In the US, patients who die in hospital are almost five times more likely to have spent some time during their last hospital stay in the Intensive Care Unit (ICU) as equivalent patients in England, according to a new study by researchers from both countries.

The study is the work of lead author Dr Hannah Wunsch, assistant professor of anesthesiology and critical care medicine at Columbia University in New York, and colleagues, and is published in the 1 November print issue of the American Journal of Respiratory and Critical Care Medicine.

Wunsch and colleagues also found that terminally ill patients over the age of 85 were 8 times more likely to spend time in the ICU during their last hospital stay than their counterparts in England.

Wunsch explained in a statement that:

“Evaluating the use of intensive care services is particularly important because it is costly, resource intensive, and often traumatic for patients and families, especially for those at the end of life.”

“We found far greater use of intensive care services in the United States during terminal hospitalizations, especially among medical patients and the elderly,” she added.

She and her colleagues wanted to pursue the study because despite wide concerns about the cost and provision of end of life health care, few studies have compared how this is done is different countries.

So they decided to compare England and the US because the two countries have similar life expectancies and demographics, but widely different healthcare systems.

For example, England has one sixth of the number of ICU beds per head of population compared to the US, and responsibility for decisions about medical care appears to lie predominantly with doctors, whereas in the US it lies mostly with patients or their surrogate decision-makers.

Wunsch said that England provides universal health care through the National Health Service (NHS) and spends much less per head of the population on intensive care services than the US.

“The use of intensive care in England is limited by supply to a greater degree than it is in the US, and there are consequently implicit and explicit decisions regarding who gets those limited services. We wished to examine what different decisions are made,” said Wunsch.

For the study she and her colleagues got the English data from the Hospital Episodes Statistics database, and the US data from all hospital discharge databases of seven states (Florida, Massachusetts, New Jersey, New York, Texas, Virginia and Washington).

When they compared the data from England and the US, they found that:

  • Of all hospital discharges, only 2.2 per cent in England received intensive care, while in the US the equivalent figure was 19.3 per cent.

  • The rate of in-hospital deaths among those who received intensive care was almost three times higher in England than in the US (19.6 versus 7.4 per cent).

  • However, when they looked at overall deaths, only 10.6 of hospital deaths in England involved the ICU, whereas the equivalent figure in the US was 47.1 per cent.

  • Among patients over 85 years old, only 1.3 per cent received ICU care in England compared with 11 per cent in the US.

  • The rate of ICU services among young adults and children was about the same in both countries.

The researchers concluded that:

“Despite similar overall hospitalization rates in England and the United States, there were marked differences in terminal hospitalizations, with far greater use of intensive care services in the United States, especially among medical patients and the elderly population.”

However, Wunsch urged people to be careful about interpreting these results, “as the differences in mortality for ICU patients likely reflect the higher severity of illness of patients admitted in the first place in England”.

She said that the figures do raise the “interesting question of how much intensive care is beneficial. Doing more may not always be better,” she added.

While the researchers established there are important differences in how the US and England use ICU services, they did not set out to find out what impact they have. Surveys have suggested that most people would prefer not to die in hospital, however many still do and questions about use of intensive interventions remain unanswered.

Wunsch said:

“Whether less intensive care for very elderly patients who are dying is a form of rationing, or is actually better recognition of what constitutes appropriate care at the end of life warrants further research.”

“These findings highlight the urgent need to understand whether there is over-use of intensive care in the US or under-use in England,” she explained.

In an accompanying editorial, Drs Theodore Iwashyna and Julia Lynch wrote that future studies should investigate not just the origins but also the implications of these differences:

“Faced with a provocative finding of cross-national difference, the scientific community faces a choice between at least two paths,” they wrote.

One path is to carefully unpack the origins of these differences and find out some general truths about the evolution of critical care systems. The other path is to observe what happens in hospitals, imagine new ways to organize care and “generate the equipoise necessary for careful interventional studies of such interventions,” wrote Iwashyna and Lynch.

“The first path helps us shape national policy levers. The latter path helps us redesign care organizations to bring change to patients. Both are necessary,” they urged.

“Use of Intensive Care Services during Terminal Hospitalizations in England and the United States.”
Hannah Wunsch, Walter T. Linde-Zwirble, David A. Harrison, Amber E. Barnato, Kathryn M. Rowan, and Derek C. Angus.
Am. J. Respir. Crit. Care Med. 2009; 180: 875-880.
DOI:10.1164/rccm.200902-0201OC

Source: American Thoracic Society.

Written by: Catharine Paddock, PhD