Critical care rationing in Hong Kong

Abstract

In Hong Kong, total health care expenditure accounts for approximately 4% of the gross domestic product estimated at US $23,000 per capita in 1995. The health care system consists of public and private sectors, and the public sector is almost entirely supported by government funding. Public hospitals receive approximately 80% of all hospital admissions, and an estimated 1% of the total number of hospital beds are intensive care beds. Apart from general intensive care units (ICUs), there are coronary care units, neurosurgical ICUs, and high dependency units. Most general ICUs in public institutions adopt the closed or transitional system. There are no territory-wide consensus triage or admission guidelines, and critical care physicians serve as gatekeepers, based on broad principles of triage according to severity of illness and relative potential for functional recovery. The APACHE II scores from several multidisciplinary ICUs range from 15.4 to 19.8, with predicted mortality rates of 27% to 39%. To meet the needs for critical care service within existing budgetary constraints, some hospitals are actively developing the graded care approach to critical care provision. This approach includes establishment of high dependency beds that, depending on the case mix and facilities of the hospital as well as its relative demand for critical care facilities, may offer critical care service ranging from monitoring to life-support therapy such as short-term acute invasive or noninvasive ventilation or longer durations of ventilation for patients in the weaning phase. Preliminary experience suggests that this approach can be cost effective, although more extensive evaluation of quality assurance and relative cost savings are required. Development of uniform criteria for broad stratification of seriously ill patients, to assign correctly various levels of critical care to such patients, is essential to the successful operation of such strategy.