Physicians' perceptions and attitudes regarding inappropriate admissions and resource allocation in the intensive care setting

A. Giannini, D. Consonni

Research output: Contribution to journalArticle

36 Citations (Scopus)

Abstract

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.

Original languageEnglish
Pages (from-to)57-62
Number of pages6
JournalBritish Journal of Anaesthesia
Volume96
Issue number1
DOIs
Publication statusPublished - Jan 2006

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Resource Allocation
Critical Care
Intensive Care Units
Physicians
Diagnosis-Related Groups
Italy
Head
Economics
Pressure
Survival
Surveys and Questionnaires
Therapeutics

Keywords

  • End-of-life decisions
  • Ethics
  • Intensive care
  • Patient admission
  • Resource allocation

ASJC Scopus subject areas

  • Anesthesiology and Pain Medicine

Cite this

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title = "Physicians' perceptions and attitudes regarding inappropriate admissions and resource allocation in the intensive care setting",
abstract = "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.",
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