Article

Short-term mortality of patients ≥80 years old admitted to European intensive care units: an international observational study

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  • French Institute of Health and Medical Research U1136
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Abstract

Background Limited evidence suggests variation in mortality of older critically ill adults across Europe. We aimed to investigate regional differences in mortality among very old ICU patients. Methods Multilevel analysis of two international prospective cohort studies. We included patients ≥80 yr old from 322 ICUs located in 16 European countries. The primary outcome was mortality within 30 days from admission to the ICU. Results are presented as n (%) with 95% confidence intervals and odds ratios (ORs). Results Of 8457 patients, 2944 (36.9% [35.9–38.0%]) died within 30 days. Crude mortality rates varied widely between participating countries (from 10.1% [6.4–15.6%] to 45.1% [41.1–49.2%] in the ICU and from 21.3% [16.3–28.9%] to 55.3% [51.1–59.5%] within 30 days). After adjustment for confounding variables, the variation in 30-day mortality between countries was substantially smaller than between ICUs (median OR 1.14 vs 1.58). Healthcare expenditure per capita (OR=0.84 per $1000 [0.75–0.94]) and social health insurance framework (OR=1.43 [1.01–2.01]) were associated with ICU mortality, but the direction and magnitude of these relationships was uncertain in 30-day follow-up. Volume of admissions was associated with lower mortality both in the ICU (OR=0.81 per 1000 annual ICU admissions [0.71–0.94]) and in 30-day follow-up (OR=0.86 [0.76–0.97]). Conclusion The apparent variation in short-term mortality rates of older adults hospitalised in ICUs across Europe can be largely attributed to differences in the clinical profile of patients admitted. The volume–outcome relationship identified in this population requires further investigation.

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Importance The high mortality rate in critically ill elderly patients has led to questioning of the beneficial effect of intensive care unit (ICU) admission and to a variable ICU use among this population. Objective To determine whether a recommendation for systematic ICU admission in critically ill elderly patients reduces 6-month mortality compared with usual practice. Design, Setting, and Participants Multicenter, cluster-randomized clinical trial of 3037 critically ill patients aged 75 years or older, free of cancer, with preserved functional status (Index of Independence in Activities of Daily Living ≥4) and nutritional status (absence of cachexia) who arrived at the emergency department of one of 24 hospitals in France between January 2012 and April 2015 and were followed up until November 2015. Interventions Centers were randomly assigned either to use a program to promote systematic ICU admission of patients (n=1519 participants) or to follow standard practice (n=1518 participants). Main Outcomes and Measures The primary outcome was death at 6 months. Secondary outcomes included ICU admission rate, in-hospital death, functional status, and quality of life (12-Item Short Form Health Survey, ranging from 0 to 100, with higher score representing better self-reported health) at 6 months. Results One patient withdrew consent, leaving 3036 patients included in the trial (median age, 85 [interquartile range, 81-89] years; 1361 [45%] men). Patients in the systematic strategy group had an increased risk of death at 6 months (45% vs 39%; relative risk [RR], 1.16; 95% CI, 1.07-1.26) despite an increased ICU admission rate (61% vs 34%; RR, 1.80; 95% CI, 1.66-1.95). After adjustments for baseline characteristics, patients in the systematic strategy group were more likely to be admitted to an ICU (RR, 1.68; 95% CI, 1.54-1.82) and had a higher risk of in-hospital death (RR, 1.18; 95% CI, 1.03-1.33) but had no significant increase in risk of death at 6 months (RR, 1.05; 95% CI, 0.96-1.14). Functional status and physical quality of life at 6 months were not significantly different between groups. Conclusions and Relevance Among critically ill elderly patients in France, a program to promote systematic ICU admission increased ICU use but did not reduce 6-month mortality. Additional research is needed to understand the decision to admit elderly patients to the ICU. Trial Registration clinicaltrials.gov Identifier: NCT01508819
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The “very old intensive care patients” (abbreviated to VOPs; greater than 80 years old) are probably the fastest expanding subgroup of all intensive care unit (ICU) patients. Up until recently most ICU physicians have been reluctant to admit these VOPs. The general consensus was that there was little survival to gain and the incremental life expectancy of ICU admission was considered too small. Several publications have questioned this belief, but others have confirmed the poor long-term mortality rates in VOPs. More appropriate triage (resource limitation enforced decisions), admission decisions based on shared decision-making and improved prediction models are also needed for this particular patient group. Here, an expert panel proposes a research agenda for VOPs for the coming years.
Article
OBJECTIVE The purpose of this study was to systematically review the research on volume and outcome relationships in critical care.METHODS From January 1, 2001, to April 30, 2014, MEDLINE and EMBASE were searched for studies assessing the relationship between admission volume and clinical outcomes in critical illness. Bibliographies were reviewed to identify other articles of interest, and experts were contacted about missing or unpublished studies. Of 127 studies reviewed, 46 met inclusion criteria, covering seven clinical conditions. Two investigators independently reviewed each article using a standardized form to abstract information on key study characteristics and results.RESULTSOverall, 29 of the studies (63%) reported a statistically significant association between higher admission volume and improved outcomes. The magnitude of the association (mortality OR between the lowest vs highest stratum of volume centers), as well as the thresholds used to characterize high volume, varied across clinical conditions. Critically ill patients with cardiovascular (n = 7, OR = 1.49 [1.11-2.00]), respiratory (n = 12, OR = 1.20 [1.04-1.38]), severe sepsis (n = 4, OR = 1.17 [1.03-1.33]), hepato-GI (n = 3, OR = 1.30 [1.08-1.78]), neurologic (n = 3, OR = 1.38 [1.22-1.57]), and postoperative admission diagnoses (n = 3, OR = 2.95 [1.05-8.30]) were more likely to benefit from admission to higher-volume centers compared with lower-volume centers. Studies that controlled for ICU or hospital organizational factors were less likely to find a significant volume-outcome relationship than studies that did not control for these factors.CONCLUSIONS Critically ill patients generally benefit from care in high-volume centers, with more substantial benefits in selected high-risk conditions. This relationship may in part be mediated by specific ICU and hospital organizational factors.Volume-outcome relationships are well established in many surgical conditions and high-risk procedures in health care.1 Under these relationships, higher numbers of procedures are thought to lead to better patient outcomes through the development of procedural skill.2 Such observations lend conceptual support to the development of regionalized systems of surgical care, in which patients are selectively referred to high-volume providers.3 Selective referral has substantially improved the quality of care for patients in need of these planned high-risk procedures, with improved outcomes over time due in large part to concentration of care.2Given the current shortage of ICU physicians and the overall complexity of critical illness, critical care is also an attractive target for regionalization. However, unlike in many surgical conditions, the volume-outcome relationship in critical illness is still incompletely characterized.4 In the absence of a well-defined volume-outcome relationship, regionalization of critical care may increase costs while delaying definitive therapy for extremely sick patients in need of rapid diagnosis and treatment. Moreover, regionalization is only one potential strategy for region-wide organization of critical care.5 Without a greater understanding of the mechanism of the volume-outcome relationship, which may in part be determined by organizational factors that are correlated with volume, we may miss out on opportunities to improve outcomes for small-volume providers without large-scale reorganization of care.The goal of this study was to perform a systematic review of literature to assess the volume-outcome relationship among critically ill adult patients. In addition to providing summary information, we sought to understand organizational factors that may be potential mechanisms for this effect by analyzing the differences between positive and negative studies.
Article
Evidence of variation in mortality after surgery may indicate preventable postoperative death. We sought to determine if regional differences in outcome were present in surgical patients admitted to critical care in the UK. We extracted data on admission characteristics, case mix and outcome of all patients admitted to UK critical care units following surgery for the calendar year of 2009. We also used publicly held data on regional population, volume of surgery and bed provision. Multilevel regression analysis was used to adjust for the effects of case mix and regional critical care bed provision on acute hospital mortality. A total of 16,147 patients admitted to critical care following surgery were included in this analysis. Median odds ratio (MOR) was used to describe regional-level variance in acute hospital mortality. Significant variation was identified (MOR 1.14; 95 % CI 1.07, 1.28) and persisted following adjustment for case mix (MOR 1.10; 95 % CI 1.04, 1.25) and regional critical care bed provision (MOR 1.09; 95 % CI 1.04, 1.24). Critical care bed utilisation (surgical critical care admissions per 100,000 surgical procedures) seemed to better explain this observation (MOR 1.03; 95 % CI 1.00, 29.26) and was associated with statistically significant reduction in mortality (OR 0.91; 95 % CI 0.85, 0.97; p = 0.01). Significant regional variation in hospital mortality for patients admitted to critical care following surgery was observed. Critical care bed utilisation seemed to better explain this observation and was associated with improved outcome.
Article
When used to prolong life without achieving a benefit meaningful to the patient, critical care is often considered "futile." Although futile treatment is acknowledged as a misuse of resources by many, no study has evaluated its opportunity cost, that is, how it affects care for others. Our objective was to evaluate delays in care when futile treatment is provided. For 3 months, we surveyed critical care physicians in five ICUs to identify patients that clinicians identified as receiving futile treatment. We identified days when an ICU was full and contained at least one patient who was receiving futile treatment. For those days, we evaluated the number of patients waiting for ICU admission more than 4 hours in the emergency department or more than 1 day at an outside hospital. One health system that included a quaternary care medical center and an affiliated community hospital. Critically ill patients. None. Boarding time in the emergency department and waiting time on the transfer list. Thirty-six critical care specialists made 6,916 assessments on 1,136 patients of whom 123 were assessed to receive futile treatment. A full ICU was less likely to contain a patient receiving futile treatment compared with an ICU with available beds (38% vs 68%, p < 0.001). On 72 (16%) days, an ICU was full and contained at least one patient receiving futile treatment. During these days, 33 patients boarded in the emergency department for more than 4 hours after admitted to the ICU team, nine patients waited more than 1 day to be transferred from an outside hospital, and 15 patients canceled the transfer request after waiting more than 1 day. Two patients died while waiting to be transferred. Futile critical care was associated with delays in care to other patients.
Article
Clinical outcomes after major surgery are poorly described at the national level. Evidence of heterogeneity between hospitals and health-care systems suggests potential to improve care for patients but this potential remains unconfirmed. The European Surgical Outcomes Study was an international study designed to assess outcomes after non-cardiac surgery in Europe. METHODS: We did this 7 day cohort study between April 4 and April 11, 2011. We collected data describing consecutive patients aged 16 years and older undergoing inpatient non-cardiac surgery in 498 hospitals across 28 European nations. Patients were followed up for a maximum of 60 days. The primary endpoint was in-hospital mortality. Secondary outcome measures were duration of hospital stay and admission to critical care. We used χ(2) and Fisher's exact tests to compare categorical variables and the t test or the Mann-Whitney U test to compare continuous variables. Significance was set at p
Article
To better define the incidence of sepsis and the characteristics of critically ill patients in European intensive care units. Cohort, multiple-center, observational study. One hundred and ninety-eight intensive care units in 24 European countries. All new adult admissions to a participating intensive care unit between May 1 and 15, 2002. None. Demographic data, comorbid diseases, and clinical and laboratory data were collected prospectively. Patients were followed up until death, until hospital discharge, or for 60 days. Of 3,147 adult patients, with a median age of 64 yrs, 1,177 (37.4%) had sepsis; 777 (24.7%) of these patients had sepsis on admission. In patients with sepsis, the lung was the most common site of infection (68%), followed by the abdomen (22%). Cultures were positive in 60% of the patients with sepsis. The most common organisms were Staphylococcus aureus (30%, including 14% methicillin-resistant), Pseudomonas species (14%), and Escherichia coli (13%). Pseudomonas species was the only microorganism independently associated with increased mortality rates. Patients with sepsis had more severe organ dysfunction, longer intensive care unit and hospital lengths of stay, and higher mortality rate than patients without sepsis. In patients with sepsis, age, positive fluid balance, septic shock, cancer, and medical admission were the important prognostic variables for intensive care unit mortality. There was considerable variation between countries, with a strong correlation between the frequency of sepsis and the intensive care unit mortality rates in each of these countries. This large pan-European study documents the high frequency of sepsis in critically ill patients and shows a close relationship between the proportion of patients with sepsis and the intensive care unit mortality in the various countries. In addition to age, a positive fluid balance was among the strongest prognostic factors for death. Patients with intensive care unit acquired sepsis have a worse outcome despite similar severity scores on intensive care unit admission.
Article
To describe triage decisions and subsequent outcomes in octogenarians referred to an ICU. Prospective observational study in the medical ICU in a tertiary nonuniversity hospital. Cohort of 180 patients aged 80 years or over who were triaged for admission. Age, underlying diseases, admission diagnoses, Mortality Probability Model score, and mortality were recorded. Self-sufficiency (Katz Index of Activities of Daily Living) and quality of life (modified Perceived Quality of Life scale and Nottingham Health Profile) were measured 1year after triage. In 132 patients (73.3%) ICU admission was refused, including 79 (43.8%) considered too sick to benefit. Factors independently associated with refusal were nonsurgical status, age older than 85 years, and full unit. Greater self-sufficiency was associated with ICU admission. Hospital mortality was 30/48 (62.5%), 56/79 (70.8%), 9/51 (17.6%), and 0/2 in the admitted, too sick to benefit, too well to benefit, and family/patient refusal groups, respectively; 1-year mortality was 34/48 (70.8%), 69/79 (87.3%), 24/51 (47%), and 0/2, respectively. Self-sufficiency was unchanged by ICU stay. Quality of life (known in only 28 patients) was significantly poorer for isolation, emotional, and mobility domains compared to the French general population matched on sex and age. More than two-thirds of patients aged over 80 years referred to our ICU were denied admission. One year later self-sufficiency was not modified and quality of life was poorer than in the general population. These results indicate a need to discuss patient preferences before triage decisions.
The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure
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