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

Abstract

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.

Long‐Term Mortality of Older Patients With Acute Myocardial Infarction Treated in US Clinical Practice

“…This may reflect less invasive practice patterns during our study period 2004 and 2006. However, revascularization rates for stable NSTEMI patients aged 65 years and older did not increase substantially when observed between 2007 and 2012, as the rates of PCI were 36% and CABG 8% then 16. Underutilization of evidence‐based therapies has been well described among older patients with MI 14.…”

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

“…The ACTION ICU risk score uses 9 variables present at the time of admission to predict the likelihood that a hemodynamically stable patient presenting with NSTEMI will develop an in‐hospital complication that requires ICU care. This risk score is of clinical importance given that 43% of patients with NSTEMI without cardiogenic shock or cardiac arrest are treated in the ICU in contemporary practice, yet limited and expensive ICU resources may only be needed in a smaller proportion of these patients . Use of the risk score could help hospitals identify patients at highest risk of clinical deterioration requiring ICU care for direct admission to the ICU, while safely admitting lower‐risk patients to a non‐ICU setting.…”

“…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 .…”

The “Burden” of Malignancy in a Tertiary Hospital Intensive Cardiovascular Care Unit

“…As life expectancy increases and populations become older, Western medicine faces new challenges. One of these is the treatment of cardiovascular patients who are becoming older with more complex valvular diseases, arrhythmias, and malignancies [12]. As a result, these patients are being admitted to the ICCU for numerous causes, as was shown in our study.…”