If intensive care is defined as close observation of critically ill persons, then its use is ancient indeed, going back to the beginning of recorded history. But if intensive care is defined to include all the modern technology, techniques, knowledge, and skilled personnel that closely monitor patients with the intent to intervene when potentially dangerous changes in physiology occur, usually in acute, life-threatening circumstances, then real medical intensive care services are only slightly more than three decades old.

The intensive care unit (ICU), one of the great achievements of modern medicine, is both a set of technologies and a space with a special function. This essay traces the evolution of the ICU's crucial technologies, and how the space bearing this name was carved out in the hospital. Ethical, legal, and social developments, an important part of this story, are incorporated in it.

It is difficult to study the epidemiology of ICUs, as they lack a uniform nomenclature and/or classification. The organization and distribution of intensive care medicine depend on the size and function of the hospital. The patients in ICUs are predominantly men, with a high proportion of elderly patients (≥70 years) constituting 25–30% of the total. Case-mix, severity of illness and outcome differ from one unit to another, and can be compared only if the patients are classified with a common classification system. Most survivors of intensive care seem to return to normal or near normal functional level within one year. Compared to Western Europe, the United States has more ICU beds and a nearly ten times higher admission rate to intensive care. These variations can be seen as a result of a fundamental difference in the attitudes toward withdrawing or withholding life support.

Any evaluation of intensive care must include an ethical assessment of that technology. This allows us to consider the use of technologyin light of the ends that we desire. The most pressing ethical issues in intensive care are: forgoing life-sustaining treatment, dehumanization of patients and staff within the technological environment, and the allocation of the technology that is integral to intensive care.

Technology assessment is becoming increasingly important in the area of critical care due both to the explosion of technology associated with this discipline and to the realization that future demand for these health care resources will undoubtedly exceed the ability to pay. Technology assessment remains both confusing and controversial to many physicians. This review tries to address some of the confusion by reviewing the basic strategies involved in this process. From there, problems and prospects for the evaluation of critical care as a program are presented, followed by the assessment of components within the area of critical care. Finally, recommendations are made on how technology assessment could proceed in the future to best achieve the efficient provision of this service.

The economic recession of the last decade brought intensive care systems under the light of cost-effectiveness analysis, making use of several instruments available in medical practice, and others adapted from for-profit enterprises. The present concept of intensive care, particularly its functional and organizational interactions with traditional specialties, is at the brink of an important revaluation. Studies of the cost-effectiveness of therapeutic actions may be grossly biased if they do not consider the complete process of care (before, during, and after treatment), analyzing even its smallest elements.

There is a wide panorama of disorders in the newborn infant where neonatal intensive care has been proven effective in reducing mortality. Although modern neonatal intensive care can be very costly, shortand simple interventions for support and resuscitation still can be highly beneficial. In reviewing the field of neonatal intensive careduring the 1980s, it becomes evident that a major challenge for the future will be to apply physiological principles of great and provenvaluefor the newborn baby to more simple devices. Only thereby canthe technology of neonatal care defined as a complex of actions–not only equipment and techniques–become justified for future generations.

We performed a cost-effectiveness analysis to evaluate whether a pediatrician who suspects an inherited disease of amino acid metabolism should refer the child to a specialist in inborn errors of amino acid metabolism or should prescribe the usual screening test, chromatography of amino acids. Actual hospital costs were used to value the referral, the tests, and the complications that occur when the diagnosis is not recognized. The percent of confirmed diagnoses was chosen as a measure of effectiveness. We conclude that it is more cost-effective for a pediatrician to refer the child to a specialist, that the best strategy in the absence of a referral is to prescribe thin-layer chromatography, and that the least cost-effective strategy is to perform ion-exchange chromatography immediately.

Different aspects of the process of evaluating research and education are discussed, using the discipline of medicine as a model. The focus is primarily on potential problems in the design of an evaluation. The most important aspects of an assessment are: to create confidence in the evaluation among scientists and/or teachers who are being assessed before beginning; to find experts for whom the scientists and/or teachers have professional respect; to choose assessment methods in relation to the focus, level, and objectives of the evaluation; and to make the report of the evaluation's findings short and explicit.

In general, technically demanding medical procedures are associated with better outcomes when they are carried out in institutions and by physicians with higher volumes of practice. This paper examines the evidence for a volume–outcome relationship in the case of organ transplantation. Although few studies have been done on this subject, existing evidence is consistent with improved outcomes at higher volumes. Therefore, evidence supports policies that regionalize transplantation services.

A computer simulation model shows that the cost-effectiveness of treating hypertension is highly sensitive to different assumptions about the effectiveness of treatment, the outcome measure, the cost concept, the discounting of effects, and the duration of therapy. Cost-effectiveness analysis should be supplemented by another approach–cost-benefit analysis based on the contingent valuation (CV) method (the measurement, by survey, of willingness to pay). The CV method is tested in two empirical applications that indicate that it is possible to use the method in this area. Its results should be interpreted with caution, however, since the reliability and validity of the method is not yet established.

A hospital's quality of care is generally assessed by a review of individual records. This study used unadjusted and risk-adjusted complication rates to measure the quality of care for hospitals that perform coronary artery bypass surgery or angioplasty. Hospitals differed greatly in their complication rates. Only a small percentage of this difference was due to differences in the risks that patients faced.

For certain single-gene disorders, DNA probes allow individuals to make more informed decisions about family size and the outcomes of pregnancies. They may also have important psychological effects. We present a method of assessing their impact on the outcomes of pregnancy. We conclude that the traditional approach, which focuses solely on the potential of prenatal diagnostic services to reduce affected births, is limited. It neglects the potential of such services to promote an increase in unaffected births by reducing the number of unnecessary terminations.