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October - 2017

   

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Effect of Systematic Intensive Care Unit Triage on Long-term Mortality Among Critically Ill Elderly Patients in France

B Guidet, G Leblanc, T Simon,et al for the ICE-CUB 2 Study Network JAMA, 2017, Online first 2017

Comment

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.

The details;

  • cluster-randomized clinical trial conducted in 24 hospitals, with at least 1 ICU and 1 ED, in France from Jan 2012 to Nov 2015
  • Hospitals randomly assigned either to the intervention or the control group
  • Intervention group: A program to promote systematic ICU admission was implemented. In this program, emergency department and ICU physicians were asked to systematically recommend an ICU admission for all included patients during the triage process. Eligible patients had prespecified clinical conditions, had to have preserved functional status, nutritional status, and be free from cancer. Other interventions to promote ICU admission included the following: 
    • a member of the steering committee visited each center and presented the trial protocol
    • when including a participant in the trial, the emergency department physician was required to systematically call the attending ICU physician
    • the ICU physician was required to systematically evaluate the patient at the bedside
    • the emergency department and ICU physicians were required to jointly decide whether to admit the patient to the ICU with consideration of participant or surrogate decision-maker opinions about ICU admission. 
    • If no ICU bed was available in the hospital, the patient had to be transferred to an ICU located in another hospital. 
    • Monthly meetings were organized with the emergency department and ICU staff. 
    • Booklets and posters presenting the recommendations for ICU admission were used.
  • Standard practice: In hospitals assigned to the standard practice (control) group, there was no specific recommendation regarding the ICU triage process. In both groups, the final decision for admission was made by the physicians at the bedside.
  • Sample size: Considering an estimated 32% 6-month mortality rate in the control group, a sample size of 2802 was required to have 74% power to detect a 6% difference in mortality. To take into account cluster randomization with inflation dependent on intraclass correlation coefficient, the number of patients to be included was increased to 3000. Recruitment was ultimately ended when the targeted sample size was achieved in each cluster
  • Demographics: Median age 85 years, 45% men, septic shock 14%, respiratory failure requiring NIV 11%, pneumonia (8%), 86% lived at home prior to admission.
  • Triage process: In the systematic strategy group, physicians inquired more often about patients’ or surrogate decision makers’ opinions about ICU admission (49% vs 24%, diff 25%; 95% CI, 22%-29%; P < .001), intensive care physicians were more often involved in the triage process (97% vs 62%, diff 35%; 95% CI, 33%-38%; P < .001) and were more favorable to an ICU admission (75% vs 66%, diff 9%; 95% CI, 5%-13%; P < .001), and patients were more favorable to an ICU admission (88% vs 66%, diff 22%; 95% CI, 15%-29%; P < .001)
  • Primary outcome: Patients in the systematic strategy group had an increased risk of death at 6 months (45% vs 39%, diff 6% [95% CI, 3%-10%]; P < .001; RR, 1.16 [95% CI, 1.07-1.26]), but the difference did not remain significant after adjustments for base-line characteristics (RR, 1.05; 95% CI, 0.96-1.14
  • Secondary outcomes: ICU admission rate was higher in the systematic strategy group (61% vs 34%, diff 27% [95% CI, 24%-31%]; P < .001; RR, 1.80 [95% CI, 1.66-1.95]), and the difference remained significant after adjustments for baseline characteristics (RR, 1.68; 95% CI, 1.54-1.8)
  • Post hoc analysis: Patients admitted to the ICU in the systematic strategy group had a higher SAPS score (diff in medians, 3), more underwent mechanical ventilation (42% vs 31%, diff 11%; 95% CI,6%-16%; P < .001), less often underwent noninvasive ventilation (28% vs 36%, diff -8%; 95% CI, –13% to –3%; P < .001) and less often underwent fluid resuscitation (21% vs 32%, diff –11%; 95% CI, –16% to –6%; P < .001)
  • ICU and hospital length of stay, and ICU mortality were not significantly different between groups
  • Hospital mortality was higher in the systematic group (30% vs 21%, diff 9% [95% CI, 5%-11%]; P < .001; RR, 1.39 [95% CI, 1.23-1.57]), and remained significant after adjustments for baseline characteristics (RR, 1.18; 95% CI, 1.03-1.33)
  • Patients discharged alive from the hospital in the systematic strategy group had an increased length of hospital stay vs patients in the standard practice group (16.8 [SD, 16.2] days in the systematic strategy group and 13.6 [SD, 20.1] days in the standard practice group; difference in means, 3.2 days; 95% CI, 1.7-4.7 days; P < .001).
  • There was a greater decrease from baseline Index of Independence in Activities of Daily Living at 6 months in the systematic strategy group
  • Self-reported physical quality of life at 6 months was not significantly different between groups
  • Self-reported mental quality of life at 6 months was higher in the systematic strategy group

 

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? 

  1. This doesn’t mean ICU admission is non-beneficial to all elderly patients. 
  2. It may mean trying to increase admission of patients not currently offered ICU care is not of benefit. That could suggest the current system is making good decisions, or, even though admission to ICU increased, the issues leading to death were not reversed. 
  3. It may reflect increased end of life decision making as a result of ICU admission, although this level of detail is not provided.
  4. This was a cohort of cancer free, non frail, independent people. What of those who are not? What should be offered them?

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.”

 

Abstract

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.

October


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