title: Implications of ICU triage decisions on patient mortality: a cost-effectiveness analysis.
abstract: BACKGROUND
  Intensive care is generally regarded as expensive, and as a result beds are limited. This has raised serious questions about rationing when there are insufficient beds for all those referred. However, the evidence for the cost effectiveness of intensive care is weak and the work that does exist usually assumes that those who are not admitted do not survive, which is not always the case. Randomised studies of the effectiveness of intensive care are difficult to justify on ethical grounds; therefore, this observational study examined the cost effectiveness of ICU admission by comparing patients who were accepted into ICU after ICU triage to those who were not accepted, while attempting to adjust such comparison for confounding factors.
  
  
  METHODS
  This multi-centre observational cohort study involved 11 hospitals in 7 EU countries and was designed to assess the cost effectiveness of admission to intensive care after ICU triage. A total of 7,659 consecutive patients referred to the intensive care unit (ICU) were divided into those accepted for admission and those not accepted. The two groups were compared in terms of cost and mortality using multilevel regression models to account for differences across centres, and after adjusting for age, Karnofsky score and indication for ICU admission. The analyses were also stratified by categories of Simplified Acute Physiology Score (SAPS) II predicted mortality (< 5%, 5% to 40% and >40%). Cost effectiveness was evaluated as cost per life saved and cost per life-year saved.
  
  
  RESULTS
  Admission to ICU produced a relative reduction in mortality risk, expressed as odds ratio, of 0.70 (0.52 to 0.94) at 28 days. When stratified by predicted mortality, the odds ratio was 1.49 (0.79 to 2.81), 0.7 (0.51 to 0.97) and 0.55 (0.37 to 0.83) for <5%, 5% to 40% and >40% predicted mortality, respectively. Average cost per life saved for all patients was $103,771 (€82,358) and cost per life-year saved was $7,065 (€5,607). These figures decreased substantially for patients with predicted mortality higher than 40%, $60,046 (€47,656) and $4,088 (€3,244), respectively. Results were very similar when considering three-month mortality. Sensitivity analyses performed to assess the robustness of the results provided findings similar to the main analyses.
  
  
  CONCLUSIONS
  Not only does ICU appear to produce an improvement in survival, but the cost per life saved falls for patients with greater severity of illness. This suggests that intensive care is similarly cost effective to other therapies that are generally regarded as essential.
authors.affiliation: Medical and Economics Research Centre Sheffield, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Trust, Glossop Road, Sheffield S10 2JF, UK.
authors.forename: David L
authors.initials: DL
authors.lastname: Edbrooke
authors.forename: Cosetta
authors.initials: C
authors.lastname: Minelli
authors.forename: Gary H
authors.initials: GH
authors.lastname: Mills
authors.forename: Gaetano
authors.initials: G
authors.lastname: Iapichino
authors.forename: Angelo
authors.initials: A
authors.lastname: Pezzi
authors.forename: Davide
authors.initials: D
authors.lastname: Corbella
authors.forename: Philip
authors.initials: P
authors.lastname: Jacobs
authors.forename: Anne
authors.initials: A
authors.lastname: Lippert
authors.forename: Joergen
authors.initials: J
authors.lastname: Wiis
authors.forename: Antonio
authors.initials: A
authors.lastname: Pesenti
authors.forename: Nicolo
authors.initials: N
authors.lastname: Patroniti
authors.forename: Romain
authors.initials: R
authors.lastname: Pirracchio
authors.forename: Didier
authors.initials: D
authors.lastname: Payen
authors.forename: Gabriel
authors.initials: G
authors.lastname: Gurman
authors.forename: Jan
authors.initials: J
authors.lastname: Bakker
authors.forename: Jozef
authors.initials: J
authors.lastname: Kesecioglu
authors.forename: Chris
authors.initials: C
authors.lastname: Hargreaves
authors.forename: Simon L
authors.initials: SL
authors.lastname: Cohen
authors.forename: Mario
authors.initials: M
authors.lastname: Baras
authors.forename: Antonio
authors.initials: A
authors.lastname: Artigas
authors.forename: Charles L
authors.initials: CL
authors.lastname: Sprung
mesh_terms: D000328:Adult; D000368:Aged; D003362:Cost-Benefit Analysis; D005060:Europe / Q000453:epidemiology; D005260:Female; D006295:Health Resources / Q000706:statistics & numerical data*; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units / Q000191:economics* / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D010343:Patient Admission / Q000706:statistics & numerical data*; D010362:Patients' Rooms / Q000191:economics* / Q000706:statistics & numerical data; D018570:Risk Assessment; D016896:Treatment Outcome; D014218:Triage