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ICU utilization fails to change mortality outcomes in older patients with non-STEMI
Thirty-day mortality rates after MI did not significantly differ among older patients with non-STEMI depending on the utilization of the ICUs in U.S. hospitals, according to results from a retrospective analysis of Medicare patients recently published in JAMA Cardiology.
All 28,018 patients were aged 65 years or older when admitted to one of 346 U.S. hospitals with non-STEMI. The hospitals were participants of the ACTION–Get With the Guidelines from April 1, 2011, to Dec. 31, 2012. A total of 46.6% (n = 13,055) of the patients were women, and 14% (n = 3,931) were nonwhite race. The researchers excluded patients who presented with cardiogenic shock or cardiac arrest. The data was analyzed from May 7 to Oct. 8, 2015.
Among the cohort, 11,934 (42.6%) had an ICU stay. Hospitals were stratified by ICU utilization: high (more than 70% of patients with non-STEMI were treated in an ICU), intermediate (30% to 70%) or low (less than 30%). Median ICU utilization was 38%.
Among hospitals with high, intermediate, or low ICU utilization hospitals, no significant differences were found in hospital or patient characteristics.
“Compared with high ICU utilization hospitals, low and intermediate ICU utilization hospitals were only marginally more selective of higher-risk patients for ICU admission, and no association was found between hospital-level ICU utilization and 30-day mortality,” Alexander C. Fanaroff, MD, from the division of cardiology at Duke University in Durham, North Carolina, and colleagues wrote.
The main outcome, 30-day mortality, was similar despite hospital ICU utilization. Hospitals with a high ICU utilization rate had an 8.7% 30-day mortality rate vs. an 8.7% mortality rate for hospitals with a low ICU utilization rate (adjusted OR = 0.91; 95% CI, 0.76-1.08). Hospitals with an intermediate ICU utilization rate had a 9.6% 30-day mortality rate vs. 8.7% for hospitals with a low ICU utilization rate (adjusted OR = 1.06; 95% CI, 0.94-1.2).
“Whether intentional or not, what the study by Fanaroff et al does is not only request that we reevaluate our practice of ICU utilization for patients with [non-STEMI], but more importantly, it challenges us to better define the appropriate patient and condition that requires coronary care unit management. Central to improving the value of any intensive care setting is the identification of patients who are likely to derive the greatest benefit from the critical care services it provides,” Jason N. Katz, MD, MHS, from the divisions of cardiology and pulmonary/critical care medicine at University of North Carolina in Chapel Hill, wrote in a related editorial. – by Suzanne Reist
Disclosure: Fanaroff reports receiving research grants through the Duke Clinical Research Institute from Gilead Sciences. Please see the full study for a list of the other researchers’ relevant financial disclosures. Katz reports no relevant financial disclosures.