October - 2017
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Effect of Systematic Intensive Care Unit Triage on Long-term Mortality Among Critically Ill Elderly Patients in France
JAMA, 2017, Online first 2017
Does a program to increase intensive care unit (ICU) admission rates among critically ill elderly patients have a beneficial effect on long-term outcomes?
Many physicians have doubts as to whether elderly patients benefit from ICU admission, due to the increased risk of death associated with decreased physiological reserve, higher prevalence of chronic diseases, and frailty. There are no RCTs addressing this, and observational studies report conflicting results.
This study - the Intensive Care for Elderly–CUB-Réa 2 (ICE-CUB 2) trial, a cluster-randomized clinical trial of the effect of systematic recommendation of ICU admission for 3036 critically ill patients aged over 75 years of age, compared to usual practice on 6-month mortality, aimed to provide some answers.
What does this tell us? A program of systematic identification and ICU admission of - independent, elderly patients, without frailty, cancer, or loss of function - leads to more ICU admission, longer hospital LOS amongst survivors, and no benefit on 6-month mortality.
What do we make of this?
Perhaps the authors provide the final word most concisely: “there is a need to systematically and thoughtfully assess the potential benefits and harms of ICU admission for every elderly patient presenting with critical illness.”
IMPORTANCE The high mortality rate in critically ill elderly patients has led to questioning of the beneficial effect of intensive care unit (ICU) admission and to a variable ICU use among this population.
OBJECTIVE To determine whether are commendation for systematic ICU admission in critically ill elderly patients reduces 6-month mortality compared with usual practice.
DESIGN, SETTING, AND PARTICIPANTS Multicenter, cluster-randomized clinical trial of 3037 critically ill patients aged 75 years or older, free of cancer, with preserved functional status (Index of Independence in Activities of Daily Living 4) and nutritional status (absence of cachexia) who arrived at the emergency department of one of 24 hospitals in France between January 2012 and April 2015 and were followed up until November 2015.
INTERVENTIONS Centers were randomly assigned either to use a program to promote systematic ICU admission of patients (n=1519 participants) or to follow standard practice (n=1518 participants).
MAIN OUTCOMES AND MEASURES The primary outcome was death at 6months. Secondary outcomes included ICU admission rate, in-hospital death, functional status, and quality of life (12-Item Short Form Health Survey, ranging from 0 to 100, with higher score representing better self-reported health) at 6 months.
RESULTS One patient withdrew consent, leaving 3036 patients included in the trial
(median age, 85 [interquartile range, 81-89] years; 1361 [45%] men). Patients in the systematic strategy group had an increased risk of death at 6 months (45% vs 39%; relative risk [RR], 1.16; 95% CI, 1.07-1.26) despite an increased ICU admission rate (61% vs 34%; RR, 1.80; 95% CI, 1.66-1.95). After adjustments for baseline characteristics, patients in the systematic strategy group were more likely to be admitted to an ICU (RR, 1.68; 95% CI, 1.54-1.82) and had a higher risk of in-hospital death (RR, 1.18; 95% CI, 1.03-1.33) but had no significant increase in risk of death at 6 months (RR, 1.05; 95% CI, 0.96-1.14). Functional status and physical quality of life
at 6 months were not significantly different between groups.
CONCLUSIONS AND RELEVANCE Among critically ill elderly patients in France, a program to promote systematic ICU admission increased ICU use but did not reduce 6-month mortality. Additional research is needed to understand the decision to admit elderly patients to the ICU.
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