BJA Advance Access originally published online on November 25, 2005
British Journal of Anaesthesia 2006 96(1):57-62; doi:10.1093/bja/aei276
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CRITICAL CARE |
Physicians' perceptions and attitudes regarding inappropriate admissions and resource allocation in the intensive care setting
1 Paediatric Intensive Care Unit, Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Via della Commenda 9, 20122 Milano, Italy. 2 Unit of Epidemiology, Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Via San Barnaba 8, 20122 Milano, Italy
* Corresponding author. E-mail: a.giannini{at}policlinico.mi.it
Accepted for publication September 12, 2005.
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Abstract |
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Background. Physicians' perceptions regarding intensive care unit (ICU) resource allocation and the problem of inappropriate admissions are unknown.
Methods. We carried out an anonymous, self-administered questionnaire survey to assess the perceptions and attitudes of ICU physicians at all 20 ICUs in Milan, Italy, regarding inappropriate admissions and resource allocation.
Results. Eighty-seven percent (225/259) of physicians responded. Inappropriate admissions were acknowledged by 86% of respondents. The reasons given were clinical doubt (33%); limited decision time (32%); assessment error (25%); pressure from superiors (13%), referring clinician (11%) or family (5%); threat of legal action (5%); and an economically advantageous ‘Diagnosis Related Group’ (1%). Respondents reported being pressurized to make more ‘productive’ use of ICU beds by Unit heads (frequently 16%), hospital management (frequently 10%) and colleagues (frequently 4%). Five percent reported refusing appropriate admissions following ‘indications’ not to admit financially disadvantageous cases. Admissions after elective surgery prioritized patients from profitable surgical departments: frequently for 6% of respondents and occasionally for 15%. Sixty-seven percent said they frequently received requests for appropriate admissions when no beds were available. This was considered sufficient reason to withdraw treatment from patients with lower survival probability (sometimes 21%) or for whom nothing more could be done (sometimes 51%, frequently 11%).
Conclusions. Inappropriate ICU admissions were perceived as a common event but were mainly attributed to difficulties in assessing suitability. Physicians were aware that their decisions were often influenced by factors other than medical necessity. Economic influences were perceived as limited but not negligible. Decisions to forgo treatment could be influenced by the need to admit other patients.
Keywords: end-of-life decisions; ethics; intensive care; patient admission; resource allocation
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Introduction |
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Much effort has gone into defining admission criteria for intensive care units (ICUs)1 –4 and drawing up the requisite guidelines.5 –7 Patients too sick or too well to benefit from intensive care should not be admitted,7 but it is not easy to identify such patients2 or to put into practice recommendations for transferring triage cases to ICU under real-life conditions.8 These clinical difficulties are compounded by the growing constraint of cost,6 9 and ICU physicians have become aware that ICU beds are a limited and expensive resource.10 11
Shortage of beds is an everyday occurrence in many ICUs,12 13 and bed allocation is considered one of the most difficult and stressful aspects of the work of ICU physicians.14 Previous studies have found that non-clinical factors influence decisions to admit patients to ICU.15 –17 However, there have been virtually no studies on ICU physicians' perceptions of this problem or of the appropriateness of their decisions. In particular, there are no data regarding inappropriate admissions to Italian ICUs. We investigated ICU physicians' perceptions of inappropriate admissions and their attitudes to resource allocation in an Italian urban setting, also evaluating perceptions of ‘extraneous’ influences on choices of bed allocation.
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Methods |
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We carried out a questionnaire-based survey among intensive care physicians of the city of Milan, Italy. The questionnaire was first tested for clarity of content on physicians in another city in the north of Italy, following which minor modifications were made. We then wrote to all physicians permanently employed in the ICUs of Milan explaining the aims of the study and asking them to take part. We gave assurances that neither the individuals nor their Units would be identifiable. The questionnaire was delivered personally to all who said they would participate. The time between questionnaire delivery and collection was 2 months (June–July 2001).
The first part of the questionnaire solicited personal and professional information; the second asked for opinions on and attitudes to clinical situations, to which the respondent usually replied by selecting one of the multiple choice answers. An additional questionnaire was given to Unit heads asking for details about their Unit. An analysis of questionnaire replies regarding end-of-life decisions has been published.18 The present analysis is concerned with attitudes to inappropriate admissions and resource allocation. An inappropriate admission was considered as the admission of a patient who, in the physician's professional opinion, would not benefit from intensive care.
We assessed the influence of the following dichotomized variables on reported opinions: respondent age (
35 yr, >35 yr), respondent sex, years as practising physician (10, >10 yr), main activity (anaesthesia, intensive care), and religious belief (believer, non-believer). We used univariate analysis and the chi-square test followed by logistic regression modelling using all variables except age (strongly related to years of service), estimating odds ratios (ORs) with 95% confidence intervals (CIs). The Stata 8.2 (Stata Corporation, College Station, TX, USA) software package was used.
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Results |
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The response rate was 87% (225/259); 34 physicians (13%) declined or did not respond. The characteristics of the respondents and their ICUs are shown in Table 1.
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Inappropriate admissions
Inappropriate admissions were acknowledged by 86% of respondents (sometimes 80%; often 6%). The most common reasons given (Table 2) were clinical doubt (33%), limited decision time (32%), assessment error (25%), pressure from superiors (13%) and pressure from the referring clinician (11%). Low frequency reasons were pressure from patient's family (5%), threat of legal action (5%) and economically advantageous Diagnosis Related Group (DRG) (1%).
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Inappropriate admissions were acknowledged more by experienced (>10 yr) than less experienced physicians (OR 3.97, 95% CI 1.65–9.53). Women were less inclined than men to acknowledge assessment error (OR 0.54, 95% CI 0.29–0.99), clinical doubt (OR 0.49, 95% CI 0.25–0.98) or threat of legal action (OR 0.41, 95% CI 0.18–0.89) as reasons for their inappropriate admissions. Those who professed religious beliefs more often reported that their inappropriate admissions were due to threat of legal action (OR 2.53, 95% CI 1.05–6.06). Physicians who worked mainly in an ICU were less influenced by fear of legal consequences than those who worked mainly in anaesthesia (OR 0.40, 95% CI 0.16–0.96).
Economic factors
Respondents (Table 3) said they were pressurized to make more ‘productive’ use of ICU beds by the Unit head (frequently or habitually, 16%), hospital management (frequently or habitually, 10%) and colleagues (frequently or habitually, 4%). Pressure by hospital management was acknowledged significantly more often by physicians who worked mainly in an ICU than anaesthetists (OR 3.15, 95% CI 1.05–9.46).
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Five percent of physicians stated they had on occasion refused admission to appropriate cases because they had received ‘indications’ not to admit cases that would result in financial loss. Financial loss occurs because the DRG reimbursement from the Health Authorities for that case is lower than the actual cost of treatment and admission. A proportion (occasionally 15%, frequently or habitually 6%) indicated that admissions after elective surgery tended to prioritize patients from the most profitable surgical departments (departments whose activities attract high payments from the Health Authorities).
Allocation of limited resources
Sixty-seven percent of respondents said they ‘frequently’ received requests for appropriate admissions when no beds were available. The arrival of such a request was considered sufficient reason to withdraw or limit treatment from an already-admitted patient with less chance of survival than the candidate admission (sometimes 21%) or from one for whom there was nothing that could be done (sometimes 51%; frequently or habitually 11%).
For the scenario of an emergency patient and one from elective surgery competing for a single available bed, 79% said they would seek to delay the surgery, 5% would try to get the emergency case transferred to another ICU, and 1% would stop treating another patient they considered they could do nothing more for, transferring him/her to a medical or surgical ward. For the scenario of an emergency patient in competition with a liver transplant case, 3% said they would stop the transplant, 84% would seek to transfer the emergency case to another ICU and 7% said they would stop treating another patient they considered they could do nothing more for, transferring him/her to a medical or surgical ward. Physicians who worked mainly in an ICU tended to be more likely than anaesthetists (OR 3.15, 95% CI 0.95–10.3) to stop treating a patient for whom they could do nothing more, so as to make way for the liver transplant case.
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Discussion |
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A high proportion (87%) of physicians who were asked to participate completed the questionnaire, suggesting that the themes investigated were of interest to the physicians, and that the findings provide a representative picture of the opinions of Milan ICU physicians (but not necessarily of those in Italy as a whole). Since self-reported attitudes and opinions, not decisions, were investigated, the findings may not correlate closely with practice. We did not set ourselves the task of assessing the actual frequency of inappropriate ICU admissions. We acknowledge that respondents may have underreported certain practices or opinions for fear of legal consequences. The questionnaire has not yet been subjected to formal validity testing.
Four major findings emerged. First, inappropriate ICU admissions were perceived by our ICU physicians as a common event but were mainly attributed to real difficulties in assessing the appropriateness of admissions. Since decisions about admissions are typically made under stress (limited time, complex clinical picture, etc.) it is not always possible to accurately ascertain who is too sick or too well to benefit, and a certain proportion of inappropriate admissions must therefore be considered ‘physiological’. In such situations we suggest it may be correct for the physician to tend towards admitting a patient to provide the best chance of recovery.
Secondly, the physicians were aware that their decisions were not based purely on medical necessity but often influenced by external factors. Similar findings have been reported by the few other studies performed in this area (none of which investigated perceived reasons for inappropriate admissions). A Europe-wide survey12 found that although ICU admissions were generally or commonly limited by bed availability, 78% of ICU physicians said they admitted patients with only a small chance of survival beyond a few days, and 64% said they admitted patients with no chance of survival. A US cohort study reported that over 40% of ICU respondents would admit patients in a chronic vegetative state,19 and a French multicentre study found that 26.1% of admitted patients had conditions for which ICU care is generally considered futile (persistent vegetative state, brain death, end-stage respiratory or heart failure and metastatic cancer).8 Similarly, a British survey found that 17.2% of ICU physicians would admit the patient when they estimated a survival probability of <1%.20 The same study also found that reported admission decisions varied even when estimates on survival agreed.20 We suggest that such behaviour can partly be attributed to physicians' concern to preserve life, leading them to override the principle of proportionality of treatment.21
However other, less ‘benign’ factors may influence admission decisions. In fact our second main finding was that physicians were aware their decisions were often influenced by non-clinical factors such as pressure from superiors, from the referring clinician and from the patient's family and also the threat of legal action. Other studies have also indicated that pressure from patients and their families to ‘do everything possible’15 22 and fear of legal action15 can influence ICU decisions, while pressure from the referring physician seems to exert a major influence.15 22 –24 In this context it is noteworthy that primary care physicians tend to overestimate (compared with ICU physicians) the probability of a patient having a favourable outcome.25 Other factors suggested in the literature are a propensity of ICU physicians to admit and then withdraw treatment rather than refuse admission,20 26 a desire to try out non-validated technology on patients too ill to benefit from established ICU procedures,15 the presence of transplant and other programmes which prioritize patients from those sources,16 27 physician seniority,28 interpersonal relations16 and even an ‘upbeat’ patient personality.29
Third, among non-clinical factors, economic factors—pressure to use ICU beds more productively—were perceived as having an important influence on decisions to admit. This is a novel finding for Italy. Public hospitals in Italy are reimbursed by the Health Authorities for treating patients according to a DRG system based on estimates of average costs of treatments, considering also mean length of hospital stay and mean rate of complications.30 Nevertheless, certain diseases and treatments are reimbursed better than others; length of admission always has a major influence on cost.
Other studies have found that economic factors have complex and multifaceted influences on medical decisions.31 –33 Financial incentives and disincentives by US health maintenance organizations have been reported to influence physicians' clinical decisions, both generally34 and in intensive care.35 Other data indicate that financial incentives tend to encourage the selection of less complex cases.10 32 A US study concluded that political power, medical provincialism and income maximization influenced bed allocation more than patient need.17 In Europe, a Swiss survey found that around 20% of ICU physicians rated costs as important when assessing patients for ICU admission.29 By contrast, in France and Italy costs are generally perceived by physicians to have no real role in end-of-life decisions in the ICU setting.18 36
Our fourth major finding is that decisions such as foregoing of treatment, which have a strong ethical dimension, could also be influenced by non-clinical considerations. Thus, for a considerable proportion of responding physicians it was acceptable to stop treating a patient with relatively low chance of survival when a request was received for an appropriate admission, yet a bed was not available. Our previous study noted that women, and physicians who worked mainly in an ICU, were less willing to stop treating patients in such circumstances.18 A US study also found that for 3% of physicians, bed requirement by another critical patient could induce them to turn off the ventilator of an admitted patient.37 This behaviour is particularly significant when we recall that for most of our respondents bed shortages were a daily occurrence and that other studies also indicate lack of ICU beds as a perennial problem.12 13 This is clearly a delicate and complex area, rendered more so by the clinical complexity, limited decision times, high demand and limited resources that are the reality of many ICUs. However it is our opinion that the doctor has an ethical and professional obligation to patients already in ICU who may be compromised by such behaviour. This opinion is supported by the SCCM Consensus Statement on the triage of critically ill patients,5 the 2003 International Consensus Conference in Critical Care38 and other publications.19 39 40
The decision to stop treating should involve the patient and the entire treating team, and respect the principle of proportionality of treatment.21 However the responsibility of treating patients requiring intensive care does not fall solely on the individual physician but also on the hospital and entire health structure: these have the moral obligation to make additional resources available in cases of exceptional or emergency need.5 41
To conclude, in the urban setting of Milan, inappropriate ICU admissions were perceived as a common event by the physicians involved but were mainly attributed to difficulties in assessing suitability for admission. However physicians were also aware that their decisions were not purely based on medical necessity but often influenced by external factors. It is interesting that the main problems were perceived as clinical and that economic influences were seen as limited though not negligible. Our study in part corroborates previous findings on inappropriate admissions. However for the first time it presents ICU physicians' views on such admissions and also sheds more light on the various reasons for their occurrence.
We agree with Martin et al.24 that the process of decision making in critical care should be more closely monitored, and in the absence of a consensus about priorities ‘a key goal is a fair decision-making process’. Furthermore, when ICU resource rationing is necessary it should be conducted openly and discussed adequately,11 with full regard to ethical considerations. A clear understanding of the factors influencing inappropriate admissions is an important starting point for improving decision-making and fairly allocating limited ICU resources.
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Acknowledgments |
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This study was partly supported by and carried out in collaboration with the Centre for Bioethics, Catholic University of Milan. We thank all the physicians who took the trouble to complete the questionnaire. We are pleased to acknowledge Enrico M. Tacchi (Department of Sociology, Catholic University of Milan) for help with the development of the questionnaire, Clemente Lanzetti (Department of Sociology, Catholic University of Milan) for the statistical advice and analysis, and Don Ward for the translation.
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Footnotes |
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Presented, in part, at the Joint Meeting of the European Society of Anaesthesiologists and European Academy of Anaesthesiology, Lisbon, Portugal, June 5–8, 2004, and published in abstract form in Eur J Anaesthesiol 2004; 21 (Suppl 32): A712. 
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