Intensive Care Unit Admitting Patterns in the Veterans Affairs Health Care System
Intensive Care Unit Admitting Patterns in the Veterans Affairs Health Care System
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DOI：
10.1001/archinternmed.2012.2606
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发表时间：
2012-09-10
影响因子：
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通讯作者：
Hofer, Timothy P.
中科院分区：
文献类型：
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作者：
Chen, Lena M.;Render, Marta;Hofer, Timothy P.
背景：重症监护资源的使用占美国国内生产总值的近1%，不同医院的情况差异很大。方法：为了描述内科患者入院时的ICU入院模式，我们对2009年7月1日至2010年6月30日118家退伍军人事务部急诊或门诊首次非手术入院的289310例患者进行了回顾性队列研究。根据实验室数据和入院前后的合并症，使用改良的退伍军人事务部ICU评分来衡量严重程度(30天预测死亡率)。结果：在直接进入ICU的31555例患者(10.9%)中，53.2%的患者在入院时30天的预计死亡率为2%或更低。这一低风险人群的ICU住院率从1.2%到38.9%不等。对于高危患者(预计死亡率和GT；30%)，ICU住院率也有很大差异。在预测死亡率增加1-SD的情况下，调整后的ICU入院几率因医院而异(优势比=0.85-2.22)。结果，66.1%的医院对低风险患者和高风险患者使用ICU的比例不同(加权kappa=0.50)。结论：ICU低风险患者和高风险患者的比例，医院间ICU入院模式的差异，以及医院排名对患者风险的敏感性，都可能反映出对于哪些患者从ICU入院中受益最大，缺乏共识。
Background: Critical care resource use accounts for almost 1% of US gross domestic product and varies widely among hospitals. However, we know little about the initial decision to admit a patient to the intensive care unit (ICU).Methods: To describe hospital ICU admitting patterns for medical patients after accounting for severity of illness on admission, we performed a retrospective cohort study of the first nonsurgical admission of 289 310 patients admitted from the emergency department or the outpatient clinic to 118 Veterans Affairs acute care hospitals between July 1, 2009, and June 30, 2010. Severity (30-day predicted mortality rate) was measured using a modified Veterans Affairs ICU score based on laboratory data and comorbidities around admission. The main outcome measure was direct admission to an ICU.Results: Of the 31 555 patients (10.9%) directly admitted to the ICU, 53.2% had 30-day predicted mortality at admission of 2% or less. The rate of ICU admission for this low-risk group varied from 1.2% to 38.9%. For high-risk patients (predicted mortality >30%), ICU admission rates also varied widely. For a 1-SD increase in predicted mortality, the adjusted odds of ICU admission varied substantially across hospitals (odds ratio =0.85-2.22). As a result, 66.1% of hospitals were in different quartiles of ICU use for low- vs high-risk patients (weighted kappa=0.50).Conclusions: The proportion of low- and high-risk patients admitted to the ICU, variation in ICU admitting patterns among hospitals, and the sensitivity of hospital rankings to patient risk all likely reflect a lack of consensus about which patients most benefit from ICU admission.