No abstract

No abstract

R, Artigas A, Strosberg M, Lemeshow S_ Defining a high-performance lCU system for the 21st century: a position paper.] Intensive Care Moo 1998; 13:195-205. In the fall of 1997 George D. Lundberg and]ohn E. Wennberg wrote an editorial in]AMA calling for comprehensh'e qualitl' improvement programs to become the drh-er of the American health care sl'stem. The suggestion came dUring the Second European Forum on Qualitl' Improvement in Health Care held in Paris, France, in April 1997 and was based on comments made bl' Donald Berwick. The concept was to focus on an organized response to problem identification and proposed solutions to improve patient care and protect the health of the public. Critical care medicine represents a large segment of health care and is undergoing dramatic changes during our managed care revolution. General lCU severity of illness models have been developed, tested, and shown to pro\'idc a useful estimate of hospital mortalitl' for populations of criticalll' ill patients. These systems have captured the imagination of clinical researchers and have become an integral component of a large number of publications as well as a part of manl' lCU databases. These risk adjustment severitl' models are remarkably robust for heterogeneous patient populations but the models have not been From the ·Center for Health Services Research, shown to validate well in new settings. We feel that by focusing on the episode of critical illness rather than each individual lCU admission and by going be}'ond the traditional acute hospital discharge to determine whether the patient lives or dies, we can bctter e\":lluatc critical carc systelll performance and cost-effectivcncss. The incentives for high quality/low cost should favor integrated comprehensive critical care delivery systems. Programs that score well should be identified as high quality and be honored as medallion level 1 lCUs. We challenge national and international critical care societies to e\":lluate and then debate the described definitions and recommendations as a call to action.In order to facilitate the study of outcomes in critical care medicine for the 21st century, it is important to better define what constitutes a high-performance leu system. leus do not function in isolation in the process of caring for an acute critical illness, and comparisons of leu mortality and length of stay are directly affected by the growing use of intermediate or step-down units and subacute or long-term ventilator facilities not necessarily linked to an leu or hospital. Measurement of system performance should include mortality, functional outcome, and resource consumption in the leU, intermediate care unit, and regular nursing units, as well as status beyond hospital discharge. Lundberg and Wennberg [II, based on a suggestion by Berwick, recently requested proposals that can provide directions for measuring the quality of major segments of our evolving health care system. We propose measuring quality of care for leu systems by focusing specifically on the first ...