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Overuse of ICU Often Means Lower Quality Care for Cardiovascular Patients

ANN ARBOR, MI – ICUs can literally be life-savers for patients who need them.

On the other hand, heart attacks or flare-ups of congestive heart failure can be treated elsewhere in the hospital — and probably should be whenever possible, according to a new study suggesting such patients fare worse in hospitals that rely heavily on ICUs to care for them.

The report, published recently in the journal CHEST, found that patients with those conditions in the ICU might be half as likely to get certain proven tests and treatments, and also be at much greater risk of dying a month after their hospital stay.

The University of Michigan Medical School-led researchers find that, in terms of cardiovascular care, hospitals sending the highest percentage of admits to the ICU perform worst on overall quality measures. Those conclusions were based on review of Medicare records from more than 570,000 hospital stays that took place in 2010.

Of the more than 150,000 hospitalizations at nearly 1,700 hospitals for acute myocardial infarction (AMI), 46% included care in an ICU. At the same time, 16% of the more than 400,000 hospitalizations for heart failure also included an ICU stay at one of 2,199 hospitals.

Hospitals were ranked on use of ICU and care quality based on the federal government's Hospital Compare website.

"In this country, we still have an open question of what to use the ICU for, and when, and very little evidence to guide physicians," explained lead researcher Thomas Valley, MD, MSc. "Is it for those who were already sick and got worse, or is it a place to send people proactively when we think they might get sicker? And the answer can vary on different days, or based on how many beds are available right then. We hope to build a body of evidence about how to use this valuable resource in the most effective way."

Hospitals treating fewer cases of AMI and heart failure also were the most likely to admit those patients to the ICU, as were for-profit hospitals.

Hospitals in the lowest quintile of ICU admission rates sent less than 29% of AMI and less than 8% of heart failure patients to ICUs. Hospitals in the top quintile, however, had rates of greater than 61% for AMI or more than 24% for heart failure.

Hospitals in the highest quintile had higher process measure failure rates for some, but not all, process measures, and also had greater 30-day mortality: 14.8% vs. 14.0% for AMI, and 11.4% vs. 10.6% for heart failure. Still, no differences were detected in 30-day readmissions or Medicare spending when compared to hospitals in the lowest quintile.

“Hospitals with the highest rates of ICU admission for patients with AMI or HF delivered lower quality of care and had higher 30-day mortality for these conditions,” the study authors concluded. “High ICU use hospitals may be targets to improve care delivery.”