BMJ Open (Jun 2021)

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

  • Antonio Artigas,
  • Nuno Catorze,
  • Bernhard Wernly,
  • Wojciech Szczeklik,
  • Raimund Helbok,
  • Pål Klepstad,
  • Emmanuel Guerot,
  • Tim Rahmel,
  • Kelly Tiercelet,
  • Louise Bell,
  • Clare Bolger,
  • Helder Filipe,
  • Michael Reay,
  • Jean-Pierre Quenot,
  • Saad Nseir,
  • Didier Thévenin,
  • Maurizio Cecconi,
  • Susan Dowling,
  • Jason Cupitt,
  • Willem Dieperink,
  • Henning Ebelt,
  • Philipp Eller,
  • Patrick Meybohm,
  • Rene Schmutz,
  • Michael Joannidis,
  • Sally Humphreys,
  • Filippo Boroli,
  • Gerardo Aguilar,
  • Jørund Langørgen,
  • Malte Kelm,
  • Marcus Franz,
  • Hans Flaatten,
  • Christian Jung,
  • Michael Beil,
  • Susannah Leaver,
  • Bertrand Guidet,
  • Tom Dormans,
  • Jonathan Ball,
  • Patrick Morgan,
  • Nick Spittle,
  • Tom Lawton,
  • Diederik Gommers,
  • Antoine Romen,
  • Camilla Brorsson,
  • Ana Rita Santos,
  • JANE EVANS,
  • Ala Khaled,
  • Hazem Ahmed,
  • Madhu Balasubramaniam,
  • Simon Dubler,
  • Jean-Philippe Rigaud,
  • Michael Schuster,
  • Julien Maizel,
  • Christophe Vinsonneau,
  • Carole Boulanger,
  • Jeremy Henning,
  • Catia Cillóniz,
  • Michael Spivey,
  • Kiran Salaunkey,
  • Raphael Romano Bruno,
  • Stephan Binnebössel,
  • Sviri Sigal,
  • Peter Vernon van Heerden,
  • Ariane Boumendil,
  • Brian Marsh,
  • Rui Moreno,
  • Sandra Oeyen,
  • Bernardo Bollen Pinto,
  • Sten Mikael Walther,
  • Joerg C Schefold,
  • Jesper Fjølner,
  • Tilemachos Zafeiridis,
  • Dylan de Lange,
  • Joke Nollet,
  • Nikolaas de Neve,
  • Pieter De Buysscher,
  • Walter Swinnen,
  • Marijana Mikačić,
  • Anders Bastiansen,
  • Andreas Husted,
  • Bård E S Dahle,
  • Christine Cramer,
  • Christoffer Sølling,
  • Dorthe Ørsnes,
  • Jakob Edelberg Thomsen,
  • Jonas Juul Pedersen,
  • Mathilde Hummelmose Enevoldsen,
  • Thomas Elkmann,
  • Agnieszka Kubisz-Pudelko,
  • Alan Pope,
  • Amy Collins,
  • Ashok S Raj,
  • Christian Frey,
  • Ciaran Hart,
  • Dominic Spray,
  • Georgina Randell,
  • Ingeborg D Welters,
  • Irina Grecu,
  • Jenny Lord,
  • Joanne Jones,
  • Julie North,
  • Laura Ortiz-Ruiz De Gordoa,
  • Marcela Vizcaychipi,
  • Maria Faulkner,
  • McDonald Mupudzi,
  • Megan Lea-Hagerty,
  • Nicholas Love,
  • Nigel White,
  • Patricia Williams,
  • Phillipa Wakefield,
  • Rachel Savine,
  • Reni Jacob,
  • Richard Innes,
  • Ritoo Kapoor,
  • Steve Rose,
  • Tarkeshwari Mane,
  • Vongayi Ogbeide,
  • Waqas Khaliq,
  • Yolanda Baird,
  • Arnaud Galbois,
  • Cyril Charron,
  • Guillaume Besch,
  • Guillaume Savary,
  • Hervé Mentec,
  • Jean-Luc Chagnon,
  • Jeremy Castaneray,
  • Jérémy Rosman,
  • Lucie Vettoretti,
  • Maud Mousset Hovaere,
  • Messika Messika,
  • Michel Djibré,
  • Nathalie Rolin,
  • Philippe Burtin,
  • Pierre Garcon,
  • Xavier Valette,
  • Christian Rabe,
  • Eberhard Barth,
  • Kristina Fuest,
  • Michael Horacek,
  • Raphael Romano Bruno,
  • Sebastian Allgäuer,
  • Stefan J Schaller,
  • Stefan Schering,
  • Stephan Steiner,
  • Thorben Dieck,
  • Tobias Graf,
  • Anastasia Koutsikou,
  • Aristeidis Vakalos,
  • Bogdan Raitsiou,
  • Elli Niki Flioni,
  • Evangelia Neou,
  • Fotios Tsimpoukas,
  • Georgios Papathanakos,
  • Giorgos Marinakis,
  • Ioannis Koutsodimitropoulos,
  • Kounougeri Aikaterini,
  • Nikoletta Rovina,
  • Stylliani Kourelea,
  • Tasioudis Polychronis,
  • Vasiiios Zidianakis,
  • Vryza Konstantinia,
  • Zoi Aidoni,
  • Catherine Motherway,
  • Chris Read,
  • Ignacio Martin-Loeches,
  • Andrea Neville Cracchiolo,
  • Aristide Morigi,
  • Italo Calamai,
  • Stefania Brusa,
  • Ahmed Elhadi,
  • Ahmed Tarek,
  • Wesal Ali Belkhair,
  • Alexander D Cornet,
  • Evavan Boven,
  • Jasper Haringman,
  • Lenneke Haas,
  • Lettie van den Berg,
  • Oscar Hoiting,
  • Peter de Jager,
  • Rik T Gerritsen,
  • Alena Breidablik,
  • Anita Slapgard,
  • Anne-Karin Rime,
  • Bente Jannestad,
  • Britt Sjøbøe,
  • Eva Rice,
  • Finn H Andersen,
  • Hans Frank Strietzel,
  • Jan Peter Jensen,
  • Kirsti Tøien,
  • Kristian Strand,
  • Michael Hahn,
  • Aleksandra Biernacka,
  • Anna Kluzik,
  • Bartosz Kudlinski,
  • Dariusz Maciejewski,
  • Dorota Studzińska,
  • Hubert Hymczak,
  • Jan Stefaniak,
  • Joanna Solek-Pastuszka,
  • Joanna Zorska,
  • Katarzyna Cwyl,
  • Lukasz J Krzych,
  • Maciej Zukowski,
  • Małgorzata Lipińska-Gediga,
  • Marek Pietruszko,
  • Mariusz Piechota,
  • Marta Serwa,
  • Miroslaw Czuczwar,
  • Mirosław Ziętkiewicz,
  • Natalia Kozera,
  • Paweł Nasiłowski,
  • Paweł Sendur,
  • Paweł Zatorski,
  • Piotr Galkin,
  • Ryszard Gawda,
  • Urszula Kościuczuk,
  • Waldemar Cyrankiewicz,
  • Wojciech Gola,
  • Alexandre Fernandes Pinto,
  • Ana Margarida Fernandes,
  • Cristina Sousa,
  • Inês Barros,
  • Isabel Amorim Ferreira,
  • Jacobo Bacariza Blanco,
  • João Teles Carvalho,
  • Jose Maia,
  • Nuno Candeias,
  • Vladislav Belskiy,
  • Africa Lores,
  • Angela Prado Mira,
  • David Perez-Torres,
  • Emilio Maseda,
  • Enver Rodriguez,
  • Estefania Prol-Silva,
  • Gaspar Eixarch,
  • Gemma Gomà,
  • Gonzalo Navarro Velasco,
  • MariánIrazábal Jaimes,
  • Mercedes Ibarz Villamayor,
  • Noemí Llamas Fernández,
  • Patricia Jimeno Cubero,
  • Sonia López-Cuenca,
  • Teresa Tomasa,
  • Anders Sjöqvist,
  • Fredrik Schiöler,
  • Henrik Westberg,
  • Jessica Nauska,
  • Joakim Sivik,
  • Johan Berkius,
  • Karin Kleiven Thiringer,
  • Lina DeGeer,
  • Sten Walther,
  • Joerg C Schefold,
  • Leila Hergafi,
  • Philippe Eckert,
  • Ismail Yıldız,
  • Ihor Yovenko,
  • Yuriy Nalapko,
  • Richard Pugh

DOI
https://doi.org/10.1136/bmjopen-2020-046909
Journal volume & issue
Vol. 11, no. 6

Abstract

Read online

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.