Economic evaluation of the very elderly admitted to intensive care unit in Canada
CCCF ePoster library. Chin-Yee N. Oct 31, 2016; 155979; ORAL
Nicolas Chin-Yee
Nicolas Chin-Yee
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Topic: Retrospective or Prospective Cohort Study

Economic evaluation of the very elderly admitted to intensive care unit in Canada


Chin-Yee, Nicolas1; D’Egidio, Gianni1; Thavorn, Kednapa2; Heyland, Daren3; Kyeremanteng, Kwadwo1,2

1Department of Medicine, University of Ottawa/The Ottawa Hospital, Ottawa, Ontario, Canada; 2The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; 3Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada
 



Abstract:

Introduction: Very elderly patients are often admitted to intensive care units (ICUs) despite known poor short and long-term clinical outcomes [1-6] and frequent patient preference to avoid unnecessary prolongation of life [7-9]. The economic cost of critical care in this population has not been previously studied.
Objectives: The objectives of this study were to (i) determine the economic cost of ICU admission for the very elderly in Canada, (ii) identify patient and family factors that influence this cost, and (iii) explore the implications of these costs in the context of clinical outcomes and patient preferences in this population.
Methods: The data source for this study was a multicentre, prospective, observational cohort of patients aged 80 years or older admitted to 22 Canadian ICUs from 2009 to 2013 [1,2]. All patients in the longtudinal cohort (consenting participants and caregivers that were followed for 12 months) were included. Economic cost of care was calculated from ICU length of stay for each patient and both indirect and direct-variable costs of ICU admission at The Ottawa Hospital, Ontario, Canada. National annual healthcare cost of patients aged 80 and older admitted to ICU in Canada was calculated using age-specific rates of ICU care from a large Canadian epidemiological study [10]. All cost figures were expressed in Canadian Dollars. Multivariable linear regression analysis was employed to investigate potentially predictive factors for cost of care, including demographic and clinical characteristics, as well as patient and family preferences for care. 
Results: In total, 3,064 patients ≥80 years old were admitted to ICU, of which 1,917 were eligible, and 610 were enrolled in the longtidunal cohort of the study. The average age was 84 years; median length of stay was 6 days in ICU and 21 days in hospital. Mortality was 26% in hospital and 41% at 12 months. The average cost of ICU admission per patient for was $30,082 ± 31,682. The calculated annual cost of ICU admission for all Canadians 80 years of age or older was $861,157,414. In the multivariable model, older age (OR=0.98, 95% CI 0.95-1.00, P=0.022) and increased comorbidity (OR=0.95, 95% CI 0.91-0.99, P=0.007), but not frailty or residence in a nursing home, were associated with a lower cost of care. Respiratory primary ICU diagnoses were most costly (OR=1.45, 95% CI 1.13-1.18, P=0.004, compared with cardiovascular diagnosis). A patient or family preference for comfort measures over life support was an independent predictor for lower cost of care (OR=0.71, 95% CI 0.60-0.84, P<0.001); excluding all patients who died at 12 months from the multivariable analysis did not alter this result.
Conclusion: The economic cost of critical care in very elderly patients in Canada is substantial. Given the poor clinical outcomes in this population and the frequent patient preference for quality of life over life-sustaining therapy, the cost figures presented in this study provide further impetus for early goals of care discussion and will be crucial for informing future clinical and policymaking decisions aiming to reduce financial strain on the heatlhcare system. Early identification of very elderly patients with probable poor outcomes and the cost implications of reducing these ICU admissions deserve further study.


References:
  1. Heyland D, Cook D, Bagshaw SM, Garland A, Stelfox HT, Mehta S, Dodek P, Kutsogiannis J, Burns K, Muscedere J et al: The Very Elderly Admitted to ICU: A Quality Finish? Crit Care Med 2015, 43(7):1352-1360.
  2. Heyland DK, Garland A, Bagshaw SM, Cook D, Rockwood K, Stelfox HT, Dodek P, Fowler RA, Turgeon AF, Burns K et al: Recovery after critical illness in patients aged 80 years or older: a multi-center prospective observational cohort study. Intensive Care Med 2015, 41(11):1911-1920.
  3. Garrouste-Orgeas M, Timsit JF, Montuclard L, Colvez A, Gattolliat O, Philippart F, Rigal G, Misset B, Carlet J: Decision-making process, outcome, and 1-year quality of life of octogenarians referred for intensive care unit admission. Intensive Care Med 2006, 32(7):1045-1051.
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  7. Heyland DK, Dodek P, Rocker G, Groll D, Gafni A, Pichora D, Shortt S, Tranmer J, Lazar N, Kutsogiannis J et al: What matters most in end-of-life care: perceptions of seriously ill patients and their family members. CMAJ 2006, 174(5):627-633.
  8. Philippart F, Vesin A, Bruel C, Kpodji A, Durand-Gasselin B, Garcon P, Levy-Soussan M, Jagot JL, Calvo-Verjat N, Timsit JF et al: The ETHICA study (part I): elderly's thoughts about intensive care unit admission for life-sustaining treatments. Intensive Care Med 2013, 39(9):1565-1573.
  9. Heyland DK, Barwich D, Pichora D, Dodek P, Lamontagne F, You JJ, Tayler C, Porterfield P, Sinuff T, Simon J et al: Failure to engage hospitalized elderly patients and their families in advance care planning. JAMA Intern Med 2013, 173(9):778-787.
  10. Garland A, Olafson K, Ramsey CD, Yogendran M, Fransoo R: Epidemiology of critically ill patients in intensive care units: a population-based observational study. Crit Care 2013, 17(5):R212.


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