PT  - JOURNAL ARTICLE
AU  - Bernhard Wernly
AU  - Michael Beil
AU  - Raphael Romano Bruno
AU  - Stephan Binnebössel
AU  - Malte Kelm
AU  - Sviri Sigal
AU  - Peter Vernon van Heerden
AU  - Ariane Boumendil
AU  - Antonio Artigas
AU  - Maurizio Cecconi
AU  - Brian Marsh
AU  - Rui Moreno
AU  - Sandra Oeyen
AU  - Bernardo Bollen Pinto
AU  - Wojciech Szczeklik
AU  - Susannah Leaver
AU  - Sten Mikael Walther
AU  - Joerg C Schefold
AU  - Michael Joannidis
AU  - Jesper Fjølner
AU  - Tilemachos Zafeiridis
AU  - Dylan de Lange
AU  - Bertrand Guidet
AU  - Hans Flaatten
AU  - Christian Jung
ED  - ,
TI  - Provision of critical care for the elderly in Europe: a retrospective comparison of national healthcare frameworks in intensive care units
AID  - 10.1136/bmjopen-2020-046909
DP  - 2021 Jun 01
TA  - BMJ Open
PG  - e046909
VI  - 11
IP  - 6
4099  - http://bmjopen.bmj.com/content/11/6/e046909.short
4100  - http://bmjopen.bmj.com/content/11/6/e046909.full
SO  - BMJ Open2021 Jun 01; 11
AB  - 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.Data are available upon reasonable request. Data are available upon reasonable request.