The Swedish Intensive Care Registry cannot show differences in quality of care in COVID-19
It has been claimed in the media that the Swedish Intensive Care Registry (SIR) shows major differences in the quality of intensive care in Covid-19. This claim is not true. The mortality rate after intensive care for COVID-19 certainly differs between departments and regions, but to be able to conclude that this would depend on the quality of the intensive care itself requires an in-depth analysis and a lot of knowledge of the unique conditions in each individual hospital. There are several factors that make comparisons cumbersome, some mentioned below.
In many ICU, the number of deaths from COVID-19 is relatively low. This means that chance can explain large variations.
During the pandemic, patients have been transferred between different intensive care units due to lack of space. SIR's output portal shows care occasions, a patient who is moved between wards is thus counted several times. If there are differences in quality of care between wards, how should this be taken into account in the analyses for patients treated in several intensive care units?
The risk of death is different for different patients. Age is important, of course, but there are other important risk factors as well. If the patients who are treated in the respective intensive care unit are not taken into account, incorrect conclusions can be drawn. The risk adjustment instruments used in intensive care are not adapted to date for COVID-19.
COVID-19 varies greatly in severity, from minor symptoms to severe illness and sometimes death. Depending on the level of care, especially in respiratory care in departments other than ICU in each hospital, in some cases less ill patients end up either in ICU or in another ward. Consequently, if only the most severely ill end up in the ICU, the mortality rate in the ICU will be higher, even if the quality of intensive care is the same.
How the patients fare depends not only on the intensive care unit, but also on the quality and conditions of other care, both before admission to ICU and after discharge from ICU.
It is also claimed that you treat differently and that there is a best way to carry out the care that not everyone follows. It is unlikely that there would be a treatment that has such a large effect on mortality and yet could not be shown in the numerous scientific studies carried out in the world during the pandemic. When it comes to effective treatments and recommendations, there has been great interest in intensive care and the recommendations that exist have been quickly adopted.
All in all, an advanced analysis is required to possibly be able to determine if there are quality differences in given intensive care. In addition, knowledge of local conditions and surrounding resources is required. Information is also needed about patients who are not being cared for in ICU. This detail resolution in disease and care process is not available at SIR.
More about mortality differences and possible explanations in intensive care for COVID-19 can be found in SIR's annual report for 2021.