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By Elaine Chen, MD
Assistant Professor, Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Section of Palliative Medicine, Rush University Medical Center, Chicago
Dr. Chen reports no financial relationships relevant to this field of study.
SOURCE: Guidet B, Leblanc G, Simon T, et al. Effect of systematic intensive care unit triage on long-term mortality among critically ill elderly patients in France: A randomized clinical trial. JAMA 2017;318:1450-1459.
With an aging population and growing numbers of ICU beds, the question arises as to whether the ICU truly is beneficial for this vulnerable population. To explore this question, a cluster-randomized, clinical trial was designed to determine whether a method of systematic ICU admission in critically ill elderly patients reduced six-month mortality.
This study, ICE-CUB 2, took place in France from 2012-2015. Twenty-four hospitals were each randomized to either the control group or intervention group. In the intervention group, the researchers implemented a program to promote systematic ICU admission. This included a direct conversation between the ED and ICU physicians, bedside evaluation by the ICU physician, and a joint decision regarding admission. Included patients were ≥ 75 years of age with a critical condition, preserved functional and nutritional status, and free of active cancer.
The primary outcome assessed was six-month mortality. Secondary outcomes included ICU admission rate, hospital mortality, functional status, and quality of life at six months. Other secondary outcomes included characteristics of the triage process.
Over a 39-month period, 1,519 patients from 11 hospitals were recruited to the systematic strategy group and 1,518 patients from 13 hospitals were recruited to the standard practice group. The recruitment rate was higher in the systematic strategy group, leading to a shorter inclusion period. The average age was 85 years, and the patients in the systematic group exhibited a higher initial severity of illness.
Regarding the primary outcome, the intervention group demonstrated a slightly higher six-month mortality rate compared to the control group (45% vs. 39%; relative risk [RR], 1.16; 95% confidence interval [CI], 1.07-1.26; P < 0.001); the statistical significance did not remain after adjustment for severity of illness (RR, 1.05; 95% CI, 0.96-1.14). Regarding secondary outcomes, the ICU admission rate was higher in the systematic group compared to the standard group (61% vs. 34%; RR, 1.80; 95% CI, 1.66-1.95; P < 0.001), and hospital mortality was higher in the systematic strategy group (30% vs. 21%; RR, 1.39; 95% CI, 1.23-1.57; P < 0.001). Comparing patients between the two groups, the systematic group exhibited statistically significant higher severity of illness and more frequent mechanical ventilation. ICU and hospital lengths of stay were not different between the groups, nor was ICU mortality.
This program to promote systematic ICU admission of critically ill elderly patients led to a higher ICU admission rate and increased hospital mortality, but produced no significant effect on six-month mortality, functional status, or physical health-related quality of life.
The authors noted that their patient selection, which excluded very sick patients, may have contributed to lower-than-expected mortality rates. The authors surmised that perhaps the higher in-hospital mortality rate in the systematic strategy group may be related to more frequent withdrawal of life-sustaining therapy.
Advanced monitoring and aggressive interventions in modern ICUs save many lives. Both ICU beds and usage are increasing. However, ICU care also can be harmful or even futile.1 Ideal triaging of patients would maximize benefit while optimizing cost. Admission practices to ICUs vary widely: locally among providers (even within a hospital), regionally among hospitals, or more broadly based on location (urban vs. rural, country by country). This large multicenter study protocolized this decision-making process. While defined objective criteria were provided, it remained a clinical decision by the physicians.
The strategy successfully doubled ICU admission rates, yet did not affect long-term outcomes. The only significant outcome was that in-hospital mortality was higher. The authors thoughtfully discussed several strengths and limitations of their study, acknowledging both benefits and challenges because of clustering. Qualitative studies regarding reasons for declining admission in the intervention group or choice of admission in the control group could reveal significant insights into practice.
Study design of this large, randomized trial was reported previously; this study failed to show benefit with increased ICU use in elderly patients.2 Prior studies, some showing improvement in mortality and others showing no benefit, were observational or retrospective in design.3-6 For American physicians, who have easier access to ICUs than the French, this study invites more questions: How do we reduce or minimize the harm because of excessive ICU use? How do we systematically monitor and audit our ICU use to optimize benefit? How can we move the question upstream, before ED presentation, to the primary care providers, geriatricians, oncologists, and other referring providers? For now, we should practice thoughtfully, and await further research.
Financial Disclosure: Hospital Medicine Alert’s Physician Editor, Kenneth P. Steinberg, MD, Peer Reviewer Rachael Safyan, MD, Editor Jesse Saffron, Editor Jill Drachenberg, and Editorial Group Manager Terrey L. Hatcher report no relevant relationship related to the material presented in this issue.