Case mix as the determinant of outcomes: The devil is in the details

摘要

Perennially thought of as best in the world, in the last decade healthcare in the United States has been exposed as having suboptimal quality, exorbitant costs, and worsening access. The latest figures quantify our national healthcare expenditure to be Dollars 2.1 trillion, or 16% of the gross domestic product, the highest in the world. Despite these staggering expenditures, inequities persist, as the figure of 47 million people uninsured in 2006 represents a 4.9% increase from the previous year. Likewise, the quality of healthcare is besieged by deficiencies. Two pivotal reports by the Institute of Medicine pointed out the magni-tude of potentially avoidable mortality caused by medical errors in our hospitals and offered approaches to solving the problem. A decade later, we are still struggling not only with finding optimal evidence-based solutions, but also with their implementation. Regional, racial, ethnic, and socio-economic disparities in access and expenditures have all put the practice of medicine under intense scrutiny. Since the technologically advanced and highly specialized environment of the intensive care-unit represents a substantial fraction of the healthcare expenditures, it too has been undergoing close examination and efforts to improve quality and efficiency