Critically ill elderly patients may not always benefit from systematic ICU admission, according to a new French study.
Researchers performed a multicenter, cluster-randomized trial in which 24 hospitals in France were randomly assigned to use a program promoting systematic ICU admission in elderly patients or to follow standard practice. Patients were 75 years of age or older, did not have cancer, had preserved functional and nutritional status, and presented at the ED between January 2012 and April 2015.
In hospitals using the systematic strategy, ED and ICU physicians were asked to systematically recommend ICU admission during triage for all patients included in the study. In addition, the trial protocol was presented at each hospital by a member of the study's steering committee, ED physicians were required to systematically call the attending ICU physicians whenever they entered a patient into the trial, ICU physicians were required to systematically evaluate patients at the bedside, and ED and ICU physicians were required to make a joint decision on whether to admit patients to the ICU. Patients for whom admission was recommended were transferred to an ICU at another hospital if no ICU beds were available. ED and ICU staff met monthly, and booklets and posters outlined recommendations for ICU admission. In hospitals using standard practice, no recommendations were made about the ICU triage process and physicians at the bedside made the final decision about ICU admission.
The study's primary outcome was death at six months. ICU admission rate, in-hospital mortality rate, functional status, and quality of life at six months were secondary outcomes. Patients were followed until November 2015. Results of the study were published online Sept. 27 by JAMA.
Overall, 3,036 critically ill patients ages 75 years and older were included in the study. Of these, 1,518 were cared for at hospitals in the systematic strategy group and 1,518 were cared for at hospitals in the control group. Patients' median age was 85 years, and 1,361 (45%) were men. Septic shock (13.6%), acute respiratory failure that required noninvasive ventilation (11.4%), severe pneumonia (8.2%), and cardiac insufficiency that required noninvasive ventilation (7.2%) were the most common reasons for hospital admission. Severity of illness at admission, as measured by the Simplified Acute Physiology Score III, was higher in the systematic strategy group.
At six months, patients in the systematic strategy group had a higher risk for death than those in the control group (45% vs. 39%; relative risk [RR], 1.16; 95% CI, 1.07 to 1.26), although their ICU admission rate was higher (61% vs. 34%; RR, 1.80; 95% CI, 1.66 to 1.95). Likelihood of ICU admission was higher in the systematic strategy group after adjustment for baseline characteristics (RR, 1.68; 95% CI, 1.54 to 1.82), and risk for in-hospital death was higher (RR, 1.18; 95% CI, 1.03 to 1.33). Also after adjustment, no significant increase in risk for death at six months was seen in the systematic strategy group (RR, 1.05; 95% CI, 0.96 to 1.14). The researchers found no significant difference between groups in functional status or quality of life at six months.
The recruitment period for the standard practice group was longer than that for the systematic strategy group, and blinding to group assignment was not possible, the authors noted. They also pointed out that data on withdrawal of life-sustaining therapies were not collected and that confounding might have occurred due to recruitment of sicker patients in the systematic strategy group, among other limitations. However, they concluded that their systematic program promoting ICU admission was associated with higher ICU admission rates and rates of hospital mortality but did not appear to affect mortality, functional status, or health-related quality of life at six months.
On the basis of their results, the authors said that systematic ICU admission of all critically ill elderly patients may not be warranted. “However, this study should not be interpreted as suggesting that no elderly patient should be admitted to the ICU,” the authors wrote. “Because of substantial uncertainty in outcomes among individual patients, 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.”
The author of an accompanying editorial said that although the study had several inherent limitations, it was well conducted and its results may have implications for clinicians and policymakers regarding ICU access for elderly patients, especially in France. The editorialist also pointed out that several questions still need to be answered, including whether and how any of the trial patients were harmed by ICU care, what criteria should be used to audit ICU use, and whether there are beneficial practices in general wards and harmful practices in ICUs that can be promoted and eradicated, respectively. In addition, for countries like the U.S. where ICU beds are in much greater supply than in France, the trial's findings “certainly support an argument for close examination of ICU admission decisions, with the potential to safely reduce ICU beds, care, and costs,” the editorialist wrote.