores in ICU.
Obstetric admission to intensive care units in Japan: a cohort study using the Japanese Intensive care PAtient Database
J Anesth. 2023 May 24. doi: 10.1007/s00540-023-03200-9. Online ahead of print.PMID: 37222956
Abstract
Purpose: This study aimed to describe the epidemiology and annual trends of obstetric patients using a multicenter intensive care database.
Methods: This multicenter, retrospective cohort study used the Japanese Intensive care PAtient Database (JIPAD). We included obstetric patients registered in the JIPAD between 2015 and 2020. We investigated the proportion of obstetric patients among all patients in the intensive care unit (ICU). We also described the characteristics, procedures, and outcomes of obstetric patients. In addition, the annual trends were examined by nonparametric tests for trends.
Results: Of the 184,705 patients enrolled in the JIPAD, 750 (0.41%) were obstetric patients from 61 facilities. The median age was 34 years, the number of post-emergency surgeries was 450 (60.0%), and the median APACHE III score was 36. Mechanical ventilation was the most common procedure performed in 247 (32.9%) patients. There were five (0.7%) in-hospital deaths. The proportion of obstetric patients in the ICU did not change between 2015 and 2020 (P for trend = 0.32). However, there was a trend for a significant decrease in the severity of illness and length of hospital stay on an annual basis between 2015 and 2020. Most patients were admitted to the ICU because of a pregnancy-related disorder postoperatively.
Conclusion: The proportion of obstetric patients was 0.41% of all ICU admissions. The proportion of obstetric patients admitted to the ICU did not change from 2015 to 2020, but the patients’ severity of illness and length of hospital stay significantly decreased over time.
Keywords: Critical care; Epidemiology; Intensive care unit; Maternal health; Obstetrics.
© 2023. The Author(s) under exclusive licence to Japanese Society of Anesthesiologists.
Determinants of Implementation of a Critical Care Registry in Asia: Lessons From a Qualitative Study
J Med Internet Res. 2023 Mar 6;25:e41028. doi: 10.2196/41028.
Abstract
Background: The Collaboration for Research, Implementation, and Training in Critical Care in Asia (CCA) is implementing a critical care registry to capture real-time data to facilitate service evaluation, quality improvement, and clinical studies.
Objective: The purpose of this study is to examine stakeholder perspectives on the determinants of implementation of the registry by examining the processes of diffusion, dissemination, and sustainability.
Methods: This study is a qualitative phenomenological inquiry using semistructured interviews with stakeholders involved in registry design, implementation, and use in 4 South Asian countries. The conceptual model of diffusion, dissemination, and sustainability of innovations in health service delivery guided interviews and analysis. Interviews were coded using the Rapid Identification of Themes from Audio recordings procedure and were analyzed based on the constant comparison approach.
Results: A total of 32 stakeholders were interviewed. Analysis of stakeholder accounts identified 3 key themes: innovation-system fit; influence of champions; and access to resources and expertise. Determinants of implementation included data sharing, research experience, system resilience, communication and networks, and relative advantage and adaptability.
Conclusions: The implementation of the registry has been possible due to efforts to increase the innovation-system fit, influence of motivated champions, and the support offered by access to resources and expertise. The reliance on individuals and the priorities of other health care actors pose a risk to sustainability.
Keywords: CCU; South Asia; critical care; health care; implementation; qualitative research; registry; stakeholders.
©Timo Tolppa, Vrindha Pari, Christopher Pell, Diptesh Aryal, Madiha Hashmi, Maryam Shamal Ghalib, Issrah Jawad, Swagata Tripathy, Bharath Kumar Tirupakuzhi Vijayaraghavan, Abi Beane, Arjen M Dondorp, Rashan Haniffa, Collaboration of Research Implementation & Training in Critical Care in Asia Investigators. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 06.03.2023.
Conflict Of Interest Statement
Conflicts of Interest: AB has received a salary from Wellcome. RH has received grants from Wellcome, Canadian Institutes of Health Research, UK Research and Innovation/Medical Research Council and International COVID-19 Data Alliance. CP has received a part-time salary from the Wellcome Trust.