impact of income on outcome · bellani et al jama 2016. ... greater ards severity profile –row...

John LaffeyCritical Illness and Injury Research Centre, Keenan

Research Centre, St Michael’s Hospital.

Departments of Anesthesia, Physiology and Interdepartmental division of Critical Care

Medicine, University of Toronto,

Toronto, CANADA

Impact of Income on Outcome

Conflict of Interest

• Tissue Regeneration Therapeutics, Toronto, Canada

• Orbsen Therapeutics Ltd, Galway, Ireland

• CommenceBio, California, USA

Diabetes

• Impact of severe acute respiratory failure in ICUs in ‘winter’ months– Burden of Severe Acute Respiratory Failure

– ARDS versus other causes

• LUNG SAFE Database– 450 participating ICUs in 50 countries across 5

continents

– Data from 12,906 patients

– 4,499 patients with AHRF/ARDS

LUNG SAFE

Distribution of Participating ICUs

• 62 Countries with ICUs Registered• 50 countries recruited patients (40/10)• 38 countries recruited > 25 patients

Bellani et al JAMA 2016

Europe – High Income Rest of World – High

Income

Middle income

Austria Australia Albania

Belgium Brunei Argentina

Czech Republic Canada Brazil

Denmark Chile China

France Japan Colombia

Germany New Zealand Costa Rica

Greece Saudi Arabia Ecuador

Ireland United States Guatemala

Italy Uruguay India

Latvia Iran

Netherlands Lebanon

Norway Malaysia

Poland Mexico

Portugal Morocco

Spain Peru

Sweden Philippines

Switzerland Romania

United Kingdom Russian Federation

Serbia

South Africa

Tunisia

Turkey

229 ICUs 110 ICUs 120 ICUs

World Bank - Gross National Income Categories

ARDS Outcome

• ARDS Demographics– European pts older; Greater ARDS Severity Profile

– ROW pts greater systemic illness severity (SOFA)

• Ventilator Management Approaches– Lower Tidal volumes in ROW-High Income patients

– Greater Oxygen use in European patients

• Use of Adjunctive Measures– Greater NMB use and Prone positioning use in Europe

– Recruitment maneuver use greatest in Middle Income countries

ARDS Demographics and Management

• Duration of MV and ICU Length of Stay– Longer in Europe than in ROW HI countries (after adjustment for covariates)

– Not explained by differences in national SE status

– Differences in patient management [Tidal volume; Oxygen; Other?]

• No association between ICU level variables and Outcome– Effects not explained by differences in ICU organization or staffing

Effect of Income on Outcome in ARDS

• Greater national per capita income was associated with increased patient survival from ARDS. – National rather than patient level indices [World Bank]

– Effects not explained by differences in ICU organization or staffing

• Association rather than ‘cause and effect’ linkage– Not necessarily reflecting differences in quality of critical care

– Potentially explained by differences in:• Access to critical care

• Public health / Preventive medicine

• Further evidence of effect of socioeconomic status on outcomes from critical illnesses

Income and Mortality in ARDS

• Nearly 13,000 patients

• Over 1,000 LUNG SAFE Investigators in ICUs across the Globe– 666 ICUs registered patients for LUNG SAFE

– 475 ICUs validated patients into the study

• National coordinators in over 50 countries

• LUNG SAFE Steering Group and Executive Committee– Giacomo Bellani

– Tai Pham

– Eddy Fan

• ESICM

Thank You