Cost awareness among intensivists in their daily clinical practice: a prospective multicentre study.

BACKGROUND: Better cost-awareness is a prerogative in achieving the best benefit/risk/cost ratio in the care. We aimed to assess the cost-awareness of intensivists in their daily clinical practice and to identify factors associated with accurate estimate of cost (50-150% of the real cost). METHODS: We performed a prospective observational study in seven French ICUs. We compared the estimate of intensivists of the daily costs of caring with the real costs on a given day. The estimates covered five categories (drugs, laboratory tests, imaging modalities, medical devices, and waste) whose sum represented the overall cost. RESULTS: Of the 234 estimates made by 65 intensivists, 70 (29.9%) were accurate. The median overall cost estimate (€330 [170; 620]) was significantly higher than the real cost (€178 [124; 239], p < 0.001). This overestimation was found in four categories, in particular for waste (€40 [15; 100] vs. €1.1 [0.6; 2.3], p < 0.001). Only the laboratory tests were underestimated (€65 [30; 120] vs. €106 [79; 138], p < 0.001). Being aware of the financial impact of prescriptions was factor associated with accurate estimate (OR: 5.05, 95%CI:1.47-17.4, p = 0.01). However, feeling able to accurately perform estimation was factor negatively associated with accurate estimate (OR: 0.11, 95%CI: 0.02-0.71, p = 0.02). CONCLUSION: French intensivists have a poor awareness of costs in their daily clinical practice. Raising awareness of the financial impact of prescriptions, and of the cost of laboratory tests and waste are the main areas for improvement that could help achieve the objective of the best care at the best cost.

Insulin therapy and blood glucose management in critically ill patients: a 1-day cross-sectional observational study in 69 French intensive care units.

BACKGROUND: Hyperglycaemia is common in critically ill patients, but blood glucose and insulin management may differ widely among intensive care units (ICUs). We aimed to describe insulin use practices and the resulting glycaemic control in French ICUs. We conducted a multicentre 1-day observational study on November 23, 2021, in 69 French ICUs. Adult patients hospitalized for an acute organ failure, severe infection or post-operative care were included. Data were recorded from midnight to 11:59 p.m. the day of the study by 4-h periods. RESULTS: Two ICUs declared to have no insulin protocol. There was a wide disparity in blood glucose targets between ICUs with 35 different target ranges recorded. In 893 included patients we collected 4823 blood glucose values whose distribution varied significantly across ICUs (P < 0.0001). We observed 1135 hyperglycaemias (> 1.8 g/L) in 402 (45.0%) patients, 35 hypoglycaemias (≤ 0.7 g/L) in 26 (2.9%) patients, and one instance of severe hypoglycaemia (≤ 0.4 g/L). Four hundred eight (45.7%) patients received either IV insulin (255 [62.5%]), subcutaneous (SC) insulin (126 [30.9%]), or both (27 [6.6%]). Among patients under protocolized intravenous (IV) insulin, 767/1681 (45.6%) of glycaemias were above the target range. Among patients receiving insulin, short- and long-acting SC insulin use were associated with higher counts of hyperglycaemias as assessed by multivariable negative binomial regression adjusted for the propensity to receive SC insulin: incidence rate ratio of 3.45 (95% confidence interval [CI] 2.97-4.00) (P < 0.0001) and 3.58 (95% CI 2.84-4.52) (P < 0.0001), respectively. CONCLUSIONS: Practices regarding blood glucose management varied widely among French ICUs. Administration of short or long-acting SC insulin was not unusual and associated with more frequent hyperglycaemia. The protocolized insulin algorithms used failed to prevent hyperglycaemic events.

Switching between thienopyridines in patients with acute myocardial infarction and quality of care.

OBJECTIVE: In acute coronary syndromes, switching between thienopyridines is frequent. The aims of the study were to assess the association between switching practices and quality of care. METHODS: Registry study performed in 213 French public university, public non-academic and private hospitals. All consecutive patients admitted for acute myocardial infarction (MI; <48 hours) between 1/10/2010 and 30/11/2010 were eligible. Clinical and biological data were recorded up to 12 months follow-up. RESULTS: Among 4101 patients receiving thienopyridines, a switch was performed in 868 (21.2%): 678 (16.5%) from clopidogrel to prasugrel and 190 (4.6%) from prasugrel to clopidogrel. Predictors of switch were ST segment elevation MI presentation, admission to a cardiology unit, previous percutaneous coronary intervention, younger age, body weight >60 kg, no history of stroke, cardiac arrest, anaemia or renal dysfunction. In patients with a switch, eligibility for prasugrel was >82% and appropriate use of a switch was 86% from clopidogrel to prasugrel and 20% from prasugrel to clopidogrel. Quality indicators scored higher in the group with a switch and also in centres where the switch rate was higher. CONCLUSIONS: As applied in the French Registry on Acute ST-elevation and non ST-elevation Myocardial Infarction (FAST-MI) registry, switching from one P2Y12 inhibitor to another led to a more appropriate prescription and was associated with higher scores on indicators of quality of care.

Impact of prolonged dual antiplatelet therapy after acute myocardial infarction on 5-year mortality in the FAST-MI 2005 registry.

BACKGROUND: We document dual antiplatelet therapy (DAPT) use from discharge to 4 years after acute myocardial infarction (AMI), and investigate whether prolonged DAPT (beyond 1 year) is related to 5-year mortality. METHODS: The French Registry of Acute ST-elevation or non-ST-elevation Myocardial Infarction (FAST-MI 2005) included 3670 patients with AMI in 223 French centres. We identified predictors of DAPT (aspirin+clopidogrel) beyond 1 and 2 years, and relation with all-cause 5-year mortality. RESULTS: Among 3319 (96%) patients with discharge data, 2432 (73%) had DAPT, 582 (17%) single antiplatelet therapy (SAPT), and 305 (9%) no antiplatelet treatment. DAPT decreased from 75% at 1 year to 29% at 4 years, with a corresponding increase in SAPT (p<0.05 for trend). Patients with DAPT were more often male, treated with a drug-eluting stent (DES), and without oral anticoagulants. Independent predictors at 1 year of prolonged DAPT were age<75 years, in-hospital bleeding, history of MI, use of DES, discharge use of beta-blockers or statins and no chronic anticoagulation. Predictors at 2 years were age<75 years, male gender, previous MI, diabetes, DES implantation, no chronic oral anticoagulation. By multivariate analysis, there was no difference in 5-year mortality between those on SAPT vs DAPT at 1 year. DAPT at 2 years was also not significantly related to 5-year mortality (Hazard Ratio 1.3, 95% CI [0.9; 1.8], p=0.21). CONCLUSION: Prolonged DAPT in selected AMI patients, observed in 47% at 1 year and 21% at 2 years, had no impact on 5-year mortality. These findings do not support the use of DAPT beyond 1 year after an initial ACS.