2015 DEPARTMENT OF MEDICINE RESEARCH DAY
Title of Presentation: Quantifying and Understanding Inappropriate Treatment in the
ICU
Speaker: Thanh H. Neville , M.D., MSHS
Division: Pulmonary and Critical Care
PLENARY SESSION ABSTRACT
Background: When used to prolong life without achieving a benefit meaningful to the patient, critical
care is often considered inappropriate. While inappropriate treatment is acknowledged as a misuse of
resources by many, it has not been rigorously studied. Our study is the first to empirically quantify its
prevalence, determine its financial and opportunity cost, and characterize the clinical and
communication factors associated with it.
Methods: On a daily basis for three months, we surveyed critical care specialists in five ICUs at an
academic health care system to identify patients that clinicians felt were receiving inappropriate
treatment. We calculated the cost by summing daily hospital charges after the patient was assessed
to be receiving inappropriate treatment. To calculate opportunity cost, we identified days when a full
ICU contained at least one patient who was receiving inappropriate treatment. For those days, we
evaluated the number of patients waiting for ICU admission for more than 4 hours in the emergency
department (ED) or more than 1 day at an outside hospital. We then abstracted the medical records
of patients who were assessed as receiving inappropriate and a subset of those who received
appropriate critical care. This abstracted data was the substrate for a mixed methods analysis using
qualitative analysis of medical record documentation with multivariable analysis to examine the
relationship between the documentation of patient, clinical, and communication factors and the receipt
of inappropriate treatment.
Results: The 6916 assessments by 36 critical care specialists on 1136 patients over three months
found that 904 (80%) patients never received futile treatment, 98 (8.6%) patients received probably
futile treatment, and 123 (11%) patients received futile treatment. Eighty-four of the 123 futile
patients died before hospital discharge and 20 patients died within 6 months of ICU care (6-month
mortality was 85%) with survivors remaining in severely compromised health states. The cost of
futile treatment in critical care was estimated to be $5.3 million for this 3 month period. On 72 (16%)
days, an ICU was full and contained at least one patient receiving inappropriate treatment. During
these days, 33 patients boarded in the ED for >4 hours after admitted to the ICU team, 9 patients
waited >1 day to be transferred from an outside hospital, and 15 patients cancelled the transfer
request after waiting >1 day. Two patients died while waiting to be transferred. Medical records
revealed 21 themes pertaining to prognosis and factors influencing treatment aggressiveness. When
the physician failed to guide (OR 3.76, 95% CI 1.21-11.70) or the patient/family delayed (OR 4.52,
95% CI 1.69-12.04) decision-making, patients were more likely to receive inappropriate treatment.
Documentation about communication about goals of care (OR 0.02, 95% CI 0.10-0.84) or
characterization of patient’s preferences driving decision-making (OR 0.29, 95% CI 0.00-0.27) were
associated with a lower likelihood of receiving inappropriate treatment.
Conclusion: Inappropriate critical care is common; its financial cost is substantial; and it is
associated with delays in care for other patients. Inappropriate treatment occurs in the setting of
communication and decision-making patterns that may be amenable to intervention.