Trendy zmian w ostatniej dekadzie w liczbie łóżek
w oddziałach intensywnej terapii, w liczbie pacjentów hospitalizowanych w oddziałach intensywnej terapii oraz w odsetkach śmiertelności w oddziałach intensywnej terapii na Ukrainie

Roman N. Fedosiuk1, Olena M. Kovalova2

1Ukrainian Institute of Strategic Studies of the Ministry of Health of Ukraine, Kyiv, Ukraine

2Ukrainian Medical Stomatological Academy, Poltava, Ukraine

 

ABSTRACT

Introduction: At present, the world faces an extremely heterogeneous situation in providing population with access to intensive care. In healthcare systems of different countries, there are significant differences in the number of available ICU beds per 10 thousand population. Even in the united Europe, the indicator is extremely variable and ranges from 0.42 ICU beds per 10.000 population in Portugal to 2.92 ICU beds per 10.000 population in Germany (a difference of almost 7 times), amounting to an average of 1.15 ICU beds per 10 thousand population

The aim: To identify major trends in the number of ICU beds, the number of ICU patients and the rates of ICU mortality in Ukraine over the period of time from 2007 to 2015 based on the analysis of available data on the national intensive care service.

Materials and methods: The data from the 2007 nationwide audit of the domestic intensive care service and the summarized 2015 annual reports from the regional intensive care services, encompassing all the healthcare facilities that provide intensive care to population (819 hospitals in total) and represent 22 out of 26 administrative territories (regions) of the country, have been used to carry out comparative, 2015 vs. 2007, analysis and establish major trends in the indicators of interest.

Results: The negligible increase in the number of ICU beds on referential territories in absolute (from 4.765 to 5.049) and relative (from 1.4 to 1.5 per 10 thousand population) figures have been found within the period of time from 2007 to 2015. In contrast, more prominent increase in the number of ICU patients (from 385.068 to 462.395 in absolute figures and from 111.6 to 138.2 per 10 thousand population) and in ICU mortality rates (from 8.4% to 8.7%) have been established. The average Ukrainian figure of the number of ICU beds per 10 thousand population for the year 2015 (1.5) seems to be roughly comparable with the corresponding European one for the year 2012 (1.15).

Conclusions: The inclining trends in the number of ICU patients and ICU mortality rates, against the background of negligible growth in the bed capacity of the national intensive care service, indicate the need in the increase in the number of ICU beds in Ukraine.

 

Wiad Lek 2018, 71, 7, -1324

 

INTRODUCTION

At present, the world faces an extremely heterogeneous situation in providing population with access to intensive care. In healthcare systems of different countries, there are significant differences in the number of available ICU beds per 10 thousand population. Even in the united Europe, the indicator is extremely variable and ranges from 0.42 ICU beds per 10.000 population in Portugal to 2.92 ICU beds per 10.000 population in Germany (a difference of almost 7 times), amounting to an average of 1.15 ICU beds per 10 thousand population [1]. According to most researchers, the need for ICU beds will continue to grow and exceed the supply [2, 3].

Significant fluctuations in the provision of population with ICU beds, and hence the availability of access to intensive care, also form significant differences in the structure of patients who are hospitalized to ICUs, concentrating on such beds in countries with low incidence only the most severe patients (mostly patients with organ dysfunctions, requiring their “prosthetics”), and in countries with higher rates – patients of moderate severity [4].

The healthcare system of Ukraine has undergone tangible changes in recent years. In the light of the country’s strategic course toward integration into the European community and the need for radical reform of the health sector, the task of adequate assessing the available resources in terms of compliance with minimum international standards is extremely relevant. The limited financial capabilities of the state, on the other hand, dictate the need to find the most rational models for organization of its medical services, in the first place – emergency and intensive care services. Given the above, the study of recent trends in providing the Ukrainian population with ICU beds and indicators of their use, as well as comparison with indicators of other countries is a prerequisite for successful planning for the immediate and long-term perspective.

THE AIM

The aim of the research is to identify major trends in the number of ICU beds, the number of ICU patients and the rates of ICU mortality in Ukraine over the period of time from 2007 to 2015 based on the analysis of available data on the national intensive care service.

MATERIALS AND METHODS

The study encompasses all healthcare facilities of the Ministry of Public Health providing intensive care that represent most (22 out of 26) administrative regions of Ukraine and include regional (23), city (151), central district (423), obstetrical and gynecological (71), and narrow-profile (151) hospitals. Due to the territorial changes that have occurred in Ukraine since 2013, Crimea, Sevastopol, Donetsk and Luhansk regions were excluded from the study. The data for the study were drawn from the results of the nationwide audit of the anesthesiology and intensive care service of Ukraine carried out in 2007 and from the unified annual reports of the regional subdivisions of the service to the Ministry of Health submitted in 2015.

The analysis of trends was carried out regarding the following indicators:

– absolute and relative (per 10 thousand population) number of ICU beds in the healthcare facilities of different levels and types;

– absolute and relative (per 10 thousand population) number of ICU patients in the healthcare facilities of different levels and types;

– absolute number of ICU deaths and ICU mortality rates in the healthcare facilities of different levels and types.

The data of the State Statistics Committee of Ukraine on 2007 and 2015 populations were used for calculations

The statistical processing of the data was performed using the STATA software, version 11 for Windows (StataCorp, Texas, USA) and MSExcelXP. The central tendency was determined using median and quartiles – Me (Q1-Q3). Comparison of relative variables was performed using the c2 criterion (chi-square) with the odds ratio (OR) and their 95% confidence intervals (95% CI). To prove the association between the relative values, the Poisson regression was used with the calculation of the coefficient β, its standard error (m), and 95% CI.

RESULTS

It has been determined that over the period of time from 2007 to 2015, the number of ICU beds in all the institutions included in the study has only slightly increased in absolute figures (from 4.765 to 5.049 in total) but did not significantly change in relative terms. Thus, in 2007, there were 1.4 and in 2015 – 1.5 ICU beds per 10 thousand population (OR 1.03; 95% CI 0.98-1.07; p=0.1508), with significant heterogeneity in separate administrative territories (Q1=1.3; Q3=1.8).

Within this period of time, distribution of the ICU beds among the facilities of different levels and types did not significantly change as well. Hence, in the group of regional hospitals, the proportion of ICU beds remained at the same level despite the increase in their absolute number by 6% (Table I).

In the group of city hospitals, the absolute number of ICU beds and their proportion in the total number of ICU beds within this period of time decreased (from 26.4% to 23.7%, p = 0.002), however, in the group of central district hospitals, the absolute number of ICU beds increased by 4% while their proportion in the overall distribution of ICU beds remained unchanged. At the same time, in the groups of obstetric and gynecological hospitals and narrow-profile establishments, the absolute numbers of ICU beds and their proportions in the total number of ICU beds increased (by 41.4% and 16.4%, respectively). Thus, in 2007-2015, the increase in the total number of ICU beds was mainly due to obstetric and gynecological hospitals and narrow-profile institutions.

In contrast, the number of patients treated in 2007-2015 in ICUs significantly increased both in absolute figures and per 10 thousand population – from 385.068 (111.6 per 10 thousand population) to 462.395 (138.2 patients per 10 thousand population), OR 1.24 95% CI (1.23-1.25), p = 0.000. In the analysis of the distribution of ICU patients among the institutions of different types, there was a significant decrease in the dynamics of the proportion of patients treated in regional hospitals’ ICUs to the entire cohort of patients treated in ICUs. Similar trends are also characteristic of the group of narrow-profile establishments. However, the increasing dynamics of the proportion of patients treated in ICUs in the groups of central district hospitals and obstetric and gynecological hospitals were confirmed (Table II).

Along with the increase in the number of ICU patients, the ICU mortality rate has also significantly increased. Thus, in 2007-2015, in the institutions included in the survey the increasing dynamics of the average Ukrainian indicator from 8.4% to 8.7% was noted, mostly at the expense of the regional hospitals (increase from 10.0% to 10.8%) and the central district hospitals (increase from 9.0% to 10.5%). In the groups of city hospitals and obstetric hospitals, however, the ICU mortality rates have significantly decreased (Table III).

A more detailed analysis of the average mortality rates in the healthcare facilities of different levels revealed significant variations in the groups of regional hospitals, city hospitals, central district hospitals and narrow-profile institutions, that is, although the median value of the mortality rate is similar to other countries, its interquartile interval is quite wide (Fig. 1).

Taking into account such heterogeneity in the ICU mortality rate, we determined the relationship between mortality and the ratio of ICU beds per 10.000 population by Poisson regression (Table IV). According to the results of the study, there is an inverse relationship between the mortality rate and the number of ICU beds in the group of city hospitals and a direct relationship between these two indicators in the group of narrow-profile institutions.

DISCUSSION

Our research showed that in 2015, the average number of ICU beds in Ukraine amounted 1.5 per 10 thousand population. Similar figures are typical for many European countries. According to Rhodes A., the average number of ICU beds per 10 thousand population in Europe in 2012 was 1.15, with significant differences between countries [1].

Over the period of time from 2007 to 2015, the absolute number of ICU beds and the number of ICU beds per 10 thousand population in Ukraine did not significantly change. Opposite tendencies are characteristic of most developed countries of the world, where the absolute numbers of ICU beds and their proportions in the hospitals’ total bed capacities increase [3]. In the USA, for example, the number of ICU beds since 2000 till 2010 increased by 17.8%, despite the reduction in the total number of hospital beds by 2.2% [3].

On the contrary, the number of patients treated in Ukrainian ICUs in 2015 vs. 2007 increased both in absolute figures and in terms of their number per 10 thousand population. A significant increase in ICU mortality rates was also found, in particular in the groups of regional and central district hospitals.

It is known that provision of population with ICU beds influences the spectrum of patients hospitalized to ICUs. In the study of H. Wunsch et al., high correlations between the number of ICU patients with sepsis and the number of ICU beds per capita are given [4]. Thus, among some European countries that have the same per capita health expenditure the incidence of serious sepsis in ICU patients dramatically differs due to the differences in the availability of ICU beds making up 10% among all hospitalizations to ICUs in Switzerland and 64% among all hospital admissions to ICUs in Portugal [5]. Similarly, the percentage of ICU patients hospitalized with acute renal failure varies from 3.3% in Germany (with many ICU beds) to 20.6% in the UK (with an eight-fold lower number of ICU beds) [6]. These data are in line with the idea that in countries with a limited number of ICU beds and ICUs, they are reserved for the most severely ill patients and are not used to treat patients with many other less life-threatening illnesses [4].

Literature sources indicate that the shortage of available ICU beds can lead to the refusal or delay in the hospitalization of patients to ICUs [7, 8]. At the same time, both circumstances are clearly associated with an increased risk of patients’ mortality, a worse prognosis and an increase in the length of stay at both ICU and hospitals [9-11]. Cardoso L.T. et al. [11] reported that every hour of delay in hospitalization of a patient to ICU is associated with an increased risk of death by 1.5% at ICU and 1% at the hospital. The systematic review of literature conducted by Sinuff T. et al. confirmed that hospital mortality is three times higher among patients who are denied admission to ICU [12].

CONCLUSIONS

The analysis of bed capacity of the intensive care service in Ukraine showed its negligible growth over the last decade (despite the increasing number of patients demanding intensive care) and the uneven pattern of ICU beds distribution among regions and institutions that implies some systemic risks and latent hazards to patient safety hidden primarily in the relative shortage of ICU beds and unequal accessibility of such beds to critically ill patients across the country. Over the period of time from 2007 to 2015, we found a significant increase in the number of ICU patients and ICU mortality rates – in Ukraine in general and in the regional and central district hospitals in particular. ICU mortality rate in the group of city hospitals has been found to be inversely related to the number of ICU beds per 10 thousand population. Such trends indicate the need in the increase in the number of ICU beds in Ukraine.

REFERENCES

1. Rhodes A., Ferdinande P., Flaatten H. [et al.]: The variability of critical care bed numbers in Europe. Intensive Care Med. 2012, 38 (10): 1647-1653.

2. Adhikari N. K., Fowler R. A., Bhagwanjee S., Rubenfeld G. D. Critical care and the global burden of critical illness in adults. Lancet. 2010, 376 (9749): 1339-1346.

3. Halpern N. A., Goldman D. A., Tan K. S., Pastores S. M. Trends in Critical Care Beds and Use Among Population Groups and Medicare and Medicaid Beneficiaries in the United States: 2000-2010. Crit. Care Med. 2016, 44 (8): 1490-1499.

4. Wunsch H., Angus D. C., Harrison D. A. [et al.]: Variation in critical care services across North America and Western Europe. Crit Care Med. 2008, 36: 2787-2793.

5. Vincent J. L., Sakr Y., Sprung C. L. [et al.]: Sepsis in European intensive care units: results of the SOAP study. Crit Care Med. 2006, 34: 344-353.

6. Uchino S., Kellum J. A., Bellomo R. [et al.]: Beginning and Ending Supportive Therapy for the Kidney (BEST Kidney) Investigators: Acute renal failure in critically ill patients: a multinational, multicenter study. JAMA. 2005, 294: 813-818.

7. Robert R., Reignier J., Tournoux-Facon C. [et al.]: Refusal of intensive care unit admission due to a full unit: impact on mortality. Am J Respir Crit Care Med. 2012, 185: 1081-1087.

8. Pilcher D. V., Duke G. J., George C. [et al.]: After-hours discharge from intensive care increases the risk of readmission and death. Anaesth Intensive Care. 2007, 35: 477-485.

9. Pastores S. M., Dakwar J., Halpern N. A.: Costs of critical care medicine. Crit Care Clin. 2012, 28: 1-10.

10. Wunsch H., Gershengorn H., Scales D. C.: Economics of ICU organization and management. Crit Care Clin. 2012, 28: 25-37.

11. Cardoso L. T., Grion C. M., Matsuo T. [et al.]: Impact of delayed admission to intensive care units on mortality of critically ill patients: a cohort study. Crit Care. 2011, 15: R28.

12. Sinuff T., Kahnamoui K., Cook D. J. [et al.]: Rationing critical care beds: a systematic review. Crit Care Med. 2004, 32: 1588-1597.

 

Authors’ contributions:

According to the order of the Authorship

Conflict of interest:

The Authors declare no conflict of interest

CORRESPONDING AUTHOR

Roman N. Fedosiuk

39 Myropolskaia St., ap. 91, Kyiv, Ukraine

tel: +380504136403

e-mail: anest.moz.1@gmail.com

Received: 10.07.2018

Accepted: 18.09.2018

Table I. The dynamics in the distribution of ICU beds among the institutions of different levels and types in 2007-2015.

Types of institutions

Number of beds

OR (95% CI) 2015 vs. 2007

р

2007

2015

abs.

%

abs.

%

Ukraine

4765

100

5049

100

   

Regional hospitals

527

11.1

559

11.1

1.0 (0.88-1.14)

0.985

City hospitals

1256

26.4

1196

23.7

0.87 (0.79-0.95)

0.002

Central district hospitals

1970

41.3

2049

40.6

0.96 (0.89-1.05)

0.444

Obstetric and gynecological hospitals

268

5.6

379

7.5

1.36(1.15-1.61)

0.000

Narrow-profile institutions

744

15.6

866

17.2

1.12 (1.0-1.25)

0.039

Table II. The dynamics in the distribution of ICU patients among the institutions of different levels and types in 2007-2015.

Types of institutions

Number of treated patients

OR (95% CI) 2015 vs. 2007

р

2007

2015

abs.

%

abs.

%

Ukraine

385068

100

462395

100

1.24 (1.23-1.25)

0.000

Regional hospitals

44011

11.4

42974

9.3

0.79 (0.78-0.80)

0.000

City hospitals

116797

30.3

140185

30.3

0.99 (0.99-1.01)

0.000

Central district hospitals

137353

35.7

169418

36.6

1.04 (1.03-1.05)

0.000

Obstetric and gynecological hospitals

29902

7.8

47586

10.3

1.36 (1.34-1.38)

0.000

Narrow-profile institutions

57005

14.8

62232

13.5

0.89 (0.88-0.9)

0.000

Table III. The dynamics in ICU mortality among the institutions of different levels and types in 2007-2015.

Types of institutions

The number of deaths among ICU patients

OR (95% CI) 2015 vs. 2007

р

2007

2015

abs.

%

abs.

%

Ukraine

32328

8.4

40276

8.7

1.04 (1.02-1.05)

0.000

Regional hospitals

4415

10.0

4654

10.8

1.09 (1.04-1.14)

0.000

City hospitals

13113

11.2

15161

10.8

0.96 (0.93-0.98)

0.009

Central district hospitals

12374

9.0

17751

10.5

1.18 (1.15-1.21)

0.000

Obstetric and gynecological hospitals

29

0.1

14

0.03

0.30 (0.15-0.59)

0.001

Narrow-profile institutions

2397

4.2

2696

4.3

1.03 (0.97-1.09)

0.277

Table IV. Relationship between the ICU mortality rate and the number of ICU beds per 10 thousand population in the institutions of different levels and types

 

Variables

β

m

р

95% CI

Ukraine

ICU beds

-0.012

0.021

0.571

-0.54-0.029

_cons

2.38

0.33

0.000

1.73-3.035

Regional hospitals

ICU beds

-0.065

0.069

0.342

-0.20-0.09

_cons

2.58

0.13

0.000

2.32-2.84

City hospitals

ICU beds

-0.104

0.032

0.001

-0.168-(-0.04)

_cons

2.907

0.109

0.000

2.69-3.12

Central district hospitals

ICU beds

-0.037

0.03

0.215

-0.98-0.02

_cons

2.62

0.209

0.000

2.21-3.03

Obstetric and gynecological hospitals

ICU beds

-0.32

2.07

0.875

-4.39-3.74

_cons

-2.81

2.34

0.230

-7.39-1.78

Narrow-profile institutions

ICU beds

0.16

0.075

0.028

0.018-0.31

_cons

0.917

0.242

0.000

0.44-1.392

Fig. 1. Major characteristics of variational series in the ICU mortality rate in the institutions of different levels and types in 2015