Outcomes for critically ill patients with haematological malignancies in specialist and non-specialist centres in the United Kingdom

Abstract

Background: Patients with haematological malignancies admitted to critical care units have a high mortality. Specialist cancer centres may demonstrate better survival rates than non-specialist centres. We compared the outcomes of patients with haematological malignancies admitted to three different centres in the United Kingdom, and examined possible reasons for differences in outcomes. Methods: We compared the characteristics and outcomes of patients with haematological malignancies admitted to critical care units at the Christie, Royal Liverpool University and Glan Clwyd hospitals between 1st January 2007 and 1st July 2011. Differences between hospitals were compared using ANOVA or Chi-squared test, as appropriate. Factors associated with hospital mortality were analysed using logistic regression analysis. Results: 187 patients with haematological malignancies were identified. More patients with Hodgkin's lymphoma were admitted to Glan Clwyd hospital (25%) compared to Royal Liverpool (5.8%) and the Christie (8.1%), p=0.0087. Patients admitted to the Christie had lower severity-of-illness scores compared to patients admitted to the other hospitals (p<0.001). Overall, 91 patients died before hospital discharge (48.7%). Unadjusted hospital mortality at the Christie was significantly lower (41.4%), compared to the Royal Liverpool (61.5%) and Glan Clwyd hospitals (54.2%), p=0.0240. On logistic regression analysis, the only factor associated with higher odds of hospital mortality was increasing APACHE II score (p=0.035, odds ratio 1.06 [95% CI 1.04-1.13] per point). Admission to a non-specialist centre was associated with higher odds of critical care unit mortality (p=0.036, odds ratio 2.17 [95% CI 1.05-4.46]), but was not associated with higher odds of hospital mortality (p=0.065). Conclusions: Admission to a specialist centre was not associated with lower hospital mortality compared to non-specialist centres for patients with haematological malignancies. However, admission to a specialist centre was associated with lower critical care unit mortality. Possible explanations for these differences in survival between centres could be the identified significant differences in casemix, or lower severity of illness at admission. In addition the severity of illness on admission to the critical care unit as indicated by the APACHE II score increased the odds of hospital mortality.

Can treating critically-ill haematological malignancy patients in a separate intensive care unit decrease intensive care unit mortality?

“…Again, monitoring a large number of patients with a specific diagnosis can enable to establish a better organizational structure, develop clearer protocols, build multidisciplinary teams, and perform better staffing in a given centre. Reduced mortality in the presence of an increased number of cases (case-volume) was demonstrated previously in haematological patients by Lecuyer et al, and by Hampshire et al [19,22].…”

“…Specialization of a unit or centre results in monitoring and treating a large number of patients having the same diagnosis, leading to accumulating experience and knowledge on the specialized subject. This, in turn, will enable the utilization of specialized experience and knowledge in the treatment of patients [19]. This is a subject matter, which has been previously proven by Kahn et al, and by Shahin et al, in studies on mechanically ventilated patients [20,21].…”

Critical care admission for acute medical patients

“…25 This improvement in survival has been attributed to better selection of appropriate patients, treatment in specialist centres and advances in treatment of organ failure. 26 Neutropenia confers little increased mortality risk. 22 Factors consistently predicting a poor outcome in patients admitted to the ICU with HM are: Severity of acute illness has greater infl uence on the outcome of ICU admission than factors related to the malignancy.…”