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The impact of variation in critical care organisation on patient mortality: evidence form the United Kingdom

Maharaj, Ritesh (2022) The impact of variation in critical care organisation on patient mortality: evidence form the United Kingdom. PhD thesis, London School of Economics and Political Science.

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Identification Number: 10.21953/lse.00004473


The changing landscape of aging population, increasing incidence of critical illness and more constrained national budgets mean physicians, policy makes, and hospital administrators must consider more efficient ways to organise critical care services. In general, policymakers have embraced the idea of centralising services and increased specialisation to improve efficiency in health care. This thesis explores these policies in the context of critical care services in the UK. Evidence of the productivity of critical care services and in particular volume-outcome relationship in critical care and the underlying mechanism by which this relationship operates is scarce. I consider several aspects of these issues. In the first study I investigate the volume-outcome relationship for sepsis using data from the Intensive Care National Audit and Research Centre which covers all ICUs in the England, Wales, and Northern Ireland. In this cohort study, sepsis case volume in an ICU was significantly associated with hospital mortality from sepsis, and a volume lower threshold of 215 patients per year was associated with an improvement in mortality. The second study explores the underlying mechanism of the volume-outcome relationship. Two possible mechanisms proposed are dynamic learning-by-doing and static scale economies. If the volume-outcome relationship operates through the learning-by-doing mechanism, then patient outcomes would improve by the volume of patients treated over time, making system-wide centralisation unnecessary. This study supports the idea that the underlying mechanism by which volume leads to improved outcomes is through learning-by-doing. ICUs tend to improve by caring for a large volume patients distributed over time. Patients may, therefore, be better served by ICUs organised to achieve minimum volume 5 standards without centralisation. The third study examines the related role of ICU specialisation in improving mortality. This study found that ICU specialisation do not have significantly lower hospital mortality for critically ill patients in the UK after adjusting for patient characteristics and caseload volume. Across the three studies I argue that a minimum volume threshold may be effective in improving patient outcomes. Centralisation may not fully leverage the benefits of the learning-by-doing mechanism. Lastly, accounting for volume, there is no compelling evidence of any added value from ICUs specialisation.

Item Type: Thesis (PhD)
Additional Information: © 2022 Ritesh Maharaj
Library of Congress subject classification: R Medicine > RA Public aspects of medicine > RA0421 Public health. Hygiene. Preventive Medicine
Supervisor: Street, Andrew and McGuire, Alistair

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