Critical care use during the course of serious illness

Intensive Care Unit Occupancy in Japan, 2015-2018: A Nationwide Inpatient Database Study

BACKGROUND

Detailed data on intensive care unit (ICU) occupancy in Japan are lacking. Using a nationwide inpatient database in Japan, we aimed to assess ICU bed occupancy to guide critical care utilization planning.

METHODS

We identified all ICU patients admitted from January 1, 2015 to December 31, 2018 to ICU-equipped hospitals participating in the Japanese Diagnosis Procedure Combination inpatient database. We assessed the trends in daily occupancy by counting the total number of occupied ICU beds on a given day divided by the total number of licensed ICU beds in the participating hospitals. We also assessed ICU occupancy for patients with mechanical ventilation, patients with extracorporeal membrane oxygenation, and patients without life-supportive therapies.

RESULTS

Over the 4 study years, 1,379,618 ICU patients were admitted to 495 hospitals equipped with 5,341 ICU beds, accounting for 75% of all ICU beds in Japan. Mean ICU occupancy on any given day was 60%, with a range of 45.0% to 72.5%. Mean ICU occupancy did not change over the 4 years. Mean ICU occupancy was about 9% higher on weekdays than on weekends and about 5% higher in the coldest season than in the warmest season. For patients with mechanical ventilation, patients with extracorporeal membrane oxygenation, and patients without life-supportive therapies, mean ICU occupancy was 24%, 0.5%, and 30%, respectively.

CONCLUSION

Only one-fourth of ICU beds were occupied by mechanically ventilated patients, suggesting that the critical care system in Japan has substantial surge capacity under normal temporal variation to care for critically ill patients.

Impact of the COVID-19 pandemic on critical care utilization in Japan: a nationwide inpatient database study

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has disrupted critical care services worldwide. Examining how critical care systems responded to the COVID-19 pandemic on a national level will be useful in setting future critical care plans. The present study aimed to describe the utilization of critical care services before and during the COVID-19 pandemic using a nationwide Japanese inpatient administrative database.

METHODS

All patients admitted to an intensive care unit (ICU) or a high-dependency care unit (HDU) from February 9, 2019, to February 8, 2021, in the Japanese Diagnosis Procedure Combination inpatient database were included. February 9, 2020, was used as the breakpoint separating the periods before and during COVID-19 pandemic. Hospital and patient characteristics were compared before and during the COVID-19 pandemic. Change in ICU and HDU bed occupancy before and during the COVID-19 pandemic was evaluated using interrupted time-series analysis.

RESULTS

The number of ICU patients before and during the COVID-19 pandemic was 297,679 and 277,799, respectively, and the number of HDU patients was 408,005 and 384,647, respectively. In the participating hospitals (383 ICU-equipped hospitals and 460 HDU-equipped hospitals), the number of hospitals which increased the ICU and HDU beds capacity were 14 (3.7%) and 33 (7.2%), respectively. Patient characteristics and outcomes in ICU and HDU were similar before and during the COVID-19 pandemic except main etiology for admission of COVID-19. The mean ICU bed occupancy before and during the COVID-19 pandemic was 51.5% and 47.5%, respectively. The interrupted time-series analysis showed a downward level change in ICU bed occupancy during the COVID-19 pandemic (- 4.29%, 95% confidence intervals - 5.69 to - 2.88%), and HDU bed occupancy showed similar trends. Of 383 hospitals with ICUs, 232 (60.6%) treated COVID-19 patients in their ICUs. Their annual hospital case volume of COVID-19 ICU patients varied greatly, with a median of 10 (interquartile range 3-25, min 1, max 444).

CONCLUSIONS

The ICU and HDU bed capacity did not increase while their bed occupancy decreased during the COVID-19 pandemic in Japan. There was no change in clinicians' decision-making to forego ICU/HDU care for selected patients, and there was no progress in the centralization of critically ill COVID-19 patients.

Intensive care unit versus high dependency care unit admission after emergency surgery: a nationwide in-patient registry study

BACKGROUND

The appropriate level of postoperative critical care for patients undergoing emergency surgery is unknown. We aimed to assess the outcomes of postoperative patients treated in the intensive care unit (ICU) and high dependency care unit (HDU) after emergency surgery.

METHODS

Analysis of national in-patient registry data in Japan from July 2010 to March 2018, including patients undergoing one of 10 emergency surgeries on the day of hospital admission. The exposures were ICU or HDU admission on the day of surgery. The primary outcome was in-hospital mortality. We performed multivariable logistic regression analysis adjusted for patient and hospital characteristics. Results are presented as n (%) and odds ratios (ORs) with 95% confidence intervals.

RESULTS

We included 158 149 patients from 646 hospitals. Crude in-hospital mortality for each procedure ranged from 168/8583 (2.0%) for cholecystectomy to 2842/12 958 (21.9%) for patients undergoing surgery for traumatic brain injury. Compared with HDU admission, ICU admission was associated with lower in-hospital mortality among the cohorts for medium-mortality risk procedures (procedure-specific mortality 5-15%) (ICU: 8834/73 616 [12.0%] vs HDU: 2586/25 262 [10.2%]; OR=0.90 [0.85-0.96]; P=0.001), and high-mortality risk procedures (procedures-specific mortality >15%) (ICU: 3445/16 334 [21.1%] vs HDU: 996/4613 [21.6%]; OR=0.86 [0.78-0.96]; P=0.005). There were no differences in mortality for low-mortality risk procedures with procedure-specific mortality <5%.

CONCLUSIONS

In this national registry study, postoperative critical care in ICU was associated with lower in-hospital mortality than in HDU for patients undergoing medium-risk and high-risk emergency surgery. Further research is needed to understand the role of critical care for surgical patients.

Postoperative ICU admission following major elective surgery: A nationwide inpatient database study

BACKGROUND

Whether the routine use of the ICU after major elective surgery improves postoperative outcomes is not well established.

OBJECTIVES

To describe the association between use of postoperative ICU admission and clinical outcomes for patients undergoing major elective surgery.

DESIGN

Observational study.

SETTING

Nationwide inpatient database in Japan, July 2010 to March 2018.

PATIENTS

Patients undergoing one of 15 major elective orthopaedic, gastrointestinal, neurological, thoracic or cardiovascular surgical procedures.

INTERVENTION

ICU admission on the day of surgery. ICU was defined as a separate unit providing critical care services with around-the-clock physician staffing and nursing, the equipment necessary for critical care and a nurse-to-patient ratio at least one to two.

MAIN OUTCOME

In-hospital mortality. Patient-level and hospital-level analyses were performed.

RESULTS

Overall, 2 011 265 patients from 1524 hospitals were assessed. The cohort size ranged from 38 547 patients in 467 hospitals for surgical clipping for cerebral aneurysms to 308 952 patients in 599 hospitals for spinal fixation, laminectomy or laminoplasty. In the patient-level analyses, there were no significant mortality differences among patients undergoing the 12 major noncardiovascular surgical procedures, whereas postoperative ICU admission was associated with trends towards lower in-hospital mortality among patients undergoing coronary artery bypass grafting, risk difference -1.0% (95% CI -1.8 to -0.1) open aortic aneurysm repair, risk difference -0.6% (95% CI -1.3 to 0.1), and heart valve replacement, risk difference -0.7% (95% CI - 1.6 to 0.1). In the hospital-level analyses, similar to the results of the patient-level analyses, a higher proportion of postoperative ICU admission at hospital level was associated with trends toward lower in-hospital mortality for patients undergoing the three cardiovascular surgical procedures.

CONCLUSION

This nationwide observational study showed that postoperative ICU admission was associated with improved survival outcomes among patients undergoing three types of cardiac surgery but not among patients undergoing low-risk elective surgery.

Epidemiology of Chronic Critical Illness in Japan: A Nationwide Inpatient Database Study

OBJECTIVES

The epidemiology of chronic critical illness is not well known. We aimed to estimate the prevalence, mortality, and costs associated with chronic critical illness in Japan.

DESIGN

A nationwide inpatient administrative database study in Japan from April 2011 to March 2018.

SETTING

Six hundred seventy-nine acute-care hospitals with ICU beds in Japan.

PATIENTS

Adult patients who met our definition for chronic critical illness: one of six eligible clinical conditions (prolonged acute mechanical ventilation, tracheotomy, stroke, traumatic brain injury, sepsis, and severe wound) plus at least 8 consecutive days in an ICU.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Among 2,395,016 ICU admissions during the study period, 216,434 (9.0%) met the definition for chronic critical illness. The most common eligible condition was prolonged acute mechanical ventilation (73.9%), followed by sepsis (50.6%), tracheostomy (23.8%), and stroke (22.8%). Overall inhospital mortality was 28.6%. The overall age-specific population prevalence was 42.0 per 100,000. The age-specific population prevalence steadily increased with age, reaching 109.6 per 100,000 in persons aged greater than 85 years. With extrapolation to national estimates in Japan, there were 47,729 chronic critical illness cases in 2011 and the number remained similar at 46,494 cases in 2017. Hospitalization costs increased gradually, rising from U.S.$2.3 billion in 2011 to U.S.$2.7 billion in 2017. Inhospital mortality decreased from 30.6% to 28.2%, whereas the proportion of patients with total/severe dependence increased from 29.6% to 33.2% and the proportion of patients with decreased consciousness at discharge increased from 18.7% to 19.6%.

CONCLUSIONS

Using a nationwide inpatient database in Japan, we found substantial clinical and economic burdens of chronic critical illness in Japan. Chronic critical illness was particularly common in elderly people. Although inhospital mortality of chronic critical illness patients continues to decrease, costs and patients with dependence for activities of daily living or decreased consciousness at discharge are increasing.

Five-Year Trends of Critical Care Practice and Outcomes

BACKGROUND

Longitudinal analyses of large, detailed adult critical care datasets provide insights into practice trends and generate useful outcome and process benchmarks.

METHODS

Data representing 991,571 consecutive critical care visits to 160 US adult ICUs from 2009 to 2013 from the eICU Research Institute clinical practice database were used to quantitate patient characteristics, APACHE IV-based acuity predictions, treatments, and outcomes. Analyses for changes over time were performed for patient characteristics, entry and discharge locations, primary admission diagnosis, treatments, adherence to consensus ICU best practices, length of stay (LOS), and inpatient mortality.

RESULTS

We detected significant trends for increasing age, BMI, and risk of mortality, higher frequency of admission from an ED and stepdown unit, and more frequent hospital discharge to substance abuse centers and skilled nursing facilities. Significantly more patients were admitted for sepsis, emphysema, coma, congestive heart failure, diabetic ketoacidosis, and fewer were admitted for asthma, unspecified chest pain, coronary artery bypass graft, and stroke care. The frequency of noninvasive mechanical ventilation and adherence to critical care best practices significantly increased, whereas the duration of renal replacement therapies, frequency of transfusions, antimicrobial use, critical care complications, LOS, and inpatient mortality decreased.

CONCLUSIONS

Analyses of patients, practices, and outcomes from a large geographically dispersed sample of adult ICUs revealed trends of increasing age and acuity, higher rates of adherence to best practice, use of noninvasive mechanical ventilation, and decreased use of antimicrobials, transfusions, and duration of renal replacement therapies. Acuity-adjusted LOS and in hospital mortality decreased.

ICU Telemedicine and Critical Care Mortality: A National Effectiveness Study

BACKGROUND

Intensive care unit (ICU) telemedicine is an increasingly common strategy for improving the outcome of critical care, but its overall impact is uncertain.

OBJECTIVES

To determine the effectiveness of ICU telemedicine in a national sample of hospitals and quantify variation in effectiveness across hospitals.

RESEARCH DESIGN

We performed a multicenter retrospective case-control study using 2001-2010 Medicare claims data linked to a national survey identifying US hospitals adopting ICU telemedicine. We matched each adopting hospital (cases) to up to 3 nonadopting hospitals (controls) based on size, case-mix, and geographic proximity during the year of adoption. Using ICU admissions from 2 years before and after the adoption date, we compared outcomes between case and control hospitals using a difference-in-differences approach.

RESULTS

A total of 132 adopting case hospitals were matched to 389 similar nonadopting control hospitals. The preadoption and postadoption unadjusted 90-day mortality was similar in both case hospitals (24.0% vs. 24.3%, P=0.07) and control hospitals (23.5% vs. 23.7%, P<0.01). In the difference-in-differences analysis, ICU telemedicine adoption was associated with a small relative reduction in 90-day mortality (ratio of odds ratios=0.96; 95% CI, 0.95-0.98; P<0.001). However, there was wide variation in the ICU telemedicine effect across individual hospitals (median ratio of odds ratios=1.01; interquartile range, 0.85-1.12; range, 0.45-2.54). Only 16 case hospitals (12.2%) experienced statistically significant mortality reductions postadoption. Hospitals with a significant mortality reduction were more likely to have large annual admission volumes (P<0.001) and be located in urban areas (P=0.04) compared with other hospitals.

CONCLUSIONS

Although ICU telemedicine adoption resulted in a small relative overall mortality reduction, there was heterogeneity in effect across adopting hospitals, with large-volume urban hospitals experiencing the greatest mortality reductions.

Elderly patients hospitalized in the ICU in France: a population-based study using secondary data from the national hospital discharge database

RATIONALE, AIMS AND OBJECTIVES

In the global context of population ageing, understanding and monitoring intensive care use by the elderly is a strategic issue. National-level data are needed to overcome sampling biases that often limit epidemiologic studies of the critically ill elderly. The objective of this study was to describe intensive care use for hospitalized elderly patients using secondary data from the French national hospital discharge database.

METHOD

Structured assessment of the national database coverage and accuracy; cross-sectional analysis of hospitalizations including at least one admission in an intensive care unit (ICU) for patients aged ≥ 80 years from 1 January to 31 December 2009.

RESULTS

In 2009, people aged ≥ 80 years accounted for 5.4% of the population but 15.3% of the 215 210 adult hospitalizations involving intensive care in France. In this elderly group, the mean age was 84.0 (± 3.56) years, and 51.6% were male. In-hospital mortality was 33.9%. The median time spent in the ICU was 3 [interquartile range (IQR), 2-8] days, the median time spent in hospital was 14 (IQR, 8-24) days and 9% of hospitalizations ended by the patient's death involved intensive care. A surgical procedure was included in 43% of hospitalizations. Medical and surgical diagnosis-related group hospitalizations were characterized by significant differences in volume, mortality, ICU days and costs.

CONCLUSIONS

There was marked clinical heterogeneity in the population of elderly patients hospitalized in the ICU. These data provide baseline information and prompt further studies comparing intensive care utilization across age groups, between countries and over time.

Adoption and de-adoption of drotrecogin alfa for severe sepsis in the United States

PURPOSE

Drotrecogin alfa was a landmark drug for treatment of severe sepsis, yet little is known about how it was adopted and de-adopted during its 10-year period of availability.

METHODS

We used hospitalization data on fee-for-service Medicare beneficiaries from 2002 to 2011 to characterize trends in the use of drotrecogin alfa in the United States.

RESULTS

Drotrecogin alfa use peaked at 5.87 per 1000 severe sepsis hospitalizations in 2003 and then steadily declined to 0.94 administrations per 1000 severe sepsis hospitalizations in 2010. Large teaching hospitals were more likely to use drotrecogin alfa than small, nonteaching hospitals. The addition of "add-on payments" to hospitals for using drotrecogin alfa in 2002 was associated with significantly increased use (P < .0001), and the withdrawal of those payments in 2004 was associated significantly decreased use (P < .0001). Neither the publication of international sepsis guidelines with favorable drotrecogin alfa recommendations (in 2004 and 2008) nor the publication of a clinical trial focused on drotrecogin alfa (in 2005) were associated with consistent changes use (P > .05).

CONCLUSIONS

Drotrecogin alfa use declined over time, with marked changes in use associated with drug-specific financial incentives but not the publication of clinical practice guidelines or clinical trials.

Effect of public reporting on intensive care unit discharge destination and outcomes

RATIONALE

Public reporting of hospital performance is designed to improve healthcare outcomes by promoting quality improvement and informing consumer choice, but these programs may carry unintended consequences.

OBJECTIVE

To determine whether publicly reporting in-hospital mortality rates for intensive care unit (ICU) patients influenced discharge patterns or mortality.

METHODS

We performed a retrospective cohort study taking advantage of a natural experiment in which California, but not other states, publicly reported hospital-specific severity-adjusted ICU mortality rates between 2007 and 2012. We used multivariable logistic regression adjusted for patient, hospital, and regional characteristics to compare mortality rates and discharge patterns between California and states without public reporting for Medicare fee-for-service ICU admissions from 2005 through 2009 using a difference-in-differences approach.

MEASUREMENTS AND MAIN RESULTS

We assessed discharge patterns using post-acute care use and acute care hospital transfer rates and mortality using in-hospital and 30-day mortality rates. The study cohort included 936,063 patients admitted to 646 hospitals. Compared with control subjects, admission to a California ICU after the introduction of public reporting was associated with a reduced odds of post-acute care use in post-reform year 2 (ratio of odds ratios [ORs], 0.94; 95% confidence interval [CI], 0.91-0.96) and increased odds of transfer to another acute care hospital in both post-reform years (year 1: ratio of ORs, 1.08; 95% CI, 1.01-1.16; year 2: ratio of ORs, 1.43; 95% CI, 1.33-1.53). There were no significant differences in in-hospital or 30-day mortality.

CONCLUSIONS

Public reporting of ICU in-hospital mortality rates was associated with changes in discharge patterns but no change in risk-adjusted mortality.

County-Level Effects of Prehospital Regionalization of Critically Ill Patients: A Simulation Study

OBJECTIVE

Regionalization may improve critical care delivery, yet stakeholders cite concerns about its feasibility. We sought to determine the operational effects of prehospital regionalization of nontrauma, nonarrest critical illness.

SETTING

King County, Washington.

DESIGN

Discrete event simulation study.

PATIENTS

All 2006 hospital discharge data, linked to all adult, eligible patients transported by county emergency medical services agencies.

INTERVENTIONS

We simulated active triage of high-risk patients to designated referral centers using a validated prehospital risk score; we studied three regionalization scenarios: 1) up triage, 2) up and down triage, and 3) up and down triage after reducing ICU beds by 25%. We determined the effect on patient routing, ICU occupancy at referral and nonreferral hospitals, and emergency medical services transport times.

MEASUREMENTS AND MAIN RESULTS

A total of 119,117 patients were hospitalized at 11 nonreferral centers and 76,817 patients were hospitalized at three referral centers. Among 20,835 emergency medical services patients, 7,817 patients (43%) were eligible for up triage and 10,242 patients (57%) were eligible for down triage. At baseline, mean daily ICU bed occupancy was 61% referral and 47% at nonreferral hospitals. Up triage increased referral ICU occupancy to 68%, up and down triage to 64%, and up and down triage with bed reduction to 74%. Mean daily nonreferral ICU occupancy did not exceed 60%. Total emergency medical services transport time increased by less than 3% with up and down triage.

CONCLUSIONS

Regionalization based on prehospital triage of the critically ill can allocate high-risk patients to referral hospitals without adversely affecting ICU occupancy or prehospital travel time.

Hospitals with the highest intensive care utilization provide lower quality pneumonia care to the elderly

OBJECTIVE

Quality of care for patients admitted with pneumonia varies across hospitals, but causes of this variation are poorly understood. Whether hospitals with high ICU utilization for patients with pneumonia provide better quality care is unknown. We sought to investigate the relationship between a hospital's ICU admission rate for elderly patients with pneumonia and the quality of care it provided to patients with pneumonia.

DESIGN

Retrospective cohort study.

SETTING

Two thousand eight hundred twelve U.S. hospitals.

PATIENTS

Elderly (age≥65 years) fee-for-service Medicare beneficiaries with either a (1) principal diagnosis of pneumonia or (2) principal diagnosis of sepsis or respiratory failure and secondary diagnosis of pneumonia in 2008.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We grouped hospitals into quintiles based on ICU admission rates for pneumonia. We compared rates of failure to deliver pneumonia processes of care (calculated as 100-adherence rate), 30-day mortality, hospital readmissions, and Medicare spending across hospital quintile. After controlling for other hospital characteristics, hospitals in the highest quintile more often failed to deliver pneumonia process measures, including appropriate initial antibiotics (13.0% vs 10.7%; p<0.001), and pneumococcal vaccination (15.0% vs 13.3%; p=0.03) compared with hospitals in quintiles 1-4. Hospitals in the highest quintile of ICU admission rate for pneumonia also had higher 30-day mortality, 30-day hospital readmission rates, and hospital spending per patient than other hospitals.

CONCLUSIONS

Quality of care was lower among hospitals with the highest rates of ICU admission for elderly patients with pneumonia; such hospitals were less likely to deliver pneumonia processes of care and had worse outcomes for patients with pneumonia. High pneumonia-specific ICU admission rates for elderly patients identify a group of hospitals that may deliver inefficient and poor-quality pneumonia care and may benefit from interventions to improve care delivery.

Absence of gender-based differences in outcome of patients with hospital-acquired pneumonia

BACKGROUND

The objective of this analysis was to evaluate the association between gender and clinical outcomes in intensive care unit (ICU) patients with hospital-acquired pneumonia (HAP) since data thus far are controversial.

METHODS

Data from a convenience sample of ICU patients with HAP, including ventilator-associated and health care-associated pneumonia, were retrospectively collected from four academic institutions (Improving Medicine through Pathway Assessment of Critical Therapy in Hospital-Acquired Pneumonia [IMPACT-HAP] study). Outcomes included 28-day mortality, clinical failure at day 14, hospital and ICU length of stay (LOS), and duration of mechanical ventilation. We compared baseline characteristics and performed multivariate analysis to identify factors independently associated with mortality.

RESULTS

Among 416 patients, 271 were men and 145 were women. Women were older (62.4±16.9 vs. 55.7±16.5 years, p<0.001) and more critically ill, with Acute Physiology and Chronic Health Evaluation (APACHE) II scores of 21 vs. 19 (p=0.004). Day-28 mortality was 30% for women and 24% for men (p=0.25). Increased 28-day mortality was associated with severity of illness, age, ventilator-associated pneumonia, vascular disease, and hospital LOS prior to pneumonia diagnosis. No significant differences were found in the distribution of bacteria pathogens or in clinical failure rates (36% vs. 31%) between genders. Duration in days of mechanical ventilation, ICU LOS and hospital LOS after the diagnosis of pneumonia were not significantly different between men and women. Analyzing data for women based on presumed pre- or postmenopausal status (age breakpoint of 50 years), showed an increased in ICU LOS (15 vs. 25 days; p=0.0026) and hospital LOS (22 vs. 30 days; p=0.05) for women ≤50 years. No differences were noted in 28-day mortality (24.3% vs. 13.1%; p=0.18) in women ≤50 years of age.

CONCLUSIONS

In ICU patients with pneumonia, female gender was not associated with worse outcomes or increased resource utilization compared to male gender. Further studies are needed to evaluate menopausal status and outcomes in women with pneumonia.

Hospitalizations, costs, and outcomes of severe sepsis in the United States 2003 to 2007

OBJECTIVES

To assess trends in number of hospitalizations, outcomes, and costs of severe sepsis in the United States.

DESIGN

Temporal trends study using the Nationwide Inpatient Sample.

PATIENTS

Adult patients with severe sepsis (defined as a diagnosis of sepsis and organ dysfunction) diagnosed between 2003 and 2007.

MEASUREMENTS AND MAIN RESULTS

We determined the weighted frequency of patients hospitalized with severe sepsis. We calculated age- and sex-adjusted population-based mortality rates for severe sepsis per 100,000 population and also used logistic regression to adjust in-hospital mortality rates for patient characteristics. We calculated inflation-adjusted costs using hospital-specific cost-to-charge ratios. We identified a rapid steady increase in the number of cases of severe sepsis, from 415,280 in 2003 to 711,736 in 2007 (a 71% increase). The total hospital costs for all patients with severe sepsis increased from $15.4 billion in 2003 to $24.3 billion in 2007 (57% increase). The proportion of patients with severe sepsis and only a single organ dysfunction decreased from 51% in 2003 to 45% in 2007 (p < .001), whereas the proportion of patients with three or four or more organ dysfunctions increased 1.19-fold and 1.51-fold, respectively (p < .001). During the same time period, we observed 2% decrease per year in hospital mortality for patients with severe sepsis (p < .001), as well as a slight decrease in the length of stay (9.9 days to 9.2 days; p < .001) and a significant decrease in the geometric mean cost per case of severe sepsis ($20,210 per case in 2003 and $19,330 in 2007; p = .025).

CONCLUSIONS

The increase in the number of hospitalizations for severe sepsis coupled with declining in-hospital mortality and declining geometric mean cost per case may reflect improvements in care or increases in discharges to skilled nursing facilities; however, these findings more likely represent changes in documentation and hospital coding practices that could bias efforts to conduct national surveillance.

ICU capacity strain and the quality and allocation of critical care

PURPOSE OF REVIEW

Increasing demand for critical care, with limited potential for comparable expansion of supply, may strain the abilities of ICUs to provide high-quality care in an equitable fashion. Efforts to counter the untoward consequences for the quality and ethics of critical care delivery are limited by the absence of a specific and validated metric of ICU capacity strain.

RECENT FINDINGS

This manuscript presents a conceptual framework for ICU capacity strain, considers what data elements may contribute to it, and suggests methods for determining the optimal metric. Next, it outlines the range of potential consequences of increased capacity strain, in terms of both the quality and ethics of care delivered. Finally, consideration is given to how untoward consequences of ICU capacity strain might be mitigated through better understanding of what makes some ICUs better able than others to withstand temporal fluctuations in the demand for their services.

SUMMARY

Development of an appropriately accurate and parsimonious measure of ICU capacity strain may augment the precision of future critical care outcomes research by reducing unexplained variance attributable to temporal fluctuations in ICU-level factors; elucidate organizational characteristics that make some ICUs better able to withstand high-capacity strain without substantive degradations in quality; and enhance the transparency of critical care rationing while helping to improve its equity and efficiency, thereby promoting the ethics of this inevitable practice.

Population-level comparative effectiveness of laparoscopic versus open radical nephrectomy for patients with kidney cancer

BACKGROUND

Because there is limited population-based evidence supporting the comparative effectiveness of laparoscopic radical nephrectomy (LRN) after its widespread adoption, we compared trends in hospital-based outcomes among patients with kidney cancer treated with LRN or open radical nephrectomy (ORN).

METHODS

Using linked SEER-Medicare data, the authors identified patients with kidney cancer who were treated with LRN or ORN from 2000 through 2005. The authors measured 4 primary outcomes: intensive care unit (ICU) admission, prolonged length of stay, 30-day hospital readmission, and in-hospital mortality. The authors then estimated the association between surgical approach and each outcome, adjusting for patient demographics, tumor characteristics, and year of surgery.

RESULTS

The authors identified 2108 (26%) and 5895 (74%) patients treated with LRN and ORN, respectively. Patients treated with LRN were more likely to be white, female, of higher socioeconomic position, and to have tumor sizes of ≤4 cm (all P < .05). The adjusted probability of ICU admission and prolonged length of stay was 41% and 46% lower, respectively, for patients undergoing LRN (P < .001). Although uncommon for both groups, the adjusted probability of in-hospital mortality was 51% higher (2.3% vs 1.5%, P = .04) for patients treated with a laparoscopic approach.

CONCLUSIONS

At a population level, patients treated with LRN have a lower likelihood of ICU admission and prolonged length of stay, supporting the convalescence benefits of laparoscopy. In-hospital mortality, however, was higher among patients treated with LRN. The latter finding suggests a potentially unanticipated consequence of this technique and highlights the need for long-term monitoring during and after the widespread adoption of new surgical technologies.

The epidemiology of mechanical ventilation use in the United States

OBJECTIVE

Few contemporary population-based data exist about the incidence, patient characteristics, and outcomes of mechanical ventilation in acute care hospitals. We sought to describe the epidemiology of mechanical ventilation use in the United States.

DESIGN

Retrospective cohort study using year 2005 hospital discharge records from six states. National projections were generated from age-, race-, and sex-specific rates in the cohort.

SETTING

Nonfederal acute care hospitals.

PATIENTS

All discharges that included invasive mechanical ventilation identified using International Classification of Diseases, 9th Revision, Clinical Modification procedure codes (96.7x).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 6,469,674 hospitalizations in the six states, 180,326 (2.8%) received invasive mechanical ventilation. There was a wide age distribution with 52.2% of patients <65 yrs of age. A total of 44.6% had at least one major comorbid condition. The most common comorbidities included diabetes (13.2%) and pulmonary disease (13.2%). Inhospital mortality was 34.5%, and only 30.8% of patients were discharged home from the hospital. Almost all patients received care in urban (73.5%) or suburban (23.6%) hospitals vs. rural hospitals (2.9%). Patients in urban hospitals experienced a higher number of organ dysfunctions, more dialysis and tracheostomies, and higher mortality compared with patients in rural hospitals. Projecting to national estimates, there were 790,257 hospitalizations involving mechanical ventilation in 2005, representing 2.7 episodes of mechanical ventilation per 1000 population. Estimated national costs were $27 billion representing 12% of all hospital costs. Incidence, mortality, and cumulative population costs rose significantly with age.

CONCLUSIONS

Mechanical ventilation use is common and accounts for a disproportionate amount of resource use, particularly in urban hospitals and in elderly patients. Mortality for mechanically ventilated patients is high. Quality improvement and cost-reduction strategies targeted at these patients are warranted.

Critical care medicine in the United States 2000-2005: an analysis of bed numbers, occupancy rates, payer mix, and costs

OBJECTIVES

To analyze the evolving role, patterns of use, and costs of critical care medicine in the United States from 2000 to 2005.

DESIGN

Retrospective study of data from the Hospital Cost Report Information System (Centers for Medicare and Medicaid Services, Baltimore, Maryland).

SETTING

Nonfederal, acute care hospitals with critical care medicine beds in the United States.

SUBJECTS

None.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We analyzed hospital and critical care medicine beds, bed types, days, occupancy rates, payer mix (Medicare and Medicaid), and costs. Critical care medicine costs were compared with national cost indexes. Between 2000 and 2005, the total number of U.S. hospitals with critical care medicine beds decreased by 12.2% (from 3,586 to 3,150). Although the number of hospital beds decreased by 4.2% (from 655,785 to 628,409), both hospital days and occupancy rates increased by 5.1% (from 145.1 to 152.5 million) and 13.7% (from 59% to 67%), respectively. Critical care medicine beds increased by 6.5% (from 88,252 to 93,955), days by 10.6% (from 21.0 to 23.2 million), and occupancy rates by 4.5% (from 65% to 68%). The majority (90%) of critical care medicine beds were classified as intensive care, premature/neonatal, and coronary care unit beds. The percentage of critical care medicine days used by Medicare decreased by 3.8% (from 37.9% to 36.5%) compared with an increase of 15.5% (from 14.5% to 16.8%) by Medicaid. From 2000 to 2005, critical care medicine costs per day increased by 30.4% (from $2698 to $3518). Although annual critical care medicine costs increased by 44.2% (from $56.6 to $81.7 billion), the proportion of hospital costs and national health expenditures allocated to critical care medicine decreased by 1.6% and 1.8%, respectively. However, the proportion of the gross domestic product used by critical care medicine increased by 13.7%. In 2005, critical care medicine costs represented 13.4% of hospital costs, 4.1% of national health expenditures, and 0.66% of the gross domestic product.

CONCLUSIONS

Critical care medicine continues to grow in a shrinking U.S. hospital system. The critical care medicine payer mix is evolving, with Medicaid increasing in its percentage of critical care medicine use. Critical care medicine is more cost controlled than other healthcare indexes, but is still using an increasing percentage of the gross domestic product. Our updated and comprehensive critical care medicine use and cost analysis provides a contemporary benchmark for the strategic planning of critical care medicine services within the U.S. healthcare system.

The structure of critical care transfer networks

RATIONALE

Moving patients from low-performing hospitals to high-performing hospitals may improve patient outcomes. These transfers may be particularly important in critical care, where small relative improvements can yield substantial absolute changes in survival.

OBJECTIVE

To characterize the existing critical care network in terms of the pattern of transfers.

METHODS

In a retrospective cohort study, the nationwide 2005 Medicare fee-for-service claims were used to identify the interhospital transfer of critically ill patients, defined as instances where patients used critical care services in 2 temporally adjacent hospitalizations.

MEASUREMENTS

We measured the characteristics of the interhospital transfer network and the extent to which intensive care unit patients are referred to each hospital in that network--a continuous quantitative measure at the hospital-level known as centrality. We evaluated associations between hospital centrality and organizational, medical, surgical, and radiologic capabilities.

RESULTS

There were 47,820 transfers of critically ill patients among 3308 hospitals. 4.5% of all critical care stays of any length involved an interhospital critical care transfer. Hospitals transferred out to a mean of 4.4 other hospitals. More central hospital positions were associated with multiple indicators of increased capability. Hospital characteristics explained 40.7% of the variance in hospitals' centrality.

CONCLUSIONS

Critical care transfers are common, and traverse an informal but structured network. The centrality of a hospital is associated with increased capability in delivery of services, suggesting that existing transfers generally direct patients toward better resourced hospitals. Studies of this network promise further improvements in patient outcomes and efficiency of care.

More men than women are admitted to 9 intensive care units in British Columbia

PURPOSE

The aim of this study is to determine if more males than females are admitted to adult intensive care units (ICUs).

MATERIALS AND METHODS

In 9 tertiary and community hospitals in British Columbia, Canada, we expressed the number of patients admitted to hospital and to ICU from 1998 to 2008 as a proportion of the population of the main regions served by these hospitals, and for ICU patients in 1 tertiary hospital, as a proportion of the hospital population. Patients not residing in the region of this tertiary hospital or whose addresses were unknown and admissions for sex-specific diagnoses were excluded from the main analyses. Male proportion was divided by female proportion for age groups by decade. Multivariate regression was used to determine the association between sex and admission to ICU after adjustment for confounders.

RESULTS

Normalized male-to-female ratio of ICU admissions to the 9 hospitals was greater than 1. In the tertiary hospital analyzed in more detail, the male-to-female ratio for admissions to hospital or to ICU, normalized to the population in the community or hospital, respectively, was greater than 1 for all age groups, and this ratio increased with age. After adjustment for covariates, males and females less than 80 years of age were roughly equally likely to be admitted to ICU from hospital, but in patients aged 80 or older, men were much more likely than women to be admitted (odds ratio, 2.14; 95% confidence interval, 1.56-2.94).

CONCLUSION

More men than women are admitted to ICUs; this difference is especially prominent in elderly patients.

Prognostication--the lost skill of medicine

Making a prognosis is one of the primary functions of the medical profession. At the end of the nineteenth century prognostication took up approximately ten percent of medical textbooks, by 1970 this had fallen to nearly zero. Given medical technology's awesome ability to prolong the process and suffering of dying today's patients need to know their prognosis in order to make choices about their treatment options. Whilst precise predictions of the future are obviously not possible, relatively simple mathematical modelling techniques can make reasonable estimates of likely outcomes for individual patients. The life expectancy of a patient of any age with any illness can be estimated provided the disease-specific mortality of the illness is known. Decision analysis or logistic regression models can then be used to determine the risks and benefits of various treatment options. A patient's prognosis does not just depend on their age and primary diagnosis, but also on the severity of their illness, their functional capacity both prior to and during the illness and the number of co-morbidities also suffered from. Several predictive instruments have been developed to help simplify the prediction of the outcome of individual patients. There are conflicting reports on how these models compare with doctors' intuition--whatever their strengths and weaknesses it is unlikely that they worsen clinical judgement. Therefore, all doctors should become familiar with them and use them appropriately.

Sex-and age-based differences in the delivery and outcomes of critical care

BACKGROUND

Previous studies have suggested that a patient's sex may influence the provision and outcomes of critical care. Our objective was to determine whether sex and age are associated with differences in admission practices, processes of care and clinical outcomes for critically ill patients.

METHODS

We used a retrospective cohort of 466,792 patients, including 24,778 critically ill patients, admitted consecutively to adult hospitals in Ontario between Jan. 1, 2001, and Dec. 31, 2002. We measured associations between sex and age and admission to the intensive care unit (ICU); use of mechanical ventilation, dialysis or pulmonary artery catheterization; length of stay in the ICU and hospital; and death in the ICU, hospital and 1 year after admission.

RESULTS

Of the 466,792 patients admitted to hospital, more were women than men (57.0% v. 43.0% for all admissions, p < 0.001; 50.1% v. 49.9% for nonobstetric admissions, p < 0.001). However, fewer women than men were admitted to ICUs (39.9% v. 60.1%, p < 0.001); this difference was most pronounced among older patients (age > or = 50 years). After adjustment for admission diagnoses and comorbidities, older women were less likely than older men to receive care in an ICU setting (odds ratio [OR] 0.68, 95% confidence interval [CI] 0.66-0.71). After adjustment for illness severity, older women were also less likely than older men to receive mechanical ventilation (OR 0.91, 95% CI 0.81-0.97) or pulmonary artery catheterization (OR 0.80, 95% CI 0.73-0.88). Despite older men and women having similar severity of illness on ICU admission, women received ICU care for a slightly shorter duration yet had a longer length of stay in hospital (mean 18.3 v. 16.9 days; p = 0.006). After adjustment for differences in comorbidities, source of admission, ICU admission diagnosis and illness severity, older women had a slightly greater risk of death in the ICU (hazard ratio 1.20, 95% CI 1.10-1.31) and in hospital (hazard ratio 1.08, 95% CI 1.00-1.16) than did older men.

INTERPRETATION

Among patients 50 years or older, women appear less likely than men to be admitted to an ICU and to receive selected life-supporting treatments and more likely than men to die after critical illness. Differences in presentation of critical illness, decision-making or unmeasured confounding factors may contribute to these findings.

Critical care medicine use and cost among Medicare beneficiaries 1995-2000: major discrepancies between two United States federal Medicare databases

OBJECTIVE

A comparison of federal Medicare databases to identify critical care medicine (CCM) use, cost discrepancies, and their possible causes.

DESIGN

A 6-yr (1995-2000) retrospective analysis of Medicare hospital and CCM use and cost, comparing the Hospital Cost Report Information System (HCRIS) with Medicare Provider Analysis and Review File (MedPAR) supplemented when necessary by Health Care Information System (HCIS) (identified herein as MedPAR/HCIS).

SETTING

All nonfederal U.S. hospitals.

SUBJECTS

None.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Data are presented as days (M = million) and costs ($; B = Billion) for both hospitals and CCM. Between 1995 and 2000, the number of hospital days decreased in both databases: HCRIS (-13.2%; 78M to 67.7M) and MedPAR/HCIS (-14.1%; 82.8M to 71.1M). CCM days decreased in HCRIS (-4.6%; 8.3M to 7.9M). In contrast, CCM days increased in MedPAR/HCIS (7.2%; 13.9M to 14.9M). The discrepancy in CCM days between HCRIS and MedPAR/HCIS increased from 40% (5.6M days) in 1995 to 47% (7M days) in 2000. Two CCM billing codes (intensive care unit and coronary care unit "post/intermediate") used in MedPAR/HCIS were responsible for 73% on average per year, over the study period, for this CCM discrepancy. The use of these two codes progressively increased (44%; 3.9M to 5.6M days) by the end of the study. The cumulative 6-yr discrepancy in CCM days between HCRIS and MedPAR/HCIS (37.3M days) had a calculated cost of $92.3B.

CONCLUSIONS

We have identified major, and progressively increasing, discrepancies between two U.S. federal databases tabulating hospital and CCM use and cost for Medicare beneficiaries. Two CCM "post/intermediate" billing codes in MedPAR/HCIS were predominantly responsible for the CCM discrepancy. To accurately assess Medicare CCM use and cost, either HCRIS, or MedPAR/HCIS without the "post/intermediate" codes, should be used.

Demographic and clinical variation of adult intensive care unit utilization from a geographically defined population

OBJECTIVE

To determine population-based rates of adult intensive care unit (ICU) use and evaluate the effects that demographic variables and chronic illness have on ICU utilization.

DESIGN

Retrospective, population-based cohort study.

SETTING

Olmsted County, Minnesota.

PARTICIPANTS

Adult residents admitted to an ICU in 1998.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Measurements included demographics, Acute Physiology and Chronic Health Evaluation III score, ICU admission diagnosis, ICU interventions, Charlson comorbidity index and conditions, ICU length of stay (LOS), and ICU, hospital, 1-month, and 1-yr mortalities. Risk of ICU admission and rates of ICU utilization increased substantially with increasing age, peaking in the very elderly. The rates of ICU admission and utilization in those > or =85 yrs old were 58.2 admissions/1,000 residents and 195.8 days/1,000 residents compared with 3.8 admissions/1,000 residents and 11.5 days/1,000 residents in those 18 to 44 yrs old. Residents > or =85 yrs old were 3.75 times as likely (p < .001) to be admitted to the ICU compared with those 18-44 yrs old after controlling for the presence of comorbid illness. ICU admission rates increased with an increasing number of comorbid illnesses. Residents with cardiovascular conditions and renal disease had high rates of ICU admission. Repeat users of the ICU were more likely to have a chronic condition and higher degree of comorbid illness compared with nonrepeat users. ICU mortality was similar across all age groups, except in those > or =85 yrs old, for whom mortality was greater. One-year mortality after ICU admission increased with increasing age.

CONCLUSIONS

Population-based rates of ICU admission and utilization in Olmsted County, Minnesota, increased with age and are highest in the very elderly. The presence of chronic illness, particularly cardiovascular conditions, significantly increases ICU utilization and risk of ICU admission.

Effect of age on survival of critically ill patients with cancer

OBJECTIVES

To estimate the effects of age on 6-month survival of critically ill patients with cancer.

DESIGN

Prospective cohort study analyzed using Cox proportional hazard models.

SETTING

Ten-bed oncologic medical-surgical intensive care unit.

PATIENTS

Eight hundred sixty-two patients with cancer, excluding bone marrow transplant patients.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The mean age was 57.8+/-16.2 yrs. The hospital and 6-month mortality rates were 48% and 58%, respectively. Age was independently associated with increased mortality (hazard ratio, 1.015; 95% confidence interval, 1.009-1.021). Martingale residual analysis, however, suggested an inflection point in the effect of age, with an upward trend for patients aged>60 yrs. Therefore, patients were stratified in two groups: young (<or=60 yrs, n=431, 50%) and elderly (>60 yrs, n=431, 50%). In young patients, uncontrolled cancer, mechanical ventilation, and number of organ failures were associated with poor outcome, whereas surgery before intensive care unit admission was protective. The variables associated with increased mortality for elderly patients were performance status 3-4, uncontrolled cancer, number of organ failures, and the presence of a severe comorbidity. In this group, age was associated with a lower survival rate. In general, the effect of covariates on the outcome was higher in the elderly group.

CONCLUSIONS

Aging was associated with increased mortality, especially for patients>60 yrs. The severity of organ failures and the presence of uncontrolled cancer were the main predictive factors, but there were important differences among the outcome predictors for young and elderly patients. Our results suggest that selected older patients with cancer can benefit from intensive care.