Compared with care on a general hospital ward, ICU care improved survival without raising costs significantly in a study of more than 1 million Medicare patients hospitalized with pneumonia, published online Sept. 22 in JAMA.

The retrospective cohort study involved older patients whose condition was considered “borderline” – not one that would clearly benefit from ICU admission but also not one for which ICU admission could clearly be ruled out. The decision of whether to admit these study participants to a general ward or an ICU was deemed discretionary. “Contrary to [our] prespecified hypothesis, [our] findings suggest that ICU admission for borderline patients … is associated with reduced mortality without a considerable increase in costs,” said Dr. Thomas S. Valley of the division of pulmonary and critical care medicine, University of Michigan, Ann Arbor, and his associates.

The investigators analyzed data from the American Hospital Association’s annual surveys and the Healthcare Cost Reporting Information Systems regarding 1,327,370 Medicare patients admitted to 2,988 hospitals across the country during a recent 2-year period. A total of 328,404 patients (29.5% of the study population) were admitted to ICUs and the remainder to general hospital wards.

After the data were adjusted to account for numerous patient, disease, and hospital variables, ICU admission was associated with significantly lower 30-day mortality (14.8%), compared with general ward admission (20.5%) – an absolute reduction of 5.7%. Yet the differences between the two groups were nonsignificant regarding payments by Medicare ($9,918 for ICU vs. $11,238 for general ward care) and hospital costs ($14,162 for ICU vs $11,320 for general ward care).

These findings were consistent across numerous sensitivity analyses, including some that compared urban against rural hospitals, white against nonwhite patients, small against large ICUs, and severely ill against less severely ill patients, Dr. Valley and his associates said (JAMA. 2015 Sep 22;314[12]:1272-79. doi: 10.1001.jama.2015.11068 ).

There are several reasons why ICU care might be beneficial for “borderline” patients with pneumonia. Greater attention from nurses and other clinicians could allow for more timely recognition of decompensation; more aggressive care is more likely to head off the development of sepsis; better adherence to guideline-based treatment is known to improve mortality; and a greater likelihood of being managed by a pulmonary or critical care specialist with greater expertise in pneumonia care should improve outcomes, the researchers noted.

Their study findings have important implications for health care reform. “In order to contain U.S. health care costs, it has been suggested that reducing critical care bed supply would result in more efficient admission decisions and cost savings with minimal mortality decrements.” This “presumes that ICU admission for discretionary patients provides minimal benefit but substantially increases costs.” The results of this study clearly refute that assumption, Dr. Valley and his associates said.


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