Variability of intensive care admission decisions for the very elderly

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.

Trial registration: ClinicalTrials.gov NCT00912600.

Figure 1. Inclusion and follow-up in the ICE-CUB study.

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

Figure 2. Flow Chart.

* 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%).

Figure 3. Association between ICU admission rate and six-month outcome.

Adjusted 6-month mortality or one-point loss of ADL rate versus adjusted ICU eligibility rate.

Figure 4. Association between ICU admission rate and six-month outcome among large hospitals (over 150 inclusions).

Adjusted 6-month mortality or one-point loss of ADL rate versus adjusted ICU eligibility rate.