Medical Research: What is the background for this study? What are the main findings?
Dr. Valley: There has been dramatic growth in intensive care unit (ICU) use over the past 30 years. As the reasons for this growth are not entirely clear, some have suggested that the ICU is a meaningful source of low-value care. The value of the ICU, however, depends on the net benefit that ICUs provide patients. Prior observational studies assessing the effectiveness of the ICU were limited because patients admitted to the ICU are inherently sicker and more likely to die than patients admitted to the general ward. Given the substantial number of patients with pneumonia who are admitted to an ICU, it is vital to understand whether admission to the ICU is beneficial.
In our study of 1.1 million Medicare beneficiaries with pneumonia between 2010 and 2012, we used an instrumental variable, a statistical technique to pseudo-randomize patients based on their proximity to a hospital that uses the ICU frequently for pneumonia, in order to determine whether ICU admission saved lives and at what financial cost. An estimated 13 percent of patients were admitted to the ICU solely because they lived closest to a hospital that used the ICU frequently for pneumonia. Among these patients, ICU admission was associated with a nearly six percent reduction in 30-day mortality compared to general ward admission. In addition, there were no significant differences in hospital costs or Medicare reimbursement between patients admitted to the ICU and to the general ward.
Medical Research: What should clinicians and patients take away from your report?
Dr. Valley: If these findings are replicated, the results may suggest that in patients who might be seen as on the borderline of needing intensive care because they might receive ICU care in one hospital but not another, ICU admission may improve survival without substantially increasing costs. It is rare to find a medical treatment that may save lives without considerably increasing costs, and these results suggest that the ICU may be such a treatment for these patients. For clinicians, the potential benefits of ICU admission for borderline patients with pneumonia should be considered. It is important to note, however, that the study’s results should not be generalized to patients who have a clear need for the ICU (i.e. those receiving mechanical ventilation) or to patients who clearly do not need the ICU (i.e. low-risk admissions). For patients and their families, it is reasonable to initiate a discussion with the medical team about the possibility of escalating to ICU-level care. For health policy makers, these results encourage a more nuanced discussion regarding more efficient use of existing ICU beds in addition to ongoing conversations about whether we need more or less ICU beds.
Medical Research: What recommendations do you have for future research as a result of this study?
Dr. Valley: While our study goes against the existing literature suggesting that the ICU is being overused, it underscores the importance of research to better identify the vulnerable population of patients who most benefit from ICU admission. If the results of this study are confirmed, a randomized trial of enhanced ICU or ICU-like access for patients with pneumonia would be useful to further test these results. In addition, it needs to be determined whether ICU admission is beneficial for other conditions beyond pneumonia.
Thomas S. Valley, Michael W. Sjoding, Andrew M. Ryan, Theodore J. Iwashyna, Colin R. Cooke. Association of Intensive Care Unit Admission With Mortality Among Older Patients With Pneumonia.
JAMA, 2015; 314 (12): 1272 DOI: 10.1001/jama.2015.11068
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Thomas Valley, MD (2015). ICU Treatment For Pneumonia May Decrease Readmissions and Costs