High ICU use linked to more procedures, no mortality benefit

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A large study suggests hospitals that used intensive care units (ICUs) more readily were more likely to perform invasive procedures and have higher costs ,while showing no improvement in mortality.

The potential clinical implications of overusing ICU care, along with its high costs, have made improving the value of ICU care an imperative for the US health care system. However, variability exists in ICU utilisation among hospitals because of a lack of clear-cut guidelines for ICU admission and differences in hospital resources, policies and culture.

Dr Dong W Chang, of the Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Centre, Torrance, California, and Dr Martin F Shapiro, of the University of California – Los Angeles, analysed ICU utilisation for four common medical conditions: diabetic ketoacidosis (DKA), pulmonary embolism (PE), congestive heart failure (CHF) and upper gastrointestinal bleeding (UGIB).

The study included data for 156,842 hospitalisations at 94 hospitals for those four conditions in Washington state and Maryland from 2010 to 2012, accounting for 4.7% of total hospitalisations at these hospitals. The authors examined ICU utilisation rates, hospital mortality, use of invasive procedures and hospital costs.

The authors report ICU admission rates ranged from 16.3% to 81.2% for DKA, 5% to 44.2% for PE, 11.5% to 51.2% for UGIB, and 3.9% to 48.8% for CHF. Smaller hospitals with fewer beds more frequently had higher ICU utilisation, as did teaching hospitals, according to the results.

While ICU utilisation was not associated with significant differences in hospital mortality, it was associated with more invasive procedures and higher costs, the study reports. For example, rates of invasive procedures in all four conditions were greater in higher ICU utilisation hospitals. Also, hospitalisation costs among lower and higher ICU hospitals were $7,141 and $8,204 for DKA, $10,660 and $11,117 for PE, $10,164 and $10,851 for UGIB and $10,175 and $13,587 for CHF, according to the results.

The authors note study limitations related to the data, including a lack of detail to fully account for medical complexity. “In summary, hospitals that utilized ICU care more frequently for DKA, PE, UGIB and CHF were more likely to perform invasive studies and have higher hospital costs with no improvement in mortality compared with lower ICU utilisation institutions. These findings suggest that optimising ICU utilisation may improve quality and value of ICU care but accomplishing that will require institutional assessments of factors that lead clinicians to admit patients to the ICU for cases in which that level of care may not be necessary,” the study concludes.

“These common illnesses may be classified as ‘in-between’ conditions if they are not presenting at extreme levels of severity. … In conclusion, patients with in-between conditions may appear to be in between to some but not to all hospitals. Chang and Shapiro have well described the high and low ICU utilising scenarios; now it is up to hospitals and clinical decision makers to reflect on their care pathways, triage decision processes, patient safety, care effectiveness and costs, whether on the wards or in their ICUs. Hopefully, further studies will clarify the characteristics of ICU triage and care pathways to favourably affect patient outcomes and resource use in the ICU,” writes Dr Neil A Halpern, of Memorial Sloan Kettering Cancer Centre, New York.

Abstract
Importance: Maximizing the value of critical care services requires understanding the relationship between intensive care unit (ICU) utilization, clinical outcomes, and costs.
Objective: To examine whether hospitals had consistent patterns of ICU utilization across 4 common medical conditions and the association between higher use of the ICU and hospital costs, use of invasive procedures, and mortality.
Design, Setting, and Participants: Retrospective cohort study of 156 842 hospitalizations in 94 acute-care nonfederal hospitals for diabetic ketoacidosis (DKA), pulmonary embolism (PE), upper gastrointestinal bleeding (UGIB), and congestive heart failure (CHF) in Washington state and Maryland from 2010 to 2012. Hospitalizations for DKA, PE, UGIB, and CHF were identified from the presence of compatible International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Multilevel logistic regression models were used to determine the predicted hospital-level ICU utilization during hospitalizations for the 4 study conditions. For each condition, hospitals were ranked based on the predicted ICU utilization rate to examine the variability in ICU utilization across institutions.
Main Outcomes and Measures: The primary outcomes were associations between hospital-level ICU utilization rates and risk-adjusted hospital mortality, use of invasive procedures, and hospital costs.
Results: The 94 hospitals and 156 842 hospitalizations included in the study represented 4.7% of total hospitalizations in this study. ICU admission rates ranged from 16.3% to 81.2% for DKA, 5.0% to 44.2% for PE, 11.5% to 51.2% for UGIB, and 3.9% to 48.8% for CHF. Spearman rank coefficients between DKA, PE, UGIB, and CHF showed significant correlations in ICU utilization for these 4 medical conditions among hospitals (ρ ≥ 0.90 for all comparisons; P < .01 for all). For each condition, hospital-level ICU utilization rate was not associated with hospital mortality. Use of invasive procedures and costs of hospitalization were greater in institutions with higher ICU utilization for all 4 conditions.
Conclusions and Relevance: For medical conditions where ICU care is frequently provided, but may not always be necessary, institutions that utilize ICUs more frequently are more likely to perform invasive procedures and have higher costs but have no improvement in hospital mortality. Hospitals had similar ICU utilization patterns across the 4 medical conditions, suggesting that systematic institutional factors may influence decisions to potentially overutilize ICU care. Interventions that seek to improve the value of critical care services will need to address these factors that lead clinicians to admit patients to higher levels of care when equivalent care can be delivered elsewhere in the hospital.

Authors
Dong W Chang; Martin F Shapiro

JAMA material
JAMA Internal Medicine abstract
JAMA Internal Medicine invited commentary


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