COMPUTED TOMOGRAPHY DETECTS LUNG CANCER AT EARLIEST STAGE
In a study that screened 1,520 individuals age 50 and over at high risk for lung cancer, low-dose computed tomography detected 23 cases alone while sputum cytology analysis detected two alone, according to Mayo Clinic investigators. (Lung cancer is the most common fatal malignancy among adults in the U.S.) Researchers pointed to studies that suggested screening with spiral computed tomography can detect lung cancers at a smaller size and earlier stage as compared with chest radiography and clinical practice. However, along with the cancers, the investigators identified 2,244 uncalcified nodules in over 1,000 patients after two years of study. They estimated that 98 percent of the nodules were “falsely positive.” The investigators also found a very high false negative rate of 26 percent missed during the baseline scan. Twenty two of the patients with identified cancers underwent curative surgical removal, and seven benign nodules were also removed. Participants in the study were asymptomatic men and women 50 years of age or older who had smoked at least 20 pack years of cigarettes. The research appears in the second issue for February of the American Thoracic Society’s peer-reviewed American Journal of Respiratory and Critical Care Medicine.
ACUTE LUNG INJURY INCIDENCE HIGHER AND MORTALITY LOWER
In a study of 21 adult intensive care units, Australian researchers reported that the incidence of acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) was higher and mortality rates lower than those reported in studies from other countries. The investigators screened 1,977 admissions to the units between October 1 and November 30, 1999. (Lung injury from pneumonia and aspiration were the most common direct lung insults causing ALI. Sepsis was the most common indirect insult. ARDS is a type of lung failure resulting from many different disorders that can cause fluid accumulation in the lungs (pulmonary edema.)) Of the total admissions, 168 patients developed ALI and 148 had ARDS. The researchers reported that the first incidence of ALI was 34 cases per 100,000 adult population per year, and ARDS was 28 cases per 100,000. The figures for incidence were higher and mortality rates lower than six out of seven studies published since 1995. The investigators believe that the high incidence and low mortality rates are representative of Australian practice. However, they noted that multicenter international studies were required to exclude methodological differences as the cause for the higher incidence and lower mortality findings. The study appears in the second issue for February of the American Thoracic Society’s peer-reviewed American Journal of Respiratory and Critical Care Medicine.
REDUCING HEALTH CARE COSTS BY RESTRICTING CRITICAL CARE TREATMENT IN LAST YEAR OF LIFE IS PRACTICALLY IMPOSSIBLE
Although a major study focusing on the years 1978 and 1988, showed that 77 percent of the expenditure for Medicare patients who died occurred in the last year of their life, it would be very difficult, if not impossible, to reduce health care costs by restricting life-sustaining treatment for such patients in the intensive care unit (ICU). In a “Critical Care Perspective,” two experts argue that although changes in the use of expensive critical care resources near the end of life and efforts to reduce suffering are desirable, they are unlikely to yield significant cost savings. Since daily ICU costs range from $2,000 to $3,000 per day in many U.S. hospitals, clinicians and administrators alike generally assume that health care, hospital, and ICU costs can be reduced by thousands of dollars by decreasing ICU length of stay. Yet many factors interfere.
For example, a study showed that the likelihood of admission to the ICU by Medicare enrollees in the last year of their life varied from 20 to 40 percent among hospital referral regions in New England. Also, research has shown that 84 percent of hospital costs are fixed (expenses hospitals must bear regardless of volume of care.) Such costs are not amenable to cost savings through reducing length of stay unless beds are closed and personnel fired. The results of various studies show that the most expensive ICU patients (those with the greatest length of stay) cannot easily be predicted. Although many elderly patients show estimates of survival of from 40 to 80 percent on their day of admittance to the ICU, the scoring systems used are not accurate enough to be employed in making life-or-death decisions at the beside,according to the experts. They said that “limiting care to dying patients in the ICU presumes perfect knowledge of outcome only available retrospectively.” Finally, the authors note that just as intensive care is not effective for a minority of patients, so the majority seem to benefit from its services. Their analysis and comments appear in the second issue for February of the American Thoracic Society’s peer-reviewed American Journal of Respiratory and Critical Care Medicine.
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Journal
American Journal of Respiratory and Critical Care Medicine