On the future of critical care medicine
Article Outline
The past 30 years has witnessed major advances in the management of the critically ill patients. With the advances in hemodynamic monitoring, organ support (notably mechanical ventilation modes, renal replacement therapies, and enteral nutrition), as well as progress in pharmacotherapy (including safer immune suppression, broad-spectrum antibiotics, and accurate drug delivery systems), critical care medicine has matured into a legitimate major hospital-based specialty. It now can boast its own subspecialty board examination in internal medicine, no longer subservient to another subspecialty, such as pulmonary medicine, infectious disease, or cardiology for precertification. With these changes, the practice of acute care medicine in the industrialized world has also evolved. Hospitals have become acute care centers, and the less ill are now treated on an ambulatory basis, whereas in the recent past they were kept in hospitals for such care. Clearly, economic pressures have driven much of these changes though their impact on costs and outcomes is less clear [1]. Still, critical care medicine must take center stage in the debate on the appropriateness of such decisions and on the processes by which resource limitation and triage of acute care are decided.
The landscape of medicine is rapidly changing and so too must our approach to these issues within the rubric of outcomes research [2]. Major public debate needs to take place on several fronts related to these issues. Presently, the major issues include (1) the ethics of cost containment; (2) effective ways to implement best practices, once known, and how to quantify their use and effectiveness; and (3) the impact of life saving therapies on the lives of the survivors of critical illness, their families and society.
Cost containment is not an option but an on-going practice. It is mandated by governments, third party payers, and, indeed, society in an indirect fashion, owing to limited resource availability. The cost of acute care is just too high to continue treating everyone with every treatment that is possible [3]. The rise of quality improvement activities, evidence-based medicine practice guidelines, and cost containment mandates directly impact the productivity and financial performance of health care systems and are at the center of modern hospital health care. Unfortunately, cost containment activities result in increasing managerial use of process of care changes often undertaken without appreciation of risks, either known or unknown, that they may pose to patients. This has created a world of confusion in research ethics and in the dual fiduciary role that physicians have to their patients and the health care system as a whole.
Major obstacles both man made and structural prevent the rapid dissemination of proven therapies to the actual practice of care [4]. For example, if the 5 most basic proven beneficial cardiovascular therapies (aspirin for acute coronary syndrome, β-adrenergic blockers after myocardial infarction, smoking cessation counseling, antihypertensive, and lipid-lowering drug therapies) were given to appropriate patient groups once identified, both overall mortality and morbidity would decrease more than that seen if we were to find a cure for AIDS [5]. And these treatments are just for one organ system disease process. Imagine how much better society would be if all the proven therapies were given to at least most patients in whom known benefit would occur. Research into ways to realize this vision is at the epicenter of health services research.
Finally, mortality rates from critical illness tell us nothing about the quality of life of the survivors or the burden of their illness of their families and related informal caregivers. For example, survivors of prolonged mechanical ventilation often have post-traumatic stress disorder often independent of their physical limitations postillness profoundly reducing their quality of life [6]. More than 40 million Americans serve as informal caregivers to their ill loved ones and often have physical, psychological, and financial burden as a result. The social and financial impact of these detrimental results of surviving critical illness result in billions of dollars lost each year [7]. Focusing on short-term mortality and morbidity ignores these very real outcomes and does not serve the medical profession or society well.
The Journal of Critical Care Medicine has long been focusing on these very issues of health services research. This area of medicine is no longer the domain of a few organizationally focused process-oriented academicians but clearly touches the very lives of our patients, their families, society, and our practice of acute care medicine. It is our hope that this vision and debate expand into all areas of medicine and become a central theme of medical education and practice into the foreseeable future.
References
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- Evidence-based clinical practice guideline for the prevention of ventilator-associated pneumonia. Ann Intern Med. 2004;141:305–313
- AHA guidelines for primary prevention of cardiovascular disease and stroke: 2002 update: consensus panel guide to comprehensive risk reduction for adult patients without coronary or other atherosclerotic vascular disease. American Heart Association science advisory and coordinating committee. Circulation. 2002;106:388–391
- Long-term mortality and quality of life after prolonged mechanical ventilation. Crit Care Med. 2004;32(1):61–69
- Informal caregiver burden among survivors of critical illness. Am J Respir Crit Care Med. 2007;175(1):167–173
PII: S0883-9441(07)00159-1
doi:10.1016/j.jcrc.2007.11.001
© 2007 Elsevier Inc. All rights reserved.
