ICU may not be better for COPD, heart failure and heart attack

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Stay in the intensive care unit may not give patients a better chance of surviving chronic obstructive pulmonary disease (COPD), heart failure or even a heart attack, compared with care in another type of hospital unit, Unless a patient is clearly critically ill,  found a University of Michigan analysis of more than 1.5m Medicare records.

The researchers decided to study how patients with the three conditions fared in the ICU after previously reporting that patients admitted to the ICU for pneumonia were more likely to survive.

The authors noted that these three conditions frequently result in an ICU admission, but there is great variability across hospitals. They estimated that approximately one in six patients was admitted to the ICU only because of living closest to a hospital that places a high percentage of its patients in ICU beds.

The researchers looked at 30-day mortality and also at cost of care. “We wanted to evaluate whether ICU care is always beneficial,” said lead author Dr Thomas Valley, a pulmonary and critical care researcher at the University of Michigan Medical School. “ICU care can save lives, but it is also very costly.”

In addition to experiencing higher costs, he added, ICU patients are more likely to undergo invasive procedures and be exposed to dangerous infections.

Although the researchers found no difference in mortality between patients treated in the ICU and those treated as regular inpatients, the cost of care in the ICU for heart failure exacerbation was significantly higher ($2,608 more) and heart attack ($4,922 more) than regular inpatient care. There was no difference in the cost of treating patients for COPD exacerbations between the two settings.

“Our results highlight that there is a large group of patients who doctors have trouble figuring out whether or not the ICU will help them or not,” Valley said. “We found that the ICU may not always be the answer. Now, we need to help doctors decide who needs the ICU and who doesn’t.”

Valley emphasised study results do not apply to patients who clearly require intensive care, such as those who cannot breathe on their own.

Study limitations include the fact that only Medicare patients were part of the study so results may not apply to younger patients. Costs include only hospital charges, not physician fees.

The authors concluded, “These findings suggest that the ICU may be overused for some COPD, heart failure, or acute myocardial infarction patients with an uncertain indication for intensive care, and opportunities exist to decrease health care costs by reducing ICU admissions for certain patients.”

Future studies, they said, should help define which patients with these conditions would benefit from the ICU and which can be treated elsewhere in the hospital without compromising their care.

Importance: Intensive care may be beneficial to pneumonia patients with uncertain ICU needs; however, evidence about the association between intensive care unit (ICU) admission and mortality for other common conditions is largely unknown.
Objective: To estimate the relationship between ICU admission and outcomes for patients with exacerbation of chronic obstructive pulmonary disease (COPD), exacerbation of heart failure (HF), or acute myocardial infarction (AMI).
Design: Retrospective cohort study with multivariable adjustment and instrumental variable analysis assessing each condition separately. The instrumental variable analysis used differential distance to a high ICU use hospital (defined separately for each condition) as an instrument for ICU admission to examine marginal patients, whose likelihood of ICU admission depended on the hospital to which they were admitted.
Setting: U.S. hospitals
Participants: Fee-for-service Medicare beneficiaries admitted with COPD exacerbation, HF exacerbation, or AMI from 2010 to 2012.
Exposure: ICU or general ward admission
Outcomes: The primary outcome was 30-day mortality. Secondary outcome included hospital costs.
Results: Among 1,555,798 Medicare beneficiaries with COPD exacerbation, HF exacerbation, or AMI, 486,272 (31%) were admitted to the ICU. The instrumental variable analysis found that ICU admission was not associated with significant differences in 30-day mortality for any condition. ICU admission was associated with significantly greater hospital costs for HF [$11,793 vs. $9,185, P<0.001; absolute increase, 2,608 (95% CI: 1377, 3840)] and AMI [$19,513 vs. $14,590, P<0.001; absolute increase, 4,922 (95% CI: 2665, 7180)], but not for COPD.
Conclusion: ICU admission did not confer a survival benefit for patients with uncertain ICU needs hospitalized with COPD exacerbation, HF exacerbation, or AMI—suggesting the ICU may be overused for some patients with these conditions. Identifying patients most likely to benefit from ICU admission may improve healthcare efficiency while reducing costs.

Thomas S Valley, Michael W Sjoding, Andrew M Ryan, Theodore J Iwashyna, Colin R Cooke

American Thoracic Society material
Annals of the American Thoracic Society abstract

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