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The Therapeutic Efficacy of Critical Care Units: Identifying Subgroups of Patients Who Benefit

The Therapeutic Efficacy of Critical Care Units: Identifying Subgroups of Patients Who Benefit Abstract • The majority of patients are admitted to critical care units for observation and to facilitate intervention if deterioration occurs or complications develop. We attempted to determine if a reduction in mortality in a subgroup of these patients admitted directly to the critical care units could be identified. A new method using the scientific principles of a randomized trial applied to the case-control design was employed. All 1905 patients admitted to the medical service over a three-month period were prospectively evaluated for illness severity and stability. Patients who would not have been eligible for a randomized clinical trial were excluded. Based on the prospective evaluations, four prognostically distinct subgroups of patients were formed. An odds ratio for each of the prognostic groups was calculated, a ratio of greater than 1 indicating a protective effect of direct critical care admission. Only one subgroup of patients, the unstable moderately ill, had an odds ratio greater than 1 (13.3). These results, in association with the results of our previous study, suggest that at the time of admission to the hospital, direct admission to the critical care unit reduced mortality among the unstable moderately ill subgroup of patients. (Arch Intern Med 1989;149:338-341) References 1. Cullen DJ, Ferrara LC, Briggs BA, et al: Survival, hospitalization charges, and follow-up results in critically ill patients . N Engl J Med 1976;294:982-987.Crossref 2. Thibault GE, Mulley AG, Barnett GO, et al: Medical intensive care: Indications, interventions and outcomes . N Engl J Med 1980;302:938-942.Crossref 3. Detsky AS, Striker SC, Mulley AG, et al: Prognosis, survival and the expenditure of hospital resources for patients in an intensive care unit . N Engl J Med 1981;305:667-672.Crossref 4. Killip T, Kimball JT: Treatment of myocardial infarction in a coronary care unit: A two year experience with 250 patients . Am J Cardiol 1967;20: 457-464.Crossref 5. Rogers RM, Weiler C, Ruppenthal B: Impact of the respiratory intensive care unit on survival of patients with acute respiratory failure . Chest 1972;62:94-97.Crossref 6. Griner PF: Treatment of acute pulmonary edema: Conventional or intensive care? Ann Intern Med 1972;77:501-506.Crossref 7. Pitner SE, Mance CJ: An evaluation of stroke intensive care units: Results in a municipal hospital . Stroke 1973;4:737-741.Crossref 8. Piper KW, Griner PF: Suicide attempts with drug overdose: Outcome of intensive vs conventional floor care . Arch Intern Med 1974;134:703-706.Crossref 9. Griner PF: Medical intensive care in the teaching hospital: Costs vs benefits: The need for anassessment . Ann Intern Med 1973;78:581-585.Crossref 10. Bendixen HH: The cost of intensive care , in Bunker JP, Barnes BA, Mosteller F (eds): Costs, Risks and Benefits of Surgery . New York, Oxford University Press, 1977, pp 372-384. 11. Hiatt HH: Protecting the medical commons: Who is responsible? N Engl J Med 1975;293:235-241.Crossref 12. Horwitz RI, Feinstein AR: The application of therapeutic trial principles to improve the design of epidemiologic research: A case-control study suggesting that anticoagulants reduce mortality in patients with myocardial infarction . J Chronic Dis 1981;33:575-583.Crossref 13. Horwitz RI, Feinstein AR: An improved observational method for studying therapeutic efficacy with evidence suggesting that lidocaine prophylaxis prevents death in myocardial infarction . JAMA 1981;246:2455-2459.Crossref 14. Charlson ME, Sax FL: The therapeutic efficacy of critical care units from two perspectives: A traditional cohort approach vs a new case-control methodology . J Chronic Dis 1987;40:31-39.Crossref 15. Charlson ME, Sax FL, MacKenzie CR, et al: Assessing illness severity: Does clinical judgment work? J Chronic Dis 1986;39:439-452.Crossref 16. Charlson ME, Sax FL: Morbidity during hospitalization: Can we predict it? J Chronic Dis 1987;40:705-712.Crossref 17. Woolf B: On estimating the relationship between blood group and disease . Ann Hum Genet 1955;19:251-253.Crossref 18. Fuchs VR: A more effective, efficient and equitable system . West J Med 1976;125:3-5. 19. Shepard DS, Ghanotakis AJ: Hospital Costs in Massachusetts: A Report of the Massachusetts Funds Flow Project , publication HRP-0029335. Springfield, Va, National Technical Information Service, 1979. 20. Mulley AG, Thibault GE, Hughes RA, et al: The course of patients with suspected myocardial infarction: The identification of low risk patients for early transfer . N Engl J Med 1980;302:943-948.Crossref 21. Singer DE, Carr PH, Mulley AG, et al: Rationing intensive care: Physician response to a resource shortage . N Engl J Med 1983;309:1155-1160.Crossref 22. Sax FL, Charlson ME: Admissions to the critical care units: Can utilization be improved? A prospective study of physician triage and patient outcomes . Arch Intern Med 1987;147:929-934.Crossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

The Therapeutic Efficacy of Critical Care Units: Identifying Subgroups of Patients Who Benefit

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Publisher
American Medical Association
Copyright
Copyright © 1989 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.1989.00390020064013
Publisher site
See Article on Publisher Site

Abstract

Abstract • The majority of patients are admitted to critical care units for observation and to facilitate intervention if deterioration occurs or complications develop. We attempted to determine if a reduction in mortality in a subgroup of these patients admitted directly to the critical care units could be identified. A new method using the scientific principles of a randomized trial applied to the case-control design was employed. All 1905 patients admitted to the medical service over a three-month period were prospectively evaluated for illness severity and stability. Patients who would not have been eligible for a randomized clinical trial were excluded. Based on the prospective evaluations, four prognostically distinct subgroups of patients were formed. An odds ratio for each of the prognostic groups was calculated, a ratio of greater than 1 indicating a protective effect of direct critical care admission. Only one subgroup of patients, the unstable moderately ill, had an odds ratio greater than 1 (13.3). These results, in association with the results of our previous study, suggest that at the time of admission to the hospital, direct admission to the critical care unit reduced mortality among the unstable moderately ill subgroup of patients. (Arch Intern Med 1989;149:338-341) References 1. Cullen DJ, Ferrara LC, Briggs BA, et al: Survival, hospitalization charges, and follow-up results in critically ill patients . N Engl J Med 1976;294:982-987.Crossref 2. Thibault GE, Mulley AG, Barnett GO, et al: Medical intensive care: Indications, interventions and outcomes . N Engl J Med 1980;302:938-942.Crossref 3. Detsky AS, Striker SC, Mulley AG, et al: Prognosis, survival and the expenditure of hospital resources for patients in an intensive care unit . N Engl J Med 1981;305:667-672.Crossref 4. Killip T, Kimball JT: Treatment of myocardial infarction in a coronary care unit: A two year experience with 250 patients . Am J Cardiol 1967;20: 457-464.Crossref 5. Rogers RM, Weiler C, Ruppenthal B: Impact of the respiratory intensive care unit on survival of patients with acute respiratory failure . Chest 1972;62:94-97.Crossref 6. Griner PF: Treatment of acute pulmonary edema: Conventional or intensive care? Ann Intern Med 1972;77:501-506.Crossref 7. Pitner SE, Mance CJ: An evaluation of stroke intensive care units: Results in a municipal hospital . Stroke 1973;4:737-741.Crossref 8. Piper KW, Griner PF: Suicide attempts with drug overdose: Outcome of intensive vs conventional floor care . Arch Intern Med 1974;134:703-706.Crossref 9. Griner PF: Medical intensive care in the teaching hospital: Costs vs benefits: The need for anassessment . Ann Intern Med 1973;78:581-585.Crossref 10. Bendixen HH: The cost of intensive care , in Bunker JP, Barnes BA, Mosteller F (eds): Costs, Risks and Benefits of Surgery . New York, Oxford University Press, 1977, pp 372-384. 11. Hiatt HH: Protecting the medical commons: Who is responsible? N Engl J Med 1975;293:235-241.Crossref 12. Horwitz RI, Feinstein AR: The application of therapeutic trial principles to improve the design of epidemiologic research: A case-control study suggesting that anticoagulants reduce mortality in patients with myocardial infarction . J Chronic Dis 1981;33:575-583.Crossref 13. Horwitz RI, Feinstein AR: An improved observational method for studying therapeutic efficacy with evidence suggesting that lidocaine prophylaxis prevents death in myocardial infarction . JAMA 1981;246:2455-2459.Crossref 14. Charlson ME, Sax FL: The therapeutic efficacy of critical care units from two perspectives: A traditional cohort approach vs a new case-control methodology . J Chronic Dis 1987;40:31-39.Crossref 15. Charlson ME, Sax FL, MacKenzie CR, et al: Assessing illness severity: Does clinical judgment work? J Chronic Dis 1986;39:439-452.Crossref 16. Charlson ME, Sax FL: Morbidity during hospitalization: Can we predict it? J Chronic Dis 1987;40:705-712.Crossref 17. Woolf B: On estimating the relationship between blood group and disease . Ann Hum Genet 1955;19:251-253.Crossref 18. Fuchs VR: A more effective, efficient and equitable system . West J Med 1976;125:3-5. 19. Shepard DS, Ghanotakis AJ: Hospital Costs in Massachusetts: A Report of the Massachusetts Funds Flow Project , publication HRP-0029335. Springfield, Va, National Technical Information Service, 1979. 20. Mulley AG, Thibault GE, Hughes RA, et al: The course of patients with suspected myocardial infarction: The identification of low risk patients for early transfer . N Engl J Med 1980;302:943-948.Crossref 21. Singer DE, Carr PH, Mulley AG, et al: Rationing intensive care: Physician response to a resource shortage . N Engl J Med 1983;309:1155-1160.Crossref 22. Sax FL, Charlson ME: Admissions to the critical care units: Can utilization be improved? A prospective study of physician triage and patient outcomes . Arch Intern Med 1987;147:929-934.Crossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Feb 1, 1989

References