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Long-term mortality risk highest among young patients after ICU discharge

Although aging was associated with an increased risk for mortality in the 3 years following hospital ICU discharge, long-term mortality was highest among young patients after standardizing for age and sex, according to a study published in JAMA Network Open.

“The benefit of ICU admission for elderly patients has been questioned because it may lead to unnecessary invasive care and avoidable health care expenditure,” Alice Atramont, MD, MSc, of Caisse Nationale d’Assurance Maladie (CNAM) in Paris, France, and colleagues wrote. “In France, the number of ICU beds per 100,000 population is at the European mean, with no financial barriers to access ICU care because of a national health insurance system offering universal coverage for the French population. However, there are few wide-scale population-based studies that document short-term and long-term outcomes of adult patients after ICU discharge across all age strata.”

Using data from the French national health system database, researchers conducted a cohort study of 133,966 patients (median age, 65 years; 59.9% men) who were admitted to French ICUs from Jan. 1 to Dec. 31, 2013 (48% admitted for surgical procedures; 16.3% admitted for respiratory disease).

Participants were divided into 10 different age strata from 18 to 34 years to 90 years and older.

To compare the mortality rate between the study population and the general population, researchers calculated age- and-sex-standardized mortality ratios, defined as the ratio of observed deaths within the study population divided by expected deaths. These ratios were considered for the first, second and third years after hospital discharge for survivors of each period.

The primary outcomes of the study were in-hospital mortality and mortality at 3 months and 3 years after hospital discharge.

Researchers found that, for the entire study population, in-hospital mortality was 19% and 3-year mortality was 39.7%. Including only those discharged alive from the hospital, 6.8% died by 3 months and 25.8% died by 3 years.

Researchers observed that risk for mortality increased progressively across all age strata, with 3-year post-discharge mortality rates at 44.9% in patients 80 years or older and 22.5% in those younger than 80.

However, after age and sex standardization, younger patients had higher mortality ratios than older patients, with excess mortality being highest among young patients during their first year after hospital discharge (6.64; 95% CI, 6.61-6.73). This persisted into the second (3.50; 95% CI, 3.48-3.55) and third year (2.86; 95% CI, 2.84-2.91). For patients 80 years or older, the mortality risk was close to that of the general population.

Although aging was associated with an increased risk for mortality in the 3 years following hospital ICU discharge, long-term mortality was highest among young patients after standardizing for age and sex.

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Finally, researchers found that age, sex, most comorbidities, most reasons for hospitalization and most ICU procedures were associated with in-hospital mortality, whereas female sex, a medical history of end-stage renal disease and the use of noninvasive mechanical ventilation were associated with in-hospital survival.

The researchers noted that, although the observation that the higher mortality risk in older patients was closer to the general population when matched for age than younger patients could appear contradictory, “these results are likely associated with the higher life expectancy of younger people. After an acute event, the youngest patients have more years of lives lost in the event of death than elderly patients.”

“Despite living in a high-income country with wide access to health care, approximately 40% of patients admitted to French ICUs did not survive 3 years,” the researchers concluded. “These results suggest that efforts are probably required to improve immediate management after ICU discharge, especially among younger patients. Such initiatives could include developing post-acute care facilities or appropriate home care in patients discharged from the ICU. Transition from acute care to home was likely underappreciated herein and may represent a factor for potential improvement in these patients.” – by Melissa J. Webb

Disclosures: Atramont reports no relevant financial disclosures. Please see study for all other authors’ relevant financial disclosures.