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March 4, 1998

Potentially Ineffective Care in Intensive Care—Reply

Author Affiliations

Margaret A.WinkerMD, Senior EditorIndividualAuthorPhil B.FontanarosaMD, Senior EditorIndividualAuthor

JAMA. 1998;279(9):651-654. doi:10-1001/pubs.JAMA-ISSN-0098-7484-279-9-jbk0304

In Reply.—The focus of our study was an examination of the effects of economic incentives on the appropriateness of using critical care services near the end of life. To this end, we used an indicator of failure of the critical care process, clinically validated in a previous study,1 to explore differences in outcomes in the most severely ill elderly patients treated in managed care and in traditional practice environments. The results of our study suggest that reimbursement method was associated with more appropriate (and hopefully more humane) use of critical care near the end of life. The strong effect of changes in reimbursement method on decision making stands in contrast to the weak effects of prognostic information2 and advance directives3 on use of critical care.