Can intensive primary care prevent primary intensive care? (Editorial).

In these days of increasing medical costs, the health care system is paying more attention to resource use and cost avoidance. Nowhere is this effort more tangible than in the intensive care unit (ICU), where costs account for as much as 20% of health care expenditures in the United States. To control costs and optimize bed use, most hospitals have formulated criteria for admission, discharge, and transfer from the ICU. Despite these administrative efforts, few studies have investigated the effect of these guidelines on the care of critically ill patients. (1,2)

In contrast, several efforts have been made to assess the appropriateness of admission to hospital services, including pediatrics (3) and general. medicine. (4,5) These studies have used various definitions of inappropriateness to include inpatient care that does not benefit patients or could be delivered outside the hospital setting. Bindman et al (6) identified five medical illnesses to be preventable conditions that are often amenable to timely outpatient care: asthma, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and diabetes. Likewise, other authors have described potentially preventable hospitalizations due to similar ambulatory care-sensitive conditions or avoidable hospital conditions. (7)

In this issue of the Southern Medical Journal, Burr et al (8) ambitiously set out to gather information prospectively for all medical admissions to a busy urban ICU during a 3-year period. Using a definition of potentially preventable admissions adapted from the literature, these authors identified 627 patients (of a total of 4,114) classified as requiring ICU hospitalization for seven specific medical illnesses: asthma, congestive heart failure, diabetes mellitus with ketoacidosis or nonketotic hyperosmolar coma, dmg overdose, epilepsy, hypertension, or pulmonary edema as a result of chronic renal failure or chronic congestive heart failure. The authors report numerous physiologic, demographic, and outcome parameters, along with ICU interventions for patients in each group. They found that although individuals with preventable admissions had a lower mortality rate and fewer complications, this group of patients accounted for significant costs of care. Perhaps not too surprisingly, patients with potentially preventable ICU admissions were younger and without health insurance. They also left the hospital against medical advice more often. The authors concluded that a substantial number of medical ICU admissions are potentially preventable and recommended the development of strategies designed to actively prevent these admissions.

On the surface, it seems easy to quibble with the authors' finding that almost one in six ICU admissions could be prevented. The 15% rate of avoidable hospitalizations is reasonable, however, compared with findings in other similar studies. Soulen et al (3) reported that 28% of admissions to the pediatric service at Johns Hopkins Hospital were potentially avoidable. Likewise, several European groups found similar results in internal medicine inpatient populations. In Norway, Eriksen et al (4) observed a 24% rate of inappropriate admissions that were associated with a cost of approximately $2,500 per admission. Perneger et al (5) determined that 15% of admissions to an internal medicine service in Switzerland were inappropriate. Furthermore, an examination of ambulatory care-sensitive admissions in the population younger than 65 years of age in several U.S. cities showed rates ranging from 6.85 per 1,000 patients in Portland, OR, to 15.16 per 1,000 patients in New York City. (8) In the same study, Canadian cit ies tended to have lower rates, ranging from 7.25 to 7.43 per 1,000 patients. (9) In addition, Darchy et al (10) reported that more than 10% of ICU admissions to a French hospital were for iatrogenic diseases. Almost certainly, a number of these admissions could be considered preventable, even though the current study did not specifically examine this patient population.

One is left to ponder the implications of this considerable number of potentially avoidable ICU admissions. Without a doubt, this group of patients offers an opportunity for possible quality improvement and cost containment. More efficient, more accessible care outside the ICU may indeed reduce this potential drain on a limited resource, the ICU bed. Burr et al (8) conclude that a substantial number of these admissions are preventable with improved outpatient management, and they call for the development of strategies or programs to actively prevent these admissions.

Preventable LCU admissions have a significant impact on individual institutions, both financially and from the standpoint of resource use. Even more important, potentially preventable ICU admissions such as ambulatory care-sensitive conditions resulting in hospitalization may theoretically identify inadequate access to ambulatory care in an entire community. Because many factors contribute to access to outpatient care, there is no clear proof that improved availability of primary care providers will affect ICU admissions. Cultural differences, patient lifestyles, and the variable incidence and prevalence of disease in certain communities affect efficacious ambulatory care. In addition, nonmedical processes such as transportation, child care, and work schedules can seriously hamper access to care. Also, financial limitations that result in inability to afford prescribed medications contribute to less than ideal medical care, despite access to primary care.

Burr et a1 (8) offer interesting insight into ICU treatment for patients who have medical conditions typically amenable to outpatient care. Given the complicated interplay between sociologic, psychologic, and economic factors, no simple strategy is likely to prevent these admissions to ICUs. Without significant changes in the current health care system, it seems unlikely that even intensive primary care will prevent primary intensive care.

Accepted July 21, 2002.

References

(1.) Azoulay E, Pochard F, Chevret 5, Vinsonneau C, Garrouste M, Cohen Y, et al; The PROTOCETIC Group. Compliance with triage to intensive care recommendations. Grit Care Med 2001 ;29:21 32-2136.

(2.) Metcalfe MA, Sloggett A, McPherson K. Mortality among appropriately referred patients refused admission to intensive-care units. Lancet 1997; 350:7-1l.

(3.) Soulen JL, Duggan AK, DeAngelis CD. Identification of potentially avoidable pediatric hospital use: Admitting physician judgment as a complement to utilization review. Pediatrics 1994;94:421-424.

(4.) Eriksen BO, Kristiansen IS, Nord E, Pape JF, Almdahl SM, Hensrud A, et al. The cost of inappropriate admissions: A study of health benefits and resource utilization in a department of internal medicine. J Intern Med 1999;246:379-387.

(5.) Pemeger TV, Chopard P, Sarasin FP, Gaspoz JM, Lovis C, Unger PF, et al. Risk factors for a medically inappropriate admission to a department of internal medicine. Arch Intern Med 1997;157:1495-1500.

(6.) Bindman AB, Grumbach K, Osmond D, Komaromy M, Vranizan K, Lurie N, et al. Preventable hospitalizations and access to health care. JAMA 1995;274:305-311.

(7.) Parchman ML, Culler S. Primary care physicians and avoidable hospitalizations. J Fam Pract 1994;39:123-128.

(8.) Burr J, Sherman G, Prentice D, Hill C, Fraser V, Kollef MH. Ambulatory care-sensitive conditions: Clinical outcomes and impact on intensive care unit resource use. South Med J 2003;96(2).

(9.) Billings J, Anderson GM, Newman LS. Recent findings on preventable hospitalizations. Health Aff (Millwood) 1996; 15:239-249.

(10.) Darchy B, Le Micre E, Figueredo B, Bavoux E, Domart Y. Jatrogenic diseases as a reason for admission to the intensive care unit: Incidence, causes, and consequences. Arch Intern Med 1999;159:71-78.

From the Ochsner Clinic Foundation, New Urteans, LA.

Reprint requests to Pulmonary/Critical Care Medicine, Ochsner Clinic Foundation, 1514 Jefferson Highway, New Orleans, LA 70121.

Copyright [c] 2003 by The Southern Medical Association 0038-4348/03/9602-0122