Hospital variation in admission to intensive care units for patients with acute myocardial infarction

Chen, Ruijun; Strait, Kelly M.; Dharmarajan, Kumar; Li, Shu Xia; Ranasinghe, Isuru; Martin, James Kirby; Fazel, Reza; Cooke, Colin R.; Nallamothu, Brahmajee K.; Krumholz, Harlan M.

doi:10.1016/j.ahj.2015.09.003

Cited by 42 publications

(60 citation statements)

References 43 publications

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“…3–5 The NCDR collected data on each patient’s MI type, hemodynamic status, troponin level, and other covariates allowing for the calculation of mortality risk on admission; thus it extends these prior findings by offering a unique perspective of how illness severity may factor into ICU utilization. While the majority of STEMI patients (80%) are treated in an ICU, 4 hospitals varied substantially in the location of care for older NSTEMI patients. There were no significant differences in hospital characteristics (including size, teaching status, and revascularization capability) across high, intermediate, and low ICU utilization hospitals.…”

Section: Discussionmentioning

confidence: 99%

Intensive Care Unit Utilization and Mortality Among Medicare Patients Hospitalized With Non–ST-Segment Elevation Myocardial Infarction

et al. 2017

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Importance Intensive care unit (ICU) utilization may have important implications for the care and outcomes of patients with non-ST-segment elevation myocardial infarction (NSTEMI). Objectives To examine inter-hospital variation in ICU utilization in the United States for older adults with hemodynamically stable NSTEMI and outcomes associated with ICU utilization among patients with at low, moderate, or high mortality risk. Design, Settings and Participants Retrospective analysis of 28,018 Medicare patients ≥65 years old admitted with NSTEMI to 346 hospitals participating in ACTION Registry-GWTG between April 1, 2011 and December 31, 2012. Patients with cardiogenic shock or cardiac arrest on presentation were excluded. Exposure Hospitals with high (>70% NSTEMI patients treated in an ICU during the index hospitalization), intermediate (30–70%), or low (< 30%) ICU utilization rates Main Outcome and Measure 30-day mortality Results Of NSTEMI patients ≥ 65 years old, 11,934 (43%) had an ICU stay. The proportion of NSTEMI patients treated in the ICU varied across hospitals (median 38% [26%, 54%]), but there were no significant differences in hospital characteristics or NSTEMI patient characteristics between hospitals with high, intermediate, or low ICU utilization rates. Compared with high ICU utilization hospitals, hospitals with low or intermediate ICU utilizations rates were only marginally more selective of higher risk patients, as determined by ACTION in-hospital mortality risk score or initial troponin level. Thirty-day mortality rates did not significantly differ based on hospital ICU utilization (high vs. low: 8.7% vs. 8.7%, adjusted OR 0.91, 95% CI 0.76–1.08; intermediate vs. low: 9.6% vs. 8.7%, adjusted OR 1.06, 95% CI 0.94–1.20). The relationship between hospital ICU utilization and mortality was similar in analyses stratified by low, moderate, or high ACTION risk score categories (adjusted interaction p 0.86). Conclusions and Relevance ICU utilization for older NSTEMI patients varied significantly among hospitals. This variability was not explained by hospital characteristics nor driven by patient risk. Post-MI mortality did not significantly differ among hospitals with high, intermediate, or low ICU utilization.

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Section: Discussionmentioning

confidence: 99%

Intensive Care Unit Utilization and Mortality Among Medicare Patients Hospitalized With Non–ST-Segment Elevation Myocardial Infarction

et al. 2017

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“…Recent studies have shown that ICU admission rates vary widely for all-comers [24], patients with diabetic ketoacidosis [25], congestive heart failure [26], pulmonary embolism [27], and acute myocardial infarction [28]. In these studies, despite wide variations in ICU admission rates, there was no difference in risk-adjusted mortality.…”

Section: Discussionmentioning

confidence: 99%

Hospitals With the Highest Intensive Care Utilization Provide Lower Quality Pneumonia Care to the Elderly*

Sjoding

Prescott

Wunsch

et al. 2015

Critical Care Medicine

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Objective Quality of care for patients admitted with pneumonia varies across hospitals, but causes of this variation are poorly understood. Whether hospitals with high intensive care unit (ICU) utilization for pneumonia patients 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, Setting, and Patients Retrospective cohort study of 2,812 US hospitals caring for at least 25 elderly (age ≥ 65) 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% versus 10.7%, p < 0.001), and pneumococcal vaccination (15.0% versus 13.3%, p = 0.03) compared to 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 Conclusion 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 pneumonia patients. 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.

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“…Considerable interhospital variability in intensive care unit (ICU) use has been observed for patients with non–ST‐segment–elevation myocardial infarction (NSTEMI) . ICU use is only minimally correlated with severity of illness, with many low‐risk patients treated in the ICU and many high‐risk patients not treated in the ICU .…”

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confidence: 99%

“…In one study, 41% of patients with NSTEMI with a predicted risk of in‐hospital mortality <1% were treated in the ICU, and more than half of patients with initial serum troponin elevations >10 times the institution's upper limit of normal were not treated in an ICU . Given non–risk‐driven use patterns, it is perhaps unsurprising that higher hospital‐level ICU use is not associated with lower patient mortality …”

mentioning

confidence: 99%

“…C onsiderable interhospital variability in intensive care unit (ICU) use has been observed for patients with non-ST-segment-elevation myocardial infarction (NSTEMI). [1][2][3][4] ICU use is only minimally correlated with severity of illness, with many low-risk patients treated in the ICU and many high-risk patients not treated in the ICU. 4 In one study, 41% of patients with NSTEMI with a predicted risk of in-hospital mortality <1% were treated in the ICU, and more than half of patients with initial serum troponin elevations >10 times the institution's upper limit of normal were not treated in an ICU.…”

mentioning

confidence: 99%

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Risk Score to Predict Need for Intensive Care in Initially Hemodynamically Stable Adults With Non–ST‐Segment–Elevation Myocardial Infarction

Chen

Thomas

Pieper

et al. 2018

JAHA

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BackgroundIntensive care unit (ICU) use for initially stable patients presenting with non–ST‐segment–elevation myocardial infarction (NSTEMI) varies widely across hospitals and minimally correlates with severity of illness. We aimed to develop a bedside risk score to assist in identifying high‐risk patients with NSTEMI for ICU admission.Methods and ResultsUsing the Acute Coronary Treatment and Intervention Outcomes Network (ACTION) Registry linked to Medicare data, we identified patients with NSTEMI aged ≥65 years without cardiogenic shock or cardiac arrest on presentation. Complications requiring ICU care were defined as subsequent development of cardiac arrest, shock, high‐grade atrioventricular block, respiratory failure, stroke, or death during the index hospitalization. We developed and validated a model and integer risk score (Acute Coronary Treatment and Intervention Outcomes Network (ACTION) ICU risk score) that uses variables present at hospital admission to predict requirement for ICU care. Of 29 973 patients with NSTEMI, 4282 (14%) developed a complication requiring ICU‐level care, yet 12 879 (43%) received care in an ICU. Signs or symptoms of heart failure, initial heart rate, initial systolic blood pressure, initial troponin, initial serum creatinine, prior revascularization, chronic lung disease, ST‐segment depression, and age had statistically significant associations with requirement for ICU care after adjusting for other risk factors. The ACTION ICU risk score had a C‐statistic of 0.72. It identified 11% of patients as having very high risk (>30%) of developing complications requiring ICU care and 49% as having low likelihood (<10%) of requiring an ICU.ConclusionsThe ACTION ICU risk score quantifies the risk of initially stable patients with NSTEMI developing a complication requiring ICU care, and could be used to more effectively allocate limited ICU resources.

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Hospital variation in admission to intensive care units for patients with acute myocardial infarction

Cited by 42 publications

References 43 publications

Intensive Care Unit Utilization and Mortality Among Medicare Patients Hospitalized With Non–ST-Segment Elevation Myocardial Infarction

Intensive Care Unit Utilization and Mortality Among Medicare Patients Hospitalized With Non–ST-Segment Elevation Myocardial Infarction

Hospitals With the Highest Intensive Care Utilization Provide Lower Quality Pneumonia Care to the Elderly*

Risk Score to Predict Need for Intensive Care in Initially Hemodynamically Stable Adults With Non–ST‐Segment–Elevation Myocardial Infarction

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