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Rationing critical care beds

Systematic review
Results
Comment

Limited availability of healthcare resource in the face of permanent or temporary excess demand leads inevitably to rationing. Hardly news, that, though the R word is perhaps the hardest to use. Given that rationing is a fact of life, it behoves us to have some idea of the consequences. A systematic review of rationing of critical care beds [1] tells us that more people die who might have lived.

Systematic review

A widespread literature search without language restriction used many databases, plus handsearching of abstracts, plus contacting authors and experts. Inclusion criteria were adult patients who were seriously ill and considered for admission to an intensive care unit, retrospective or prospective cohort study, rationing based on reduced bed availability or triaging of patients referred for admission, and with outcomes including severity of illness, length of stay, or mortality. Medical, surgical, trauma, neurological or mixed intensive care units, intermediary care units, or step-down units were allowed.

Excluded were cost effectiveness studies, evaluation of protocols to make triaging decisions or rationing or triaging studies of coronary care units. Three different types of study were recognised:

  1. Triaging studies comparing patients admitted to an ICU and those refused a bed in ICU.
  2. Rationing bed studies comparing patients admitted during at least two different periods of time, one of which had reduced bed availability.
  3. Single cohort studies of patients either admitted or refused admission during a single period of bed shortage.

Results

Ten studies were available. Five were triaging studies, three were rationing studies, and two single cohort studies. There were considerable differences in the studies, though most reported patient outcomes and nine had follow-up rates above 90%.

The most useful information came from the triaging studies, four of which reported mortality rates for 1,220 patients admitted and 558 not admitted to an intensive care bed (Figure 1). In each of these four studies mortality was higher in patients refused admission to an intensive care bed. These studies were performed in Israel (2), Hong Kong, UK and USA.



Figure 1: Mortality by ICU bed admission





Overall mortality was 29% (357/1,220) in those admitted to ICU, compared with 50% (280/558) in those refused an intensive care bed (relative risk 1.7; 95% confidence interval 1.5 to 1.9). For every five patients refused an intensive care bed, one more died (95% CI 4 to 6) than would have been the case if they had been admitted to intensive care.

Comment

This is a headline result from some quite complex data, though any results other than this headline should probably not have much weight because they mostly come from single studies. But this remains an important heads up for those responsible for provision of healthcare and use of resources. Rationing comes with the price, for intensive care beds, of more deaths in those refused admission. Clearly a topic that demands more research, especially because saving money might mean spending it elsewhere in the system.

Reference:

  1. T Sinuff et al. Rationing critical care beds: a systematic review. Critical Care Medicine 2004 32: 1588-1597.

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