Variation In Use Of Intensive Care For Adults With Diabetic Ketoacidosis

Abstract

Objective-Intensive care unit (ICU) beds are limited, yet few guidelines exist for triage of patients to the ICU, especially patients at low-risk for mortality. The frequency with which lowrisk patients are admitted to ICUs in different hospitals is unknown. Our objective was to assess variation in use of intensive care for patients with diabetic ketoacidosis (DKA), a common condition with a low-risk of mortality.Design-Observational study using the New York State Inpatient Database (2005Database ( -2007. Setting-159New York State acute care hospitals.Patients-15,994 adult (≥18) hospital admissions with a primary diagnosis of DKA (ICD-9-CM 250.1x). Interventions-None.Measurements and Main Results-We calculated reliability-and risk-adjusted ICU utilization, hospital length of stay (LOS), and mortality. We identified hospital-level factors associated with increased likelihood of ICU admission after controlling for patient characteristics using multilevel mixed-effects logistic regression analyses; we assessed the amount of residual variation in ICU utilization using the intra-class correlation coefficient. Use of intensive care for DKA patients varied widely across hospitals (adjusted range: 2.1% to 87.7%), but was not associated with hospital LOS or mortality. After multilevel adjustment, hospitals with a high each additional ten percent increase). In the multi-level model, more than half (58%) of the variation in ICU admission practice attributable to hospitals remained unexplained.Conclusions-We observed variation across hospitals in use of intensive care for DKA patients that was not associated with differences in hospital LOS or mortality. Institutional practice patterns appear to impact admission decisions and represent a potential target for reduction of resource utilization in higher use institutions.

Association between age and use of intensive care among surgical Medicare beneficiaries

“…Recent data show that there is large variation across hospitals with regard to use of intensive care [13, 14]. For example, in a large, national study of admissions to ICUs across US Veterans Affairs hospitals, even after risk adjustment, admission rates for the ICU ranged from 1.6% to 29.5% [14].…”

ICU beds: less is more? Yes

“…For example, one study from the U.S. Veterans Affairs health care system demonstrated that the majority of their ICU patients had a predicted mortality of less than 2% [15]. Other studies among patients with pulmonary embolism and diabetic ketoacidosis have also suggested that many hospitals overuse ICU care for these traditionally low-mortality conditions [16,17]. Reducing the number of available ICU beds should constrain ICU use and lessen the urge to expand the critical care workforce, without negatively impacting clinical outcomes.…”

The Role of Stepdown Beds in Hospital Care

“…In a study of U.S. ICU utilization, rates of admission to ICU for all hospitalized patients ranged from 3 to 55% (15), and rates of ICU admission for patients with a diagnosis of diabetic ketoacidosis ranged from 0 to 100% (16). These findings suggest great heterogeneity in the patients that are cared for in U.S. ICU beds.…”