Provision of critical care for the elderly in Europe: a retrospective comparison of national healthcare frameworks in intensive care units

Abstract

Objectives: In Europe, there is a distinction between two different healthcare organisation systems, the tax-based healthcare system (THS) and the social health insurance system (SHI). Our aim was to investigate whether the characteristics, treatment and mortality of older, critically ill patients in the intensive care unit (ICU) differed between THS and SHI.

Setting: ICUs in 16 European countries.

Participants: In total, 7817 critically ill older (≥80 years) patients were included in this study, 4941 in THS and 2876 in the SHI systems.

Primary and secondary outcomes measures: We chose generalised estimation equations with robust standard errors to produce population average adjusted OR (aOR). We adjusted for patient-specific variables, health economic data, including gross domestic product (GDP) and human development index (HDI), and treatment strategies.

Results: In SHI systems, there were higher rates of frail patients (Clinical Frailty Scale>4; 46% vs 41%; p<0.001), longer length of ICU stays (90±162 vs 72±134 hours; p<0.001) and increased levels of organ support. The ICU mortality (aOR 1.50, 95% CI 1.09 to 2.06; p=0.01) was consistently higher in the SHI; however, the 30-day mortality (aOR 0.89, 95% CI 0.66 to 1.21; p=0.47) was similar between THS and SHI. In a sensitivity analysis stratifying for the health economic data, the 30-day mortality was higher in SHI, in low GDP per capita (aOR 2.17, 95% CI 1.42 to 3.58) and low HDI (aOR 1.22, 95% CI 1.64 to 2.20) settings.

Conclusions: The 30-day mortality was similar in both systems. Patients in SHI were older, sicker and frailer at baseline, which could be interpreted as a sign for a more liberal admission policy in SHI. We believe that the observed trend towards ICU excess mortality in SHI results mainly from a more liberal admission policy and an increase in treatment limitations.

Trial registration numbers: NCT03134807 and NCT03370692.

Keywords: adult intensive & critical care; geriatric medicine; public health.

Figure 1

Sensitivity analyses stratifying 30-day mortality for patient-specific characteristics using generalised estimation equations producing population average ORs. The depicted aORs from model-1 include only the intensive care unit (ICU) as panel. The 30-day mortality was similar between tax-based healthcare system (THS) and health insurance system (SHI) in male (aOR 1.26, 95% CI 0.98 to 1.61), frail (aOR 1.15, 95% CI 0.998 to 1.710), non-frail (aOR 1.15, 95% CI 0.88 to 1.52), nonagenarian (aOR 1.27, 95% CI 0.81 to 2.02) patients. There was a higher mortality in SHI in octogenarian (aOR 1.29, 95% CI 1.10 to 1.59) and female (aOR 1.32, 95% CI 1.02 to 1.70) patients and in patients staying below 72 hours (aOR 1.41, 95% CI 1.08 to 1.85).

Figure 2

Sensitivity analyses stratifying 30-day mortality for treatment strategies using generalised estimation equations producing population average ORs. The depicted aORs from model-1 include only the intensive care unit as panel. The 30-day mortality was similar in patients with renal replacement therapy (RRT), without vasoactive drugs, intubated and non-intubated paitents and patients on non-invasive ventilation (NIV). There was a trend towards higher 30-day mortality in patients without RRT (aOR 1.29, 95% CI 1.04 to 1.60) and without NIV (aOR 1.50, 95% CI 1.16 to 1.94). SHI, health insurance system; THS, tax-based healthcare system.

Figure 3

Sensitivity analyses stratifying 30-day mortality for health economic data using generalised estimation equations producing population average ORs. The depicted aORs from model-1 include only the intensive care unit (ICU) as panel. The 30-day-mortality was higher in SHI, in settings with low ICU beds per capita (aOR 2.17 95%CI 1.57-3.02), low gross domestic product (GDP) per capita (aOR 2.17 95% CI 1.42-3.58) and low human development index (HDI) (aOR 1.22 95% CI 1.64-2.20), as well as in high total health spending settings. SHI, health insurance system; THS, tax-based healthcare system.

Figure 4

Risk model calibration accuracy/goodness of fit was evaluated graphically by stratification of patients into Sequential Organ Failure Assessment (SOFA) quartiles (Q1: SOFA 0–4; Q2:>4–7; Q3>7–10, Q4>10) and comparison of observed versus expected events within risk strata. In the graphical calibration analysis, both tax-based healthcare system (THS) and health insurance system (SHI) showed agreement of predicted intensive care unit (ICU) mortality probability and observed events in SOFA risk quartiles, both in all patients (A) and in patients without any treatment limitation (B).