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Future directions. What is critical illness? Difficult t

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Future directions. What is critical illness? Difficult to define. High risk of death ... Future directions. Intensive care in critical access hospitals ... – PowerPoint PPT presentation

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Title: Future directions. What is critical illness? Difficult t


1
Intensive care in critical access hospitals a
demographic and outcome evaluation
  • Tariro Mupombwa
  • SUMR Mentor Jeremy Kahn, MD MS
  • August 8, 2008

2
Overview
  • The state of US critical care
  • Critical access hospitals
  • Intensive care in critical access hospitals
  • Future directions

3
Overview
  • The state of US critical care
  • Critical access hospitals
  • Intensive care in critical access hospitals
  • Future directions

4
What is critical illness?
  • Difficult to define
  • High risk of death
  • Admission to an ICU
  • Anyone requiring a intensive monitoring
  • Is a syndrome and not a disease
  • Can happen anywhere and at any time

5
The current state of critical care
  • 5.6 million adult ICU admissions annually
  • Mean ICU admissions per life 1.7
  • 15 mortality
  • 600,000 hospital deaths (1/5 of US)
  • 67 billion per year
  • 0.56 to 0.67 of GDP

Kersten CCM 2004 Angus CCM 2004
6
Critical care in small hospitals is associated
with a higher risk of death
Kahn NEJM 2006
7
Overview
  • The state of US critical care
  • Critical access hospitals
  • Intensive care in critical access hospitals
  • Future directions

8
What are critical access hospitals (CAHs)?
  • Small rural hospitals
  • Designated by Medicare and States
  • Cost-based reimbursement
  • Should provide 24 hour intensive and emergency
    services
  • Typically
  • Less than 25 inpatient beds
  • Average LOS of 96hrs or less

CMS CAH fact sheet 2007
9
The scope and scale of intensive care services in
CAHs is unknown
  • Research objectives
  • Determine number of patients receiving intensive
    care in critical access hospitals
  • Compare demographics and outcomes to other
    hospitals

10
Overview
  • The state of US critical care
  • Critical access hospitals
  • Intensive care in critical access hospitals
  • Future directions

11
Intensive care in critical access hospitals
  • 2004-2006 Pennsylvania state discharge database
  • CAHs identified by Medicare cost reports
  • Critical illness identified by resource
    utilization codes
  • Diagnoses and procedures identified by ICD-9 code
  • 30-day mortality linkage to DOH death index

12
12 hospitals in PA certified as CAH
13
CAH characteristics
14
Admission characteristics
15
Admission characteristics cont
16
Transfers were relatively uncommon
  • 16 of patients were transferred to another
    hospital at some point
  • 5 of patients transferred directly to a referral
    hospital ICU
  • Median transfer distance 31 miles
    interquartile range 17 38

17
What about rural hospitals that arent CAHs?
  • Valid comparisons are difficult
  • We identified 7 similar non-CAH designated
    hospitals
  • Less than 50 beds
  • Rural hospitals by 2000 US Census
  • 3,548 patients

18
(No Transcript)
19
Conclusions
  • Intensive care in CAHs represents a small but
    important part of all intensive care
  • ICU patients in CAHs tend to be less sick than
    those in other hospitals
  • CAHs transfer a minority of their ICU patients
  • Patients in similar rural hospitals are sicker
    with a higher risk of death (with a caveat)

20
Limitations
  • Single state (PA)
  • Critical care defined by resource utilization
    codes rather than clinical condition
  • Different severity measures frequently produce
    different impressions about hospital performance

21
Policy Implications
  • CAHs represent an important target for improving
    quality of care of ICU patients
  • Policy interventions such as regionalization and
    state-wide quality improvement efforts should be
    considered

22
Overview
  • The state of US critical care
  • Critical access hospitals
  • Intensive care in critical access hospitals
  • Future directions

23
Future directions
  • To determine the economic outcomes of critical
    care in CAHs in relation to similar rural
    hospitals
  • Look at organizational characteristics of ICUs
    within CAHs

24
Special thanks to the following organizations for
their generous support
  • The University of Pennsylvania Provosts
    Diversity Fund
  • The Center for Health Equity Research and
    Promotion (CHERP)
  • Pennsylvania Department of HealthOffice of
    Health Equity

25
Acknowledgements
  • Jeremy Kahn, MD MS
  • Jason Lott, MA
  • Joanne Levy, MBA MCP
  • SUMR scholars
  • Leonard Davis Institute
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