Cost effectiveness of intensive care in a low resource setting: A prospective cohort of medical critically ill patients

Table 1 Characteristics of the studies included in the systematic review

Ref.	Patients population and country	Year of publication	Refusal reasons	No. of deaths with ICU support out of total patients treated in ICU (% mortality)	No. of deaths without ICU support out of total patients not treated in ICU (% mortality)	Difference in mortality rates (%)	OR (95%CI)
Frisho-Lima et al[20]	General, Israel	1994	Moribund, no beds	7/62 (11.3)	31/65 (47.7)	36.4	7.16 (2.84-18.07)
Metcalfe et al[21]	6 general, United Kingdom	1997	Lack of beds or staff or other	178/480 (37.1)	75/165 (45.5)	8.4	1.41 (0.99-2.02)
Sprung et al[22]	General, Israel	1999	Too good or too poor prognosis, no beds, more data required, another crit. care area more appropriate	51/321 (15.9)	28/61 (45.9)	30	4.49 (2.50-8.07)
Joynt et al[23]	General, Hong Kong	2001	Triage, futility, inappropriate referral.	142/388 (36.6)	145/236 (61.4)	24.8	2.76 (1.98-3.85)
Garrouste-Oregas et al[24]	Medical and surgical, France	2003	too well/too sick	46/189 (24.3)	38/141 (27.0)	2.6	1.15 (0.70-1.89)
Simchen et al[25]	5 ICUs. Medical and surgical, Israel	2004	All hospital patients screened	80/190 (42.1)	192/349 (55.0)	12.9	1.68 (1.18-2.40)
Garrouste-Oregas et al[12]	4 medical and 7 general, France	2005	Too well/too sick, patients refusal, ICU occupied	120/412 (29.1)	49/128 (38.3)	9.2	1.51 (1.00-2.29)
Thiéry G et al[26]	Medical ICU, cancer patients 30 d mortality, France	2005	Too sick	57/105 (54.3)	39/54 (74.0)	19.7	2.19 (1.08-4.45)
Simchen et al[27]	5 acute care hospitals, medical and surgical patients Israel	2007	Died > 24 h deteriorated on ward	23/97 (23.7)	44/169 (26.0)	2.3	1.13 (0.63-2.02)
			Died < 24 h	4/97 (4.1)	55/414 (13.3)	9.2	3.56 (1.26-10.08)
Iapichino et al[28]	11 university hospitals from 7 countries: Denmark, France, Israel, Italy, The Netherlands, Spain, United Kingdom	2010	28 d mortality	1482/6708 (22.1)	197/600 (32.8)	10.7	1.72 (1.44-2.06)
Edbrooke et al[29]	11 hospitals in 7 EU countries	2011	28 d mortality	1389/6312 (22.0)	375/1137 (33.0)	11.0	1.74 (1.52-2.00)
Robert et al[30]	10 medical ICUs, France	2012	Too good or too sick 28 d	277/1,139 (24.3)	58/193 (30.1)	5.7	1.34 (0.96-1.87)
Cabrini et al[31]	Early ICU transfer, medical patients	2012	Too well/too sick or lack of ICU beds	6/15 (40.0)	13/40 (32.5)	-7.5	0.72 (0.21-2.46)
	Italy
Stelfox et al[32]	Canada, medical ICU	2012	Too well/too sick or lack of ICU beds	1106/3245 (34.1)	80/249 (32.1)	-2.0	0.92 (0.69-1.21)
Total				4968/19760 (25.1)	1419/4001 (35.5)	10.3	1.64 (1.52-1.76)

ICU: Intensive care unit.

Table 2 Patient characteristics

		All n = 148	1 yr survivors	Dead after one year	P
Age
	Mean (SD)	56 (17)	49 (17)	63 (15)	< 0.01a
Male (%)			58.6	57.7	1b
SAPSII	Mean (SD)	51 (20)	42 (19)	59 (17)	< 0.001a
Dg.(%)
	Cardiac arrest	16.9	18.6	15.4	0.17b
	Cardiogenic shock	1.4	0	2.6
	Coma	12.2	5.7	17.9
	Status epilepticus.	4.7	2.9	6.4
	CHF	3.4	4.3	2.6
	Hypercapnic ARF	10.1	10.0	10.3
	Hypoxic ARF	12.8	12.9	12.8
	Intoxication	9.5	15.7	3.8
	Malignant neurolept.sy	0.7	1.4	0
	Neuromuscular ARF	2.7	4.3	1.3
	Other	2	2.9	1.3
	Renal/metabolic	1.4	1.4	1.3
	Sepsis (including shock)	22.3	20.0	24.4
	Other	16.20%	12.90%	1.30%
ICU LOS
	Sum	1474
	Median (IQR)	6 (3-12)	6 (4-16)	5 (3-10)	0.116c
28 d ICU free days	Median (IQR)	0 (0-22)	12.5 (0-23)	0 (0-19)	0.002c
Ward LOS after ICU
	Sum	1694
	Median (IQR)	14 (0-14)	14 (13.75-15.25)	0 (0-1.25)	< 0.001c
Mechanical ventilation	%	80	74	87	0.097b
Ventilator-free days at 28 d	Median (IQR)	23 (18-25)	23.5 (18-26)	22 (18-25)	0.150c

^aStudent’s t test;

^bχ² test,

^cMann Whitney U test; Dg: Admission diagnosis; ICU: Intensive care unid; LOS: Length of stay; SAPSII: Simplified Acute Physiology Score II. IQR: Interquartile range; CHF: Chronic heart failure.

Table 3 Distribution of responses to EQ-5D modalities at one year

	Problems	n = 49	%
Mobility	No	25	51.0
	Some	22	44.9
	Severe	2	4.10
Self-care	No	37	75.5
	Some	8	16.3
	Severe	4	8.2
Usual activities
	No	13	26.5
	Some	26	53.1
	Severe	10	20.4
Pain/discomfort
	No	30	61.2
	Some	14	28.6
	Severe	5	10.2
Anxiety/depression
	No	27	55.1
	Some	19	38.8
	Severe	3	6.10
VAS	0.63 (0.56-0.70)

VAS: Visual analogue scale. Data are presented as numbers (percentage). EQ-5D-3Lquestionnaire is an instrument developed by the EuroQol group with five health related quality of life dimensions and a visual analogue scale for patients to subjectively evaluate the state of their quality of life.

Table 4 Costs, effects, incremental analysis of costs and effects and cost effectiveness ratio

	Hospital treatment costs	Future costs (present value)	Total
Cost-ICU ($)	410212	524432	934644
Cost-ward ($)	234240	454158	688398
Incremental cost ($)	175972	70274	246246
Effects-ICU (QALYs)	567
Effects-ward (QALYs)	4913
Incremental effects (QALYs)	757
ICER ($/QALY)	3254

Incremental cost represents the difference between the total ICU patient cohort cost and the comparator cohort cost and was calculated based on the decision model assumptions and attributable mortality risk reduction, using the formula presented in detail in the methods section, and after discounting future costs and health effects at an annual rate of 3% to the year 2012. ICU: Intensive care unit; ICER: Incremental cost-effectiveness ratio; QALY: Quality adjusted life year.