Variation Exists in Rates of Admission to Intensive Care Units for Heart Failure Patients Across Hospitals in the United States

Abstract

Background Despite increasing attention on reducing relatively costly hospital practices while maintaining the quality of care, few studies have examined how hospitals use the intensive care unit (ICU), a high-cost setting, for patients admitted with heart failure (HF). We characterized hospital patterns of ICU admission for patients with HF and determined their association with the use of ICU-level therapies and patient outcomes. Methods and Results We identified 166,224 HF discharges from 341 hospitals in the 2009–10 Premier Perspective® database. We excluded hospitals with <25 HF admissions, patients <18 years old, and transfers. We defined ICU as including medical ICU, coronary ICU, and surgical ICU. We calculated the percent of patients admitted directly to an ICU. We compared hospitals in the top-quartile (high ICU admission) with the remaining quartiles. The median percentage of ICU admission was 10% (Interquartile Range 6% to 16%; range 0% to 88%). In top-quartile hospitals, treatments requiring an ICU were used less often: percentage of ICU days receiving mechanical ventilation (6% top quartile versus 15% others), non-invasive positive pressure ventilation (8% versus 19%), vasopressors and/or inotropes (9% versus 16%), vasodilators (6% versus 12%), and any of these interventions (26% versus 51%). Overall HF in-hospital risk standardized mortality was similar (3.4% versus 3.5%; P = 0.2). Conclusions ICU admission rates for HF varied markedly across hospitals and lacked association with in-hospital risk-standardized mortality. Greater ICU use correlated with fewer patients receiving ICU interventions. Judicious ICU use could reduce resource consumption without diminishing patient outcomes.

Hospital-Level Variation in ICU Admission and Critical Care Procedures for Patients Hospitalized for Pulmonary Embolism

“…Moreover, Goldman et al 21 demonstrated that POA codes were very accurate when compared with direct medical record abstraction, suggesting that the PE cases identifi ed in this study represent PEs diagnosed on admission. Finally, our study is limited to patients with PE, and although it complements previous work among patients with other conditions, [4][5][6] further work is necessary to assess the validity of these fi ndings in patients without PE.…”

“…29 However, past work demonstrates that ICU admission may be more discretionary for patients at lower risk. 4,5,30 Chen et al 30 evaluated patients admitted to Veterans Administration hospitals and found signifi cant variation in ICU admission rates between hospitals that persisted aft er adjustment for both predicted mortality on admission and admission diagnosis. In their mortality analysis, they found a protective eff ect of ICU admission but only at the highest rates of predicted mortality.…”

“…2,3 Wide variation in ICU admission practice across hospitals suggests an opportunity to improve the effi ciency in the use of this expensive resource. [4][5][6][7] Aggressive ICU admission practices, however, can only be deemed inefficient to the extent that they do not improve outcomes. 8,9 Studies of patients with heterogeneous diagnoses along with studies limited to specific diseases have revealed significant hospitallevel variability in ICU use without differences in mortality.…”

Trends in Mechanical Ventilation Among Patients Hospitalized With Acute Exacerbations of COPD in the United States, 2001 to 2011

“…16,17 In brief, this dataset contains a date-stamped log of all items and services charged to the patient or his/her insurer, including medications, laboratory, and ventilation therapies at the individual patient level. Hospitals in the dataset represent all regions of the United States, are predominantly small-to medium-sized nonteaching facilities, and serve mostly urban patient populations.…”

Controlling Health Costs: Physician Responses to Patient Expectations for Medical Care

“…1 In this role, physicians are often the final arbiter regarding the wise and efficient use of medical resources. 2 Wasteful medical practices have been documented in virtually every aspect of medical care, [3][4][5][6] accounting for nearly 30 % of all medical expenditures. 7 Recent policy interventions that aim to encourage more cost-efficient practice among physicians include promoting transparency (publishing cost or quality outcomes), pay for performance, payment bundling and shared financial risk models.…”