Thomas S Valley1,2,3, Michael W Sjoding1,3, Andrew M Ryan2,4, Theodore J Iwashyna1,2,5, Colin R Cooke1,2,3,4. 1. 1 Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine. 2. 2 Institute for Healthcare Policy and Innovation. 3. 3 Michigan Center for Integrative Research in Critical Care, and. 4. 4 Center for Health Outcomes and Policy, University of Michigan; and. 5. 5 Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan.
Abstract
RATIONALE: Admission to an intensive care unit (ICU) may be beneficial to patients with pneumonia with uncertain ICU needs; however, evidence regarding the association between ICU admission and mortality for other common conditions is largely unknown. OBJECTIVES: To estimate the relationship between ICU admission and outcomes for hospitalized patients with exacerbation of chronic obstructive pulmonary disease (COPD), exacerbation of heart failure (HF), or acute myocardial infarction (AMI). METHODS: We performed a retrospective cohort study of all acute care hospitalizations from 2010 to 2012 for U.S. fee-for-service Medicare beneficiaries aged 65 years and older admitted with COPD exacerbation, HF exacerbation, or AMI. We used multivariable adjustment and instrumental variable analysis to assess each condition separately. The instrumental variable analysis used differential distance to a high ICU use hospital (defined separately for each condition) as an instrument for ICU admission to examine marginal patients whose likelihood of ICU admission depended on the hospital to which they were admitted. The primary outcome was 30-day mortality. Secondary outcomes included hospital costs. RESULTS: Among 1,555,798 Medicare beneficiaries with COPD exacerbation, HF exacerbation, or AMI, 486,272 (31%) were admitted to an ICU. The instrumental variable analysis found that ICU admission was not associated with significant differences in 30-day mortality for any condition. ICU admission was associated with significantly greater hospital costs for HF ($11,793 vs. $9,185, P < 0.001; absolute increase, $2,608 [95% confidence interval, $1,377-$3,840]) and AMI ($19,513 vs. $14,590, P < 0.001; absolute increase, $4,922 [95% confidence interval, $2,665-$7,180]), but not for COPD. CONCLUSIONS: ICU admission did not confer a survival benefit for patients with uncertain ICU needs hospitalized with COPD exacerbation, HF exacerbation, or AMI. These findings suggest that the ICU may be overused for some patients with these conditions. Identifying patients most likely to benefit from ICU admission may improve health care efficiency while reducing costs.
RATIONALE: Admission to an intensive care unit (ICU) may be beneficial to patients with pneumonia with uncertain ICU needs; however, evidence regarding the association between ICU admission and mortality for other common conditions is largely unknown. OBJECTIVES: To estimate the relationship between ICU admission and outcomes for hospitalized patients with exacerbation of chronic obstructive pulmonary disease (COPD), exacerbation of heart failure (HF), or acute myocardial infarction (AMI). METHODS: We performed a retrospective cohort study of all acute care hospitalizations from 2010 to 2012 for U.S. fee-for-service Medicare beneficiaries aged 65 years and older admitted with COPD exacerbation, HF exacerbation, or AMI. We used multivariable adjustment and instrumental variable analysis to assess each condition separately. The instrumental variable analysis used differential distance to a high ICU use hospital (defined separately for each condition) as an instrument for ICU admission to examine marginal patients whose likelihood of ICU admission depended on the hospital to which they were admitted. The primary outcome was 30-day mortality. Secondary outcomes included hospital costs. RESULTS: Among 1,555,798 Medicare beneficiaries with COPD exacerbation, HF exacerbation, or AMI, 486,272 (31%) were admitted to an ICU. The instrumental variable analysis found that ICU admission was not associated with significant differences in 30-day mortality for any condition. ICU admission was associated with significantly greater hospital costs for HF ($11,793 vs. $9,185, P < 0.001; absolute increase, $2,608 [95% confidence interval, $1,377-$3,840]) and AMI ($19,513 vs. $14,590, P < 0.001; absolute increase, $4,922 [95% confidence interval, $2,665-$7,180]), but not for COPD. CONCLUSIONS: ICU admission did not confer a survival benefit for patients with uncertain ICU needs hospitalized with COPD exacerbation, HF exacerbation, or AMI. These findings suggest that the ICU may be overused for some patients with these conditions. Identifying patients most likely to benefit from ICU admission may improve health care efficiency while reducing costs.
Authors: David J Wallace; Derek C Angus; Christopher W Seymour; Amber E Barnato; Jeremy M Kahn Journal: Am J Respir Crit Care Med Date: 2015-02-15 Impact factor: 21.405
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Authors: Michael W Sjoding; Hallie C Prescott; Hannah Wunsch; Theodore J Iwashyna; Colin R Cooke Journal: Crit Care Med Date: 2015-06 Impact factor: 7.598
Authors: Thomas S Valley; Brahmajee K Nallamothu; Michael Heung; Theodore J Iwashyna; Colin R Cooke Journal: Crit Care Med Date: 2018-02 Impact factor: 7.598
Authors: George L Anesi; Vincent X Liu; Marzana Chowdhury; Dylan S Small; Wei Wang; M Kit Delgado; Brian Bayes; Erich Dress; Gabriel J Escobar; Scott D Halpern Journal: Am J Respir Crit Care Med Date: 2022-03-01 Impact factor: 30.528
Authors: Thomas S Valley; Andrew J Admon; Darin B Zahuranec; Allan Garland; Angela Fagerlin; Theodore J Iwashyna Journal: Crit Care Med Date: 2019-01 Impact factor: 7.598
Authors: George L Anesi; Marzana Chowdhury; Dylan S Small; M Kit Delgado; Rachel Kohn; Brian Bayes; Wei Wang; Erich Dress; Gabriel J Escobar; Scott D Halpern; Vincent X Liu Journal: Ann Am Thorac Soc Date: 2020-11