Outcomes Among Patients Discharged From Busy Intensive Care Units

Wagner, Jason; Gabler, Nicole B.; Ratcliffe, Sarah J.; Brown, Sydney E. S.; Strom, Brian L.; Halpern, Scott D.

doi:10.7326/0003-4819-159-7-201310010-00004

Cited by 125 publications

(121 citation statements)

References 44 publications

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“…IMPACT data have been shown to be highly reliable, and ICUs are largely representative of US ICUs. 32 As in prior studies, 18,19,25,[34][35][36] we used a specially prepared version of this dataset in which ICU and hospital admission and discharge dates and times were available for all patients; more detailed patient data were collected on a random sample of 50% to 100% of patients.…”

Section: Data Sourcementioning

confidence: 99%

“…3,18,[20][21][22][23][24] Th ese latter observations suggest that ICU readmissions may result from practice variations residing outside the causal pathway to other poor outcomes. 3,18,25 Opportunity exists to better address the question of whether ICU readmissions are causally related to downstream outcomes. If a policy change infl uenced ICU readmission rates, identifying temporal concordance between changes in ICU readmission rates and changes in other outcomes would support a causal association; absence of correspondence would argue against causality.…”

mentioning

confidence: 97%

“…12,18,19,35 ICU readmissions included patients readmitted within two calendar days to the ICU from which they were originally discharged. Readmissions to other ICUs may be more likely to be elective 35 ; readmissions after longer intervals are less likely to be related to ICU discharge circumstances.…”

Section: Variables and Eligible Patientsmentioning

confidence: 99%

“…[17][18][19] Additionally, the performance of ICUs on ICU readmissions is not correlated with performance on other measures of ICU quality, such as mortality or process measures. 3,18,[20][21][22][23][24] Th ese latter observations suggest that ICU readmissions may result from practice variations residing outside the causal pathway to other poor outcomes. 3,18,25 Opportunity exists to better address the question of whether ICU readmissions are causally related to downstream outcomes.…”

mentioning

confidence: 99%

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Assessing the Utility of ICU Readmissions as a Quality Metric

Brown

Ratcliffe

Halpern

2015

Chest

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BACKGROUND: ICU readmissions are associated with increased mortality and costs; however, it is unclear whether these outcomes are caused by readmissions or by residual confounding by illness severity. An assessment of temporal changes in ICU readmission in response to a specific policy change could help disentangle these possibilities. We sought to determine whether ICU readmission rates changed aft er 2003 Accreditation Council for Graduate Medical Education Resident Duty Hours reform ("reform") and whether there were temporally corresponding changes in other ICU outcomes.

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Section: Data Sourcementioning

confidence: 99%

mentioning

confidence: 97%

Section: Variables and Eligible Patientsmentioning

confidence: 99%

mentioning

confidence: 99%

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Assessing the Utility of ICU Readmissions as a Quality Metric

Brown

Ratcliffe

Halpern

2015

Chest

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“…7 For example, in our study, labor costs represented nearly 40% of total ICU costs and nearly the entire portion of direct fixed costs. Assuming that ICUs do not change ICU admission practices, 21 a reduction in inappropriate or unwanted ICU utilization may prompt reductions in ICU staffing and labor costs.…”

Section: Costs Of Care In the Icu At The End Of Life 1175mentioning

confidence: 99%

Patterns of Cost for Patients Dying in the Intensive Care Unit and Implications for Cost Savings of Palliative Care Interventions

Khandelwal

Benkeser

Coe

et al. 2016

Journal of Palliative Medicine

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Background: Terminal intensive care unit (ICU) stays represent an important target to increase value of care. Objective: To characterize patterns of daily costs of ICU care at the end of life and, based on these patterns, examine the role for palliative care interventions in enhancing value. Design: Secondary analysis of an intervention study to improve quality of care for critically ill patients. Setting/Patients: 572 patients who died in the ICU between 2003 and 2005 at a Level-1 trauma center. Methods: Data were linked with hospital financial records. Costs were categorized into direct fixed, direct variable, and indirect costs. Patterns of daily costs were explored using generalized estimating equations stratified by length of stay, cause of death, ICU type, and insurance status. Estimates from the literature of effects of palliative care interventions on ICU utilization were used to simulate potential cost savings under different time horizons and reimbursement models. Main Results: Mean cost for a terminal ICU stay was 39.3K -45.1K. Direct fixed costs represented 45% of total hospital costs, direct variable costs 20%, and indirect costs 34%. Day of admission was most expensive (mean 9.6K -7.6K); average cost for subsequent days was 4.8K -3.4K and stable over time and patient characteristics. Conclusions: Terminal ICU stays display consistent cost patterns across patient characteristics. Savings can be realized with interventions that align care with patient preferences, helping to prevent unwanted ICU utilization at end of life. Cost modeling suggests that implications vary depending on time horizon and reimbursement models.

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Assessment of the Safety of Discharging Select Patients Directly Home From the Intensive Care Unit

et al. 2018

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IMPORTANCE The safety of discharging adult patients recovering from critical illness directly home from the intensive care unit (ICU) is unknown.OBJECTIVE To compare the health care utilization and clinical outcomes for ICU patients discharged directly home from the ICU with those of patients discharged home via the hospital ward. DESIGN, SETTING, AND PARTICIPANTSRetrospective population-based cohort study of adult patients admitted to the ICU of 9 medical-surgical hospitals from January 1, 2014, to January 1, 2016, with 1-year follow-up after hospital discharge. All adult ICU patients were discharged home alive from hospital, and the propensity score matched cohort (1:1) was based on patient characteristics, therapies received in the ICU, and hospital characteristics.EXPOSURES Patient disposition on discharge from the ICU: directly home vs home via the hospital ward. MAIN OUTCOMES AND MEASURESThe primary outcome was readmission to the hospital within 30 days of hospital discharge. The secondary outcomes were emergency department visit within 30 days and death within 1 year. RESULTS Among the 6732 patients included in the study, 2826 (42%) were female; median age, 56 years (interquartile range, 41-67 years); 922 (14%) were discharged directly home, with significant variation found between hospitals (range, 4.4%-44.0%). Compared with patients discharged home via the hospital ward, patients discharged directly home were younger (median age 47 vs 57 years; P < .001), more likely to be admitted with a diagnosis of overdose, substance withdrawal, seizures, or metabolic coma (32% [295] vs 10% [594]; P < .001), to have a lower severity of acute illness on ICU admission (median APACHE II score 15 vs 18; P < .001), and receive less than 48 hours of invasive mechanical ventilation (42% [389] vs 34% [1984]; P < .001). In the propensity score matched cohort (n = 1632), patients discharged directly home had similar length of ICU stay (median, 3.1 days vs 3.0 days; P = .42) but significantly shorter length of hospital stay (median, 3.3 days vs 9.2 days; P < .001) compared with patients discharged home via the hospital ward. There were no significant differences between patients discharged directly home or home via the hospital ward for readmission to the hospital (10% [n = 81] vs 11% [n = 92]; hazard ratio [HR], 0.88; 95% CI, 0.64-1.20) or emergency department visit (25% [n = 200] vs 26% [n = 212]; HR, 0.94; 95% CI, 0.81-1.09) within 30 days of hospital discharge. Four percent of patients in both groups died within 1 year of hospital discharge (n = 31 and n = 34 in the discharged directly home and discharged home via the hospital ward groups, respectively) (HR, 0.90; 95% CI, 0.60-1.35). CONCLUSIONS AND RELEVANCEThe discharge of select adult patients directly home from the ICU is common, and it is not associated with increased health care utilization or increased mortality.

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Outcomes Among Patients Discharged From Busy Intensive Care Units

Cited by 125 publications

References 44 publications

Assessing the Utility of ICU Readmissions as a Quality Metric

Assessing the Utility of ICU Readmissions as a Quality Metric

Patterns of Cost for Patients Dying in the Intensive Care Unit and Implications for Cost Savings of Palliative Care Interventions

Assessment of the Safety of Discharging Select Patients Directly Home From the Intensive Care Unit

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