Variability of Intensive Care Admission Decisions for the Very Elderly

Although increasing numbers of very elderly patients are requiring intensive care, few large sample studies have investigated ICU admission of very elderly patients. Data on pre triage by physicians from other specialities is limited. This observational cohort study aims at examining inter-hospital variability of ICU admission rates and its association with patients' outcomes. All patients over 80 years possibly qualifying for ICU admission who presented to the emergency departments (ED) of 15 hospitals in the Paris (France) area during a one-year period were prospectively included in the study. Main outcome measures were ICU eligibility, as assessed by the ED and ICU physicians; in-hospital mortality; and vital and functional status 6 months after the ED visit. 2646 patients (median age 86; interquartile range 83–91) were included in the study. 94% of participants completed follow-up (n = 2495). 12.4% (n = 329) of participants were deemed eligible for ICU admission by ED physicians and intensivists. The overall in-hospital and 6-month mortality rates were respectively 27.2% (n = 717) and 50.7% (n = 1264). At six months, 57.5% (n = 1433) of patients had died or had a functional deterioration. Rates of patients deemed eligible for ICU admission ranged from 5.6% to 38.8% across the participating centers, and this variability persisted after adjustment for patients' characteristics. Despite this variability, we found no association between level of ICU eligibility and either in-hospital death or six-month death or functional deterioration. In France, the likelihood that a very elderly person will be admitted to an ICU varies widely from one hospital to another. Influence of intensive care admission on patients' outcome remains unclear

Variability of intensive care admission decisions for the very elderly. PLoS One.

Abstract Although increasing numbers of very elderly patients are requiring intensive care, few large sample studies have investigated ICU admission of very elderly patients. Data on pre triage by physicians from other specialities is limited. This observational cohort study aims at examining inter-hospital variability of ICU admission rates and its association with patients' outcomes. All patients over 80 years possibly qualifying for ICU admission who presented to the emergency departments (ED) of 15 hospitals in the Paris (France) area during a one-year period were prospectively included in the study. Main outcome measures were ICU eligibility, as assessed by the ED and ICU physicians; in-hospital mortality; and vital and functional status 6 months after the ED visit. 2646 patients (median age 86; interquartile range 83-91) were included in the study. 94% of participants completed follow-up (n = 2495). 12.4% (n = 329) of participants were deemed eligible for ICU admission by ED physicians and intensivists. The overall in-hospital and 6-month mortality rates were respectively 27.2% (n = 717) and 50.7% (n = 1264). At six months, 57.5% (n = 1433) of patients had died or had a functional deterioration. Rates of patients deemed eligible for ICU admission ranged from 5.6% to 38.8% across the participating centers, and this variability persisted after adjustment for patients' characteristics. Despite this variability, we found no association between level of ICU eligibility and either in-hospital death or six-month death or functional deterioration. In France, the likelihood that a very elderly person will be admitted to an ICU varies widely from one hospital to another. Influence of intensive care admission on patients' outcome remains unclear

Geriatric conditions of the patients according to physician decisions.

<p>Results for continuous and categorical variables are presented respectively as the mean (sd; median ; Inter-Quartile Range) and % (n).</p>*<p>significant difference (P<0.05).</p>†<p>assessed using Katz's Activities of Daily Living scale (ADL).</p>‡<p>  as assessed by the evaluating physician.</p

Flow Chart.

<p>* To evaluate exhaustiveness of patient inclusion in the study, one week was randomly drawn from the inclusion period, excluding the first and last month in each center. A study coordinator and a member of the steering committee reviewed the emergency department charts to estimate the number of patients missed during the randomly chosen week. Exhaustiveness was defined as the number of included patients divided by the total number of patients who should have been included in the study (sum of missed and included patients). It was extrapolated based on the estimation in each center: 62% (36%–88%).</p

Inclusion and follow-up in the ICE-CUB study.

<p>*documented in the CRF, including complete evaluation of the patient's state: functional status, comorbidities, medication, falls, recent hospitalization.</p

Multivariate models of outcome following the ED visit.

<p>Results are adjusted for severity (logit of the MPM₀ score corrected from the points attributed to age) and main presenting problem as assessed in ED.</p>*<p>defined as a one-point loss on at least one dimension of the ADL score six months after the ED visit;</p>**<p>estimated true inter-hospital variance;</p>***<p>The Median Odds Ratio (MOR) is defined as the median value of the odds ratio between the hospital at highest risk and the hospital at lowest risk for two randomly chosen hospital.</p

Hospital characteristics.

*<p>Standardized mortality ratio based on mortality predicted by SAPS II score.</p

Association of standardized ICU eligibility rate with all standardized outcomes.

<p>Association of standardized ICU eligibility rate with all standardized outcomes.</p

ICU admission and outcomes according to physicians' decisions.

<p>Results for continuous and categorical variables are presented respectively as the mean (sd; median ; Inter-Quartile Range) or % (n).</p>*<p>significant difference (P<0.05).</p>†<p>estimation based on the Mortality Probability Model 0 (MPM0).</p>‡<p>assessed using Katz's Activities of Daily Living scale (ADL).</p>§<p>defined as a one-point loss in at least one dimension of the ADL score six months after the ED visit.</p