Association of Intensive Care Unit Admission With Mortality Among Older Patients With Pneumonia

Abstract

IMPORTANCE Among patients whose need for intensive care is uncertain, the relationship of intensive care unit (ICU) admission with mortality and costs is unknown. OBJECTIVE To estimate the relationship between ICU admission and outcomes for elderly patients with pneumonia. DESIGN, SETTING, AND PATIENTS Retrospective cohort study of Medicare beneficiaries (aged >64 years) admitted to 2988 acute care hospitals in the United States with pneumonia from 2010 to 2012. EXPOSURES ICU admission vs general ward admission. MAIN OUTCOMES AND MEASURES Primary outcome was 30-day all-cause mortality. Secondary outcomes included Medicare spending and hospital costs. Patient and hospital characteristics were adjusted to account for differences between patients with and without ICU admission. To account for unmeasured confounding, an instrumental variable was used—the differential distance to a hospital with high ICU admission (defined as any hospital in the upper 2 quintiles of ICU use). RESULTS Among 1 112 394 Medicare beneficiaries with pneumonia, 328 404 (30%) were admitted to the ICU. In unadjusted analyses, patients admitted to the ICU had significantly higher 30-day mortality, Medicare spending, and hospital costs than patients admitted to a general hospital ward. Patients (n = 553 597) living closer than the median differential distance (<3.3 miles) to a hospital with high ICU admission were significantly more likely to be admitted to the ICU than patients living farther away (n = 558 797) (36%for patients living closer vs 23%for patients living farther, P < .001). In adjusted analyses, for the 13%of patients whose ICU admission decision appeared to be discretionary (dependent only on distance), ICU admission was associated with a significantly lower adjusted 30-day mortality (14.8%for ICU admission vs 20.5%for general ward admission, P = .02; absolute decrease, −5.7%[95%CI, −10.6%, −0.9%]), yet there were no significant differences in Medicare spending or hospital costs for the hospitalization. CONCLUSIONS AND RELEVANCE Among Medicare beneficiaries hospitalized with pneumonia, ICU admission of patients for whom the decision appeared to be discretionary was associated with improved survival and no significant difference in costs. A randomized trial may be warranted to assess whether more liberal ICU admission policies improve mortality for patients with pneumonia.

Surviving sepsis campaign: research priorities for sepsis and septic shock

“…There is strong clinical and physiologic plausibility that interventions considered as best practice with respect to short-term outcomes will also translate into improved long-term mortality and morbidity. Credible in-hospital interventions for which long-term consequences should be considered include (but are not limited to) (a) sepsis screening and detection strategies, (b) ICU triage and use of ICU, about which there is conflicting evidence in terms of short-term mortality in the United States and France, at least among elderly patients [173,174], (c) alternative antibiotic regimens, including empiric strategies, culture guidance, and de-escalation strategies, and the ABCDEF bundle [175]. Ultimately, however, our knowledge about the relationship between in-hospital interventions and long-terms outcomes is limited, which precludes any definitive statements about the impact of such interventions.…”

Pneumonia and hospitalizations in the elderly

“…In elderly patients hospitalized for pneumonia, the mortality rate is about 20%. 6 If pneumonia develops in patients already hospitalized for other conditions, mortality increase to 50-70%, and is higher in women than in men. 6 Pneumonia is the most common form of hospital-acquired infection.…”

“…6 If pneumonia develops in patients already hospitalized for other conditions, mortality increase to 50-70%, and is higher in women than in men. 6 Pneumonia is the most common form of hospital-acquired infection. Data from European Center Disease Control (ECDC), published in 2015, related to a survey conducted on 231,459 patients hospitalized between 2011 and 2012, identified 13829 patients (6.0%) with hospital infection.…”

Intensive Care Unit Utilization and Mortality Among Medicare Patients Hospitalized With Non–ST-Segment Elevation Myocardial Infarction

“…A recent study of Medicare beneficiaries diagnosed with pneumonia found that ICU care was associated with lower adjusted mortality. 6 While ICU care has not been associated with reduced mortality in all-comer MI patients, 4 whether hemodynamically stable but higher risk patients specifically derive benefit has not been tested. It is also uncertain whether hospitals effectively triage NSTEMI patients at higher mortality risk to the ICU.…”