Relationship between Volume and Survival in Closed Intensive Care Units Is Weak and Apparent Only in Mechanically Ventilated Patients

Fernández, Rafael; Altaba, Susana; Cabré, Lluís; Lacueva, V.; Santos, Antonio; Solsona, J. F.; Añon, Jose-Manuel; Catalan, Rosa-Maria; Gutiérrez, María-José; Fernandez-Cid, Ramon; Gómez-Tello, V.; Curiel, E.; Fernández-Mondéjar, E.; Oliva, Joan-Carles

doi:10.1097/aln.0b013e31829c3029

Cited by 14 publications

(8 citation statements)

References 29 publications

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“…A relationship between high volume and better outcome was reported in the EURICUS I database [ 37 ], for some high-risk surgical patients [ 38 ] and ICU cancer patients with septic shock [ 39 ], and a systematic review [ 40 ] confirmed this finding. Nevertheless, the volume-outcome relationship has been questioned [ 41 ] and a recent study found no correlation between standardized mortality ratio and ICU volume with only mechanically ventilated patients in very low-volume centres [ 42 ]. However, in our study we adjusted hospital mortality also for the size of the hospitals, which was strongly related to the volume of activity.…”

Section: Discussionmentioning

confidence: 99%

Hospital mortality of adults admitted to Intensive Care Units in hospitals with and without Intermediate Care Units: a multicentre European cohort study

et al. 2014

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IntroductionThe aim of the study was to assess whether adults admitted to hospitals with both Intensive Care Units (ICU) and Intermediate Care Units (IMCU) have lower in-hospital mortality than those admitted to ICUs without an IMCU.MethodsAn observational multinational cohort study performed on patients admitted to participating ICUs during a four-week period. IMCU was defined as any physically and administratively independent unit open 24 hours a day, seven days a week providing a level of care lower than an ICU but higher than a ward. Characteristics of hospitals, ICUs and patients admitted to study ICUs were recorded. The main outcome was all-cause in-hospital mortality until hospital discharge (censored at 90 days).ResultsOne hundred and sixty-seven ICUs from 17 European countries enrolled 5,834 patients. Overall, 1,113 (19.1%) patients died in the ICU and 1,397 died in hospital, with a total of 1,397 (23.9%) deaths. The illness severity was higher for patients in ICUs with an IMCU (median Simplified Acute Physiology Score (SAPS) II: 37) than for patients in ICUs without an IMCU (median SAPS II: 29, P <0.001). After adjustment for patient characteristics at admission such as illness severity, and ICU and hospital characteristics, the odds ratio of mortality was 0.63 (95% CI 0.45 to 0.88, P = 0.007) in favour of the presence of IMCU. The protective effect of the IMCU was absent in patients who were admitted for basic observation, for example, after surgery (odds ratio 1.15, 95% CI 0.65 to 2.03, P = 0.630) but was strong in patients admitted to an ICU for other reasons (odds ratio 0.54, 95% CI 0.37 to 0.80, P = 0.002).ConclusionsThe presence of an IMCU in the hospital is associated with significantly reduced adjusted hospital mortality for adults admitted to the ICU. This effect is relevant for the patients requiring full intensive treatment.Trial registrationClinicaltrials.gov NCT01422070. Registered 19 August 2011.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-014-0551-8) contains supplementary material, which is available to authorized users.

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Section: Discussionmentioning

confidence: 99%

Hospital mortality of adults admitted to Intensive Care Units in hospitals with and without Intermediate Care Units: a multicentre European cohort study

et al. 2014

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“…An expansive body of literature demonstrates the volume-outcome relationship in a number of medical conditions, operations, and procedures. 6,[12][13][14][15][16][17][18][19][20] Consensus guidelines exist regarding threshold numbers for institutional competency of both total and primary PCI, pointing toward worse outcomes below these recommended thresholds. 14,21,22 This relationship has not been explored for patients with CS.…”

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confidence: 99%

Effect of Cardiogenic Shock Hospital Volume on Mortality in Patients With Cardiogenic Shock

Shaefi

O’Gara

Kociol

et al. 2015

JAHA

143

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BackgroundCardiogenic shock (CS) is associated with significant morbidity, and mortality rates approach 40% to 60%. Treatment for CS requires an aggressive, sophisticated, complex, goal‐oriented, therapeutic regimen focused on early revascularization and adjunctive supportive therapies, suggesting that hospitals with greater CS volume may provide better care. The association between CS hospital volume and inpatient mortality for CS is unclear.Methods and ResultsWe used the Nationwide Inpatient Sample to examine 533 179 weighted patient discharges from 2675 hospitals with CS from 2004 to 2011 and divided them into quartiles of mean annual hospital CS case volume. The primary outcome was in‐hospital mortality. Multivariate adjustments were performed to account for severity of illness, relevant comorbidities, hospital characteristics, and differences in treatment. Compared with the highest volume quartile, the adjusted odds ratio for inpatient mortality for persons admitted to hospitals in the lowest‐volume quartile (≤27 weighted cases per year) was 1.27 (95% CI 1.15 to 1.40), whereas for admission to hospitals in the low‐volume and medium‐volume quartiles, the odds ratios were 1.20 (95% CI 1.08 to 1.32) and 1.12 (95% CI 1.01 to 1.24), respectively. Similarly, improved survival was observed across quartiles, with an adjusted inpatient mortality incidence of 41.97% (95% CI 40.87 to 43.08) for hospitals with the lowest volume of CS cases and a drop to 37.01% (95% CI 35.11 to 38.96) for hospitals with the highest volume of CS cases. Analysis of treatments offered between hospital quartiles revealed that the centers with volumes in the highest quartile demonstrated significantly higher numbers of patients undergoing coronary artery bypass grafting, percutaneous coronary intervention, or intra‐aortic balloon pump counterpulsation. A similar relationship was demonstrated with the use of mechanical circulatory support (ventricular assist devices and extracorporeal membrane oxygenation), for which there was significantly higher use in the higher volume quartiles.ConclusionsWe demonstrated an association between lower CS case volume and higher mortality. There is more frequent use of both standard supportive and revascularization techniques at the higher volume centers. Future directions may include examining whether early stabilization and transfer improve outcomes of patients with CS who are admitted to lower volume centers.

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“…These may be key aspects that allow these level III ICUs to adequately care for sicker patients. Similar to the article by Kluge and colleagues [3], some previous publications have questioned the volume- [1]. Some of these variables were known in this study and included in the models while others remain unknown or are estimates.…”

mentioning

confidence: 61%

“…The strongest associations are found when the task or treatment is high risk or of high complexity. In trauma surgery, percutaneous coronary interventions in myocardial infarction, and many high-risk surgical procedures such a correlation between volume and outcome has been established [1]. It is very tempting to assume that such a volume-outcome relationship does exist for intensive care units (ICUs) as well, which combine both high risk and high complexity.…”

mentioning

confidence: 99%

Comparing intensive care units by size or level

2015

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Relationship between Volume and Survival in Closed Intensive Care Units Is Weak and Apparent Only in Mechanically Ventilated Patients

Cited by 14 publications

References 29 publications

Hospital mortality of adults admitted to Intensive Care Units in hospitals with and without Intermediate Care Units: a multicentre European cohort study

Hospital mortality of adults admitted to Intensive Care Units in hospitals with and without Intermediate Care Units: a multicentre European cohort study

Effect of Cardiogenic Shock Hospital Volume on Mortality in Patients With Cardiogenic Shock

Comparing intensive care units by size or level

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