Borderline pneumonia patients may benefit from intensive care, study findsBMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h5017 (Published 24 September 2015) Cite this as: BMJ 2015;351:h5017
Admission of older, low risk patients with pneumonia to intensive care is associated with reduced mortality without a considerable increase in costs, research published in JAMA has shown.1 The researchers said that the findings contradicted moves to reduce intensive care unit (ICU) admissions to contain healthcare costs.
Observational studies have previously shown that greater use of ICUs does not achieve better outcomes, but those results may have been influenced by sicker patients being more likely to be admitted to ICU.
The retrospective cohort study included more than a million US Medicare beneficiaries aged over 64 who were admitted with pneumonia to almost 3000 acute care hospitals in the United States. Of these patients, 30% (328 404) were admitted to ICU.
In 13% of patients the decision to admit to ICU seemed discretionary, depending only on how close they lived to a hospital with a high admission rate. Admission to ICU among patients in this group was associated with a 5.7% absolute survival advantage at 30 days (a 14.8% mortality rate among patients admitted to ICU, compared with a 20.5% mortality rate among general ward admissions). Additionally, no statistically significant differences were seen between the two groups in total costs or total Medicare payments.
The authors noted several reasons why ICU admission may be beneficial in borderline patients with pneumonia: for example, the low ratio of nurses to patients in ICU may prevent clinical deterioration, and, if sepsis occurs earlier, more aggressive care can be readily delivered.
In an accompanying editorial Ian Barbash and Jeremy Kahn, of the University of Pittsburgh School of Medicine in Pennsylvania, said that the findings “argue against active efforts to reduce ICU admissions through triage guidelines or bed supply reductions, at least for older patients with pneumonia.”2 However, they called for more research to examine why intensive care saves lives and for hospital care to be made safe and effective for all patients, regardless of where in the hospital they receive care.
Cite this as: BMJ 2015;351:h5017
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