ICU admission for older, low-risk patients with pneumonia associated with improved survival, with little difference in costs

Among Medicare beneficiaries hospitalized with pneumonia, intensive care unit (ICU) admission of patients which appeared to be discretionary was associated with improved survival and no significant differences in Medicare spending or hospital costs, compared with patients admitted to general wards, according to a study in JAMA.

Observational studies examining the relationship between ICU admission frequency and patient outcomes often suggest that greater ICU use does not achieve better outcomes. However, these results are likely influenced by factors such as indication, because sicker patients are more likely to be admitted to the ICU. Among patients whose need for intensive care is uncertain, the relationship of ICU admission with mortality and costs has been unknown, according to background information in the article.

Thomas S. Valley, M.D., of the University of Michigan, Ann Arbor, and colleagues examined the association between ICU admission and outcomes, 30-day mortality and costs, among elderly patients hospitalized for pneumonia. The study included Medicare beneficiaries (older than 64 years of age) admitted to 2,988 acute care hospitals in the United States with pneumonia from 2010 to 2012.

Among 1,112,394 Medicare beneficiaries with pneumonia, 328,404 (30 percent) were admitted to the ICU. Patients (n = 553,597) living closer than the median differential distance (less than 3.3 miles) to a hospital with high ICU admission were significantly more likely to be admitted to the ICU than patients living farther away (n = 558,797) (36 percent for patients living closer vs 23 percent for patients living farther).

For the 13 percent of patients whose ICU admission decision appeared to be discretionary (dependent only on distance), ICU admission was associated with a significantly lower adjusted 30-day mortality (14.8 percent for ICU admission vs 20.5 percent for general ward admission), yet there were no significant differences in Medicare spending or hospital costs for the hospitalization.

The authors write that contrary to the study's prespecified hypothesis, "these findings suggest that ICU admission for borderline patients (those for whom ICU admission depends on the hospital to which they present) is associated with reduced mortality without a considerable increase in costs."

"A randomized trial may be warranted to assess whether more liberal ICU admission policies improve mortality for patients with pneumonia."

Editorial: Assessing the Value of Intensive Care

The findings of this study "argue against active efforts to reduce ICU admissions through triage guidelines or bed supply reductions, at least for older patients with pneumonia," write Ian J. Barbash, M.D., and Jeremy M. Kahn, M.D., M.S., of the University of Pittsburgh School of Medicine, in an accompanying editorial.

"In the current health care system, more judicious use of the ICU may well lead to higher mortality in some patient populations. Indeed, the greatest lesson from this study may be that low-value health care is difficult to find. Reducing health care spending by preventing ICU readmissions will require addressing the difficult questions about rationing ICU care and the degree to which the nation can afford to make intensive care available to anyone at any time. While this conversation is underway, the task at hand is to study why the intensive care saves lives, and then use this information to make hospital care as safe and effective for all patients, regardless of where in the hospital they receive care."