High value health care is low carbon health care

Culling low value care will cut health care carbon emission

The incidence and outcome of septic shock patients in the absence of early-goal directed therapy

INTRODUCTION: The purpose of the present study was to measure the incidence and outcome of septic patients presenting at the emergency department (ED) with criteria for early goal-directed therapy (EGDT). METHOD: This hospital-based, retrospective, observational study using prospectively collected electronic databases was based in a teaching hospital in Melbourne, Australia. We conducted outcome-blinded electronic screening of patients with infection admitted via the ED from 1 January 2000 to 30 June 2003. We obtained data on demographics, laboratory and clinical features on admission. We used paper records to confirm electronic identification of candidates for EGDT and to study their treatment. We followed up all patients until hospital discharge or death. RESULTS: Of 4,784 ED patients with an infectious disease diagnosis, only 50 fulfilled published clinical inclusion criteria for EGDT (EGDT candidates). Of these patients, 37 (74%) survived their hospital admission, two (4%) died in the ED, eight (16%) died in the intensive care unit and three (6%) died in the ward. After review of all ward cardiac arrests and non-NFR ('not for resuscitation') ward deaths, we identified a further two potential candidates for EGDT for an overall mortality of 28.8% (15 out of 52 patients). Analysis of treatment showed that twice as many (70%) of the EGDT candidates received vasopressor therapy in the ED, and their initial mean central venous pressure (10.8 mmHg) was almost twice that in patients from the EGDT study conducted by Rivers and coworkers. CONCLUSION: In an Australian teaching hospital candidates for EGDT were uncommon and, in the absence of an EGDT protocol, their mortality was lower than that reported with EGDT

The environmental footprint of morphine: a life cycle assessment from opium poppy farming to the packaged drug

OBJECTIVE: To examine the environmental life cycle from poppy farming through to production of 100 mg in 100 mL of intravenous morphine (standard infusion bag). DESIGN: \u27Cradle-to-grave\u27 process-based life cycle assessment (observational). SETTINGS: Australian opium poppy farms, and facilities for pelletising, manufacturing morphine, and sterilising and packaging bags of morphine. MAIN OUTCOME MEASURES: The environmental effects (eg, CO2 equivalent (\u27CO2 e\u27) emissions and water use) of producing 100 mg of morphine. All aspects of morphine production from poppy farming, pelletising, bulk morphine manufacture through to final formulation. Industry-sourced and inventory-sourced databases were used for most inputs. RESULTS: Morphine sulfate (100 mg in 100 mL) had a climate change effect of 204 g CO2 e (95% CI 189 to 280 g CO2 e), approximating the CO2 e emissions of driving an average car 1 km. Water use was 7.8 L (95% CI 6.7- to 9.0 L), primarily stemming from farming (6.7 L). All other environmental effects were minor and several orders of magnitude less than CO2 e emissions and water use. Almost 90% of CO2 e emissions occurred during the final stages of 100 mg of morphine manufacture. Morphine\u27s packaging contributed 95 g CO2 e, which accounted for 46% of the total CO2 e (95% CI 82 to 155 g CO2 e). Mixing, filling and sterilisation of 100 mg morphine bags added a further 86 g CO2 e, which accounted for 42% (95% CI 80 to 92 g CO2 e). Poppy farming (6 g CO2 e, 3%), pelletising and manufacturing (18 g CO2 e, 9%) made smaller contributions to CO2 emissions. CONCLUSIONS: The environmental effects of growing opium poppies and manufacturing bulk morphine were small. The final stages of morphine production, particularly sterilisation and packaging, contributed to almost 90% of morphine\u27s carbon footprint. Focused measures to improve the energy efficiency and sources for drug sterilisation and packaging could be explored as these are relevant to all drugs. Comparisons of the environmental effects of the production of other drugs and between oral and intravenous preparations are required

Health, financial and environmental impacts of unnecessary vitamin D testing: a triple bottom line assessment adapted for healthcare

To undertake an assessment of the health, financial and environmental impacts of a well-recognised example of low-value care; inappropriate vitamin D testing. Design Combination of systematic literature search, analysis of routinely collected healthcare data and environmental analysis. Setting Australian healthcare system. Participants Population of Australia. Outcome measures We took a sustainability approach, measuring the health, financial and environmental impacts of a specific healthcare activity. Unnecessary vitamin D testing rates were estimated from best available published literature; by definition, these provide no gain in health outcomes (in contrast to appropriate/necessary tests). Australian population-based test numbers and healthcare costs were obtained from Medicare for vitamin D pathology services. Carbon emissions in kg CO2e were estimated using data from our previous study of the carbon footprint of common pathology tests. We distinguished between tests ordered as the primary test and those ordered as an add-on to other tests, as many may be done in conjunction with other tests. We conducted base case (8% being the primary reason for the blood test) and sensitivity (12% primary test) analyses. Results There were a total of 4 457 657 Medicare-funded vitamin D tests in 2020, on average one test for every six Australians, an 11.8% increase from the mean 2018–2019 total. From our literature review, 76.5% of Australia’s vitamin D tests provide no net health benefit, equating to 3 410 108 unnecessary tests in 2020. Total costs of unnecessary tests to Medicare amounted to >$A87 000 000. The 2020 carbon footprint of unnecessary vitamin D tests was 28 576 kg (base case) and 42 012 kg (sensitivity) CO2e, equivalent to driving ~160 000–230 000 km in a standard passenger car. Conclusions Unnecessary vitamin D testing contributes to avoidable CO2e emissions and healthcare costs. While the footprint of this example is relatively small, the potential to realise environmental cobenefits by reducing low-value care more broadly is significant

The green ICU:how to interpret green? A multiple perspective approach

Mitigating environmental impacts is an urgent challenge supported by (scientific) intensive care societies worldwide. However, making green choices without compromising high-quality care for critically ill patients may be challenging. The current paper describes a three-step approach towards green intensive care units. Starting with the measurement of environmental sustainability, intensive care units can identify hotspots, quantify the environmental impacts of products and procedures, and monitor sustainable progress. Subsequently, a multidisciplinary approach is proposed to improve environmental sustainability, including a collaboration of procurement specialists and healthcare professionals, using co-creation and green teams as efficient grassroots change agents. A context-specific approach for enhancing sustainable healthcare practices is key in order to fit local regulatory requirements and create support of professionals. A final step is to share results and create momentum, including publishing initiatives and participating in online (inter)national networks. Based on the core sustainability principles, this three-step approach towards green ICUs provides a valuable tool to professionals worldwide to facilitate change towards environmentally responsible intensive care units

Learning to treat the climate emergency together: social tipping interventions by the health community

Accelerating the decarbonisation of local and national economies is a profound public health imperative. As trusted voices within communities around the world, health professionals and health organisations have enormous potential to influence the social and policy landscape in support of decarbonisation. We assembled a multidisciplinary, gender-balanced group of experts from six continents to develop a framework for maximising the social and policy influence of the health community on decarbonisation at the micro levels, meso levels, and macro levels of society. We identify practical, learning-by-doing approaches and networks to implement this strategic framework. Collectively, the actions of health-care workers can shift practice, finance, and power in ways that can transform the public narrative and influence investment, activate socioeconomic tipping points, and catalyse the rapid decarbonisation needed to protect health and health systems

Protocol for development of SPIRIT and CONSORT extensions for reporting climate and environmental outcomes in randomised trials (SPIRIT-ICE and CONSORT-ICE)

IntroductionThe WHO has declared climate change the defining public health challenge of the 21st century. Incorporating climate and environmental outcomes in randomised trials is essential for enhancing healthcare treatments' sustainability and safeguarding global health. To implement such outcomes, it is necessary to establish a framework for unbiased and transparent planning and reporting. We aim to develop extensions to the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT 2025) and Consolidated Standards of Reporting Trials (CONSORT 2025) statements by introducing guidelines for reporting climate and environmental outcomes.Methods and analysisThis is a protocol for SPIRIT and CONSORT extensions on reporting climate and environmental outcomes in randomised trials termed SPIRIT-Implementing Climate and Environmental (ICE) and CONSORT-ICE. The development of the extensions will consist of five phases: phase 1-project launch, phase 2-review of the literature, phase 3-Delphi survey, phase 4-consensus meeting and phase 5-dissemination and implementation. The phases are expected to overlap. The SPIRIT-ICE and CONSORT-ICE extensions will be developed in parallel. The extensions will guide researchers on how and what to report when assessing climate and environmental outcomes.Ethics and disseminationThe protocol was submitted to the Danish Research Ethics Committees, Denmark in June 2025. Ethics approval is expected in September 2025. The SPIRIT and CONSORT extensions will be published in international peer-reviewed journals

Regional Practice Variation and Outcomes in the Standard Versus Accelerated Initiation of Renal Replacement Therapy in Acute Kidney Injury (STARRT-AKI) Trial: A Post Hoc Secondary Analysis

OBJECTIVES: Among patients with severe acute kidney injury (AKI) admitted to the ICU in high-income countries, regional practice variations for fluid balance (FB) management, timing, and choice of renal replacement therapy (RRT) modality may be significant. DESIGN: Secondary post hoc analysis of the STandard vs. Accelerated initiation of Renal Replacement Therapy in Acute Kidney Injury (STARRT-AKI) trial (ClinicalTrials.gov number NCT02568722). SETTING: One hundred-fifty-three ICUs in 13 countries. PATIENTS: Altogether 2693 critically ill patients with AKI, of whom 994 were North American, 1143 European, and 556 from Australia and New Zealand (ANZ). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Total mean FB to a maximum of 14 days was +7199 mL in North America, +5641 mL in Europe, and +2211 mL in ANZ (p < 0.001). The median time to RRT initiation among patients allocated to the standard strategy was longest in Europe compared with North America and ANZ (p < 0.001; p < 0.001). Continuous RRT was the initial RRT modality in 60.8% of patients in North America and 56.8% of patients in Europe, compared with 96.4% of patients in ANZ (p < 0.001). After adjustment for predefined baseline characteristics, compared with North American and European patients, those in ANZ were more likely to survive to ICU (p < 0.001) and hospital discharge (p < 0.001) and to 90 days (for ANZ vs. Europe: risk difference [RD], -11.3%; 95% CI, -17.7% to -4.8%; p < 0.001 and for ANZ vs. North America: RD, -10.3%; 95% CI, -17.5% to -3.1%; p = 0.007). CONCLUSIONS: Among STARRT-AKI trial centers, significant regional practice variation exists regarding FB, timing of initiation of RRT, and initial use of continuous RRT. After adjustment, such practice variation was associated with lower ICU and hospital stay and 90-day mortality among ANZ patients compared with other regions