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Original Investigation | Less Is More

Association Between Intensive Care Unit Utilization During Hospitalization and Costs, Use of Invasive Procedures, and Mortality ONLINE FIRST

Dong W. Chang, MD, MS1; Martin F. Shapiro, MD, PhD2
[+] Author Affiliations
1Division of Respiratory and Critical Care Physiology and Medicine, Los Angeles Biomed Research Institute, Harbor–University of California, Los Angeles Medical Center
2Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles
JAMA Intern Med. Published online August 08, 2016. doi:10.1001/jamainternmed.2016.4298
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Importance  Maximizing the value of critical care services requires understanding the relationship between intensive care unit (ICU) utilization, clinical outcomes, and costs.

Objective  To examine whether hospitals had consistent patterns of ICU utilization across 4 common medical conditions and the association between higher use of the ICU and hospital costs, use of invasive procedures, and mortality.

Design, Setting, and Participants  Retrospective cohort study of 156 842 hospitalizations in 94 acute-care nonfederal hospitals for diabetic ketoacidosis (DKA), pulmonary embolism (PE), upper gastrointestinal bleeding (UGIB), and congestive heart failure (CHF) in Washington state and Maryland from 2010 to 2012. Hospitalizations for DKA, PE, UGIB, and CHF were identified from the presence of compatible International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Multilevel logistic regression models were used to determine the predicted hospital-level ICU utilization during hospitalizations for the 4 study conditions. For each condition, hospitals were ranked based on the predicted ICU utilization rate to examine the variability in ICU utilization across institutions.

Main Outcomes and Measures  The primary outcomes were associations between hospital-level ICU utilization rates and risk-adjusted hospital mortality, use of invasive procedures, and hospital costs.

Results  The 94 hospitals and 156 842 hospitalizations included in the study represented 4.7% of total hospitalizations in this study. ICU admission rates ranged from 16.3% to 81.2% for DKA, 5.0% to 44.2% for PE, 11.5% to 51.2% for UGIB, and 3.9% to 48.8% for CHF. Spearman rank coefficients between DKA, PE, UGIB, and CHF showed significant correlations in ICU utilization for these 4 medical conditions among hospitals (ρ ≥ 0.90 for all comparisons; P < .01 for all). For each condition, hospital-level ICU utilization rate was not associated with hospital mortality. Use of invasive procedures and costs of hospitalization were greater in institutions with higher ICU utilization for all 4 conditions.

Conclusions and Relevance  For medical conditions where ICU care is frequently provided, but may not always be necessary, institutions that utilize ICUs more frequently are more likely to perform invasive procedures and have higher costs but have no improvement in hospital mortality. Hospitals had similar ICU utilization patterns across the 4 medical conditions, suggesting that systematic institutional factors may influence decisions to potentially overutilize ICU care. Interventions that seek to improve the value of critical care services will need to address these factors that lead clinicians to admit patients to higher levels of care when equivalent care can be delivered elsewhere in the hospital.

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Association Between Hospital-Level ICU Utilization and Hospital Mortality for the 4 Study Conditions

Increased utilization of the intensive care unit (ICU) was not associated with significant differences in hospital mortality for any of the 4 study conditions (diabetic ketoacidosis [DKA], pulmonary embolism [PE], upper gastrointestinal bleeding [UGIB], and congestive heart failure [CHF]). The slopes of the linear regression analyses between hospital mortality and ICU utilization were −0.0013% mortality per percent predicted ICU admission for DKA (P = .22); 0.0061% for PE (P = .59), −0.0061% for UGIB (P = .49), and 0.0083% for CHF (P = .37).

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