ICU Is Best for Older, Low-Risk Patients With Pneumonia

By Sondra Forsyth

Among Medicare beneficiaries hospitalized with pneumonia, intensive care unit (ICU) admission of patients, which appeared to be discretionary, was associated with improved survival and no significant differences in Medicare spending or hospital costs compared with patients admitted to general wards. That is the finding of a University of Michigan study published in the September 22/29 2015 issue of JAMA.

A release from the publisher explains that observational studies examining the relationship between ICU admission frequency and patient outcomes often suggest that greater ICU use does not achieve better outcomes. However, these results are likely influenced by factors such as indication, because sicker patients are more likely to be admitted to the ICU. Among patients whose need for intensive care is uncertain, the relationship of ICU admission with mortality and costs has been unknown, according to background information in the article.

Thomas S. Valley, M.D. and colleagues examined the association between ICU admission and outcomes, 30-day mortality and costs, among elderly patients hospitalized for pneumonia. The study included Medicare beneficiaries (older than 64 years of age) admitted to 2,988 acute care hospitals in the United States with pneumonia from 2010 to 2012.

Among 1,112,394 Medicare beneficiaries with pneumonia, 328,404 (30 percent) were admitted to the ICU. Patients (n = 553,597) living closer than the median differential distance (less than 3.3 miles) to a hospital with high ICU admission were significantly more likely to be admitted to the ICU than patients living farther away (n = 558,797) (36 percent for patients living closer vs 23 percent for patients living farther).

For the 13 percent of patients whose ICU admission decision appeared to be discretionary (dependent only on distance), ICU admission was associated with a significantly lower adjusted 30-day mortality (14.8 percent for ICU admission vs 20.5 percent for general ward admission), yet there were no significant differences in Medicare spending or hospital costs for the hospitalization.

The authors write that contrary to the study’s prespecified hypothesis, “these findings suggest that ICU admission for borderline patients (those for whom ICU admission depends on the hospital to which they present) is associated with reduced mortality without a considerable increase in costs.”

“A randomized trial may be warranted to assess whether more liberal ICU admission policies improve mortality for patients with pneumonia.”