Critical Care Resources in Mainland China: When More May Not Always Be Better*

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Critical care medicine, as a new specialty of clinical medicine, has been officially recognized by the Chinese government in 2008, since its first emergence in the form of a surgical ICU in 1982 (1). Last decade has witnessed a rapid progress of critical care medicine, attributable to improved public awareness, unmet patient needs, requirements of hospital accreditation, and dedicated efforts of critical care teams, not only during routine clinical work, but also in all natural disasters and mass casualties (1). However, such progress, as well as its impact on patient outcome and the healthcare system, has not been extensively studied.
In this issue of Critical Care Medicine, Wu et al (2) summarized the results of three surveys of critical care resources in Guangdong Province, the richest province in China (3), during a 10-year period. Completion of the online questionnaires was preceded by planned training courses and followed by site visits for validity of data collection. Also unique to this study was the 100% response rate, which was not uncommon when such surveys were almost always coupled with similar missions from the local healthcare authorities. Wu et al (2) reported a 122% increase in the number of ICUs, from 146 in 2005 to 324 in 2015. During the same period, the number of ICU beds also increased by 188%, to 3956 in 2015, corresponding to 1.76% of total hospital beds or 3.69 ICU beds per 100,000 population. Data concerning human resources were only available in 2011 and 2015, which demonstrated a 39% and 58% increase in the number of intensivists and ICU nurses, respectively. Furthermore, Wu et al (2) observed significant geographic variation in critical care resources, which could be explained, at least partly, by the difference in gross domestic product (GDP).
Based on the above findings, Wu et al (2) called for more critical care resources in the future to meet the need of rapidly growing aging population. It has been widely reported that more critical care resources are associated with fewer ICU refusals and premature discharges or even improved patient outcome (4). However, we believe that the results of the current study (2) should be interpreted cautiously. First, data on critical care resources in China may not be directly comparable with those of the western countries. In the United States, ICU beds have steadily increased from 69,300 in 1985 to 103,900 in 2010 or 7.8% to 16.2% of total hospital beds (5, 6). However, these calculations were based on acute care hospital beds only. In contrast, we do not have the differentiation between acute care hospitals and long-term facilities in China at present, leading to systemic underestimation of the ICU-to-hospital bed ratio. Second, more critical care resources do not necessarily mean better quality of care because they may either fill the gap caused by previously unmet needs for intensive care (4) or create their own ICU demand (7), that is, increase the chance of admitting less severe patients into the ICU. Compared with United Kingdom (whose population-adjusted ICU beds were similar to that of the current study [2]), higher United States ICU bed availability was associated with lower overall severity of illness and mechanical ventilation rates (10–30%), with many patients admitted to ICUs only for monitoring (8). Interestingly, a prospective analysis of 44,814 patients from 27 countries did not identify any survival benefit from ICU admission following elective surgery (9), supporting the argument that postoperative care for most surgical patients might be safely delivered in general wards.
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