Intensive care accessibility and outcomes in pandemics
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EDITORIAL
Intensive care accessibility and outcomes in pandemics Fernando G. Zampieri1* , Markus B. Skrifvars2 and James Anstey3 © 2020 Springer-Verlag GmbH Germany, part of Springer Nature
Limited access to intensive care units (ICU) during pandemics can be a contributor to excessive mortality. While lots of attention is given to individual ICU’s performance focusing on staffing, organizational features and adherence to best care management protocols [1, 2], there are few discussions as to how to optimize access to ICU at a regional level taking into account population densities [3]. Such efforts could theoretically result in a more homogeneous distribution of patients and a lower risk of overloading units in a given geographical area. In this issue of Intensive Care Medicine, Bauer and coworkers provide an in-depth study of accessibility to ICU beds in 14 European countries during the coronavirus disease 2019 (COVID-19) pandemic [4]. They demonstrate that great variability exists in geographical access to intensive care in different European countries, and also imply that this may be associated with case fatality ratio (CFR) from COVID-19 (that is, the ratio of deaths due to COVID-19 to the number of COVID-19 cases during a given time). Any attempt to provide clear data on this question is to be commended. There are, however, many challenges to such efforts that are recognized and discussed by the authors. First, there is currently no uniform definition of what constitutes an ICU bed [5]. Some authors suggest that this requires the immediate availability of mechanical ventilation within the ward in question, but this definition is by no means universally accepted. Second, it is hard to define “accessibility” where multiple models of health care coexist. For example, in countries with mixed public–private models (such as Brazil or Australia), it is *Correspondence: [email protected] 1 HCor Research Institute, Rua Abílio Soares 250, 12th floor, São Paulo, Brazil Full author information is available at the end of the article
commonplace to have an empty private ICU bed a few 100 m from patients in need of ICU care inside a public hospital (or even inside another private hospital with fewer resources). The scarcity of data in low-income countries also precludes similar analysis [6]. In this sense, European countries that have strong public health-care systems and lower social inequalities may represent the best model to evaluate how ease of access is related to outcome. The authors quite reasonably chose a pragmatic method to address the first issue: using the local definition of an ICU. For the second issue, they measured accessibility in terms of a regional ratio of hospital beds to 100,000 population (accessibility index, AI) and the distance to the closest hospital providing intensive care. While imperfect, this definition captures two important factors influencing access to a resource: how available the resource is, and how far away it is. First, by using detailed geographical information, the authors co
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