Risk of Death Influences Regional Variation in Intensive Care Unit Admission Rates among the Elderly in the United States

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Common medical and surgical diagnoses (e.g., acute myocardial infarction, congestive heart failure, pneumonia) (n=15047516). Intervention: High regional ICU use (Quartile 4) vs. Low regional ICU use (Quartile 1). Primary outcome: Risk of ICU admission for patients with moderate (quartile 2) risk of death in high versus low ICU use regions (RR 1.63, 95% CI 1.53-1.72, p=<0.001).

Q: What does this research mean for the field?

Geographic variation in ICU admission rates is largely driven by patients with low to moderate risk of death, with living in a high ICU use region increasing the risk of admission by 63% for moderate-risk patients compared to low-use regions. Novelty: ClaimNovelty.NOVEL_FINDING. Consensus alignment: ConsensusAlignment.NEUTRAL.

Colin R. Cooke

doi:10.1371/journal.pone.0166933

November 29, 2016PLoS ONEOpen Access

Risk of Death Influences Regional Variation in Intensive Care Unit Admission Rates among the Elderly in the United States

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Key result

Living in a high ICU use region increased the risk of ICU admission by 63% (RR 1.63) for patients with a moderate risk of death compared to a low ICU use region.

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Why the study?

Does geographic region influence the likelihood of ICU admission for elderly patients with varying risks of death?

Study Design

Type

Cohort (n=15,047,516)

Multicenter

Yes

Structured PICO

Does geographic region influence the likelihood of ICU admission for elderly patients with varying risks of death?

P

Population

15,047,516 hospitalizations among fee-for-service Medicare beneficiaries (age > 64 years) admitted for ten common medical and surgical diagnoses (including acute myocardial infarction, congestive heart failure, COPD, pneumonia, gastrointestinal hemorrhage, acute renal failure, ischemic stroke, colectomy, hip fracture surgery, and non-cervical spine fusion) between 2004-2009 in the United States.

I

Intervention

Residence in a Health Referral Region (HRR) with high ICU admission rates (Quartile 4)

C

Comparator

Residence in a Health Referral Region (HRR) with low ICU admission rates (Quartile 1)

O

Outcome

ICU admission

Main Result

Effect estimate: RR 1.63 (95% CI 1.53-1.72)

p-value: p=<0.001

Geographic variation in ICU admission rates is heavily driven by patients with low to moderate risks of death, indicating that efficiency efforts should not focus exclusively on end-of-life care.

Limitations

Use of administrative claims data may not fully capture an individual's risk of ICU admission and death
Imperfect calibration of the mortality prediction model
Study population limited to individuals older than 65 years enrolled in fee-for-service Medicare
Unable to account for regional variability in intermediate care ICU beds
Potential for residual confounding from unmeasured regional characteristics
Use of administrative claims data
Inability to fully capture an individual's risk of ICU admission and death
Potential for misclassification of risk estimates
Imperfect model calibration

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Implication

Regional ICU variation may reflect inefficiency for moderate-risk patients; hypothesis-generating for efficiency targets beyond end-of-life care.

Abstract

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Cite This Study

Colin R. Cooke (2016) conducted a cohort in Common medical and surgical diagnoses (e.g., acute myocardial infarction, congestive heart failure, pneumonia) (n=15,047,516). High regional ICU use (Quartile 4) vs. Low regional ICU use (Quartile 1) was evaluated on Risk of ICU admission for patients with moderate (quartile 2) risk of death in high versus low ICU use regions (RR 1.63, 95% CI 1.53-1.72, p=<0.001). Living in a high ICU use region increased the risk of ICU admission by 63% (RR 1.63) for patients with a moderate risk of death compared to a low ICU use region.

synapsesocial.com/papers/6a1aaeed8198c9a8aa45fc1d https://doi.org/10.1371/journal.pone.0166933

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Risk of Death Influences Regional Variation in Intensive Care Unit Admission Rates among the Elderly in the United States

Figures

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Risk of Death Influences Regional Variation in Intensive Care Unit Admission Rates among the Elderly in the United States

Figures

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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