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American Heart Journal

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The associations between direct and delayed critical care unit admission with mortality and readmissions among patients with heart failure - 18/02/21

Doi : 10.1016/j.ahj.2020.11.002 
Ismail R. Raslan, MD, MSc a, b, Heather J. Ross, MD, MHSc b, c, Robert A. Fowler, MDCM, MSc a, b, e, i, Damon C. Scales, MD, PhD a, b, e, i, Henry T. Stelfox, MD, PhD f, Susanna Mak, MD, PhD b, g, Jack V. Tu, MD, PhD a, b, i, Michael E. Farkouh, MD, MSc b, c, Therese A. Stukel, PhD a, b, i, Xuesong Wang, MSc a, Sean van Diepen, MD, MSc h, Hannah Wunsch, MD, MSc a, b, e, i, Peter C. Austin, PhD a, b, i, Douglas S. Lee, MD, PhD a, b, c, d, i, ⁎
a ICES, formerly the Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada 
b University of Toronto, Toronto, Ontario, Canada 
c Ted Rogers Centre for Heart Research at the Peter Munk Cardiac Centre, Toronto, Ontario, Canada 
d Joint Department of Medical Imaging of University Health Network, Toronto, Ontario, Canada 
e Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada 
f Department of Critical Care Medicine and the O’Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada 
g Division of Cardiology, Sinai Health System, Toronto, Ontario, Canada 
h Department of Critical Care Medicine and Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada 
i The Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada 

⁎Reprint requests: Douglas S. Lee, MD PhD, ICES, Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, Ted Rogers Chair in Heart Function Outcomes, University of Toronto, 2075 Bayview Avenue Rm G-106, Toronto, ON, Canada M4N 3M5.Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, Ted Rogers Chair in Heart Function Outcomes, University of Toronto2075 Bayview Avenue Rm G-106TorontoON,M4N 3M5Canada

Riassunto

Background

Although greater than 20% of patients hospitalized with heart failure (HF) are admitted to a critical care unit, associated outcomes, and costs have not been delineated. We determined 30-day mortality, 30-day readmissions, and hospital costs associated with direct or delayed critical care unit admission.

Methods

In a population-based analysis, we compared HF patients who were admitted to critical care directly from the emergency department (direct), after initial ward admission (delayed), or never admitted to critical care during their hospital stay (ward-only).

Results

Among 178,997 HF patients (median age 80 [IQR 71-86] years, 49.6% men) 36,175 (20.2%) were admitted to critical care during their hospitalization (April 2003 to March 2018). Critical care patients were admitted directly from the emergency department (direct, 81.9%) or after initial ward admission (delayed, 18.1%). Multivariable-adjusted hazard ratios (HR) for all-cause 30-day mortality were: 1.69 for direct (95% confidence interval [CI]; 1.55, 1.84) and 4.92 for delayed (95% CI; 4.26, 5.68) critical care-admitted compared to ward-only patients. Multivariable-adjusted repeated events analysis demonstrated increased risk for all-cause 30-day readmission with both direct (HR 1.04, 95% CI; 1.01, 1.08, P = .013) and delayed critical care unit admissions (HR 1.20, 95% CI; 1.13, 1.28, P < .001). Median 30-day costs were $12,163 for direct admissions, $20,173 for delayed admissions, and $9,575 for ward-only patients (P < .001).

Conclusions

While critical care unit admission indicates increased risk of mortality and readmission at 30 days, those who experienced delayed critical care unit admission exhibited the highest risk of death and highest costs of care.

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 Disclosures: The authors have no conflicts of interest to declare.
 Funding: The Institute for Clinical Evaluative Sciences (ICES) is supported in part by a grant from the Ontario Ministry of Health and Long Term Care. The opinions, results and conclusions are those of the authors and no endorsement by the Ministry of Health and Long-Term Care or by the Institute for Clinical Evaluative Sciences is intended or should be inferred. Parts of this material are based on data and information compiled and provided by CIHI. However, the analyses, conclusions, opinions and statements expressed herein are those of the author, and not necessarily those of CIHI. This study was supported by a Foundation Grant from the Canadian Institutes of Health Research (grant # FDN 148446). Dr. Lee is the Ted Rogers Chair in Heart Function Outcomes, a Hospital Chair of the University Health Network at the University of Toronto. Dr. Austin is a Mid-Career investigator of the Heart and Stroke Foundation. Dr. Tu is a Tier 1 Canada Research Chair in Health Services Research and an Eaton Scholar of the Department of Medicine, University of Toronto. Parts of this report are based on Ontario Registrar General information on deaths, the original source of which is ServiceOntario. The views expressed therein are those of the author and do not necessarily reflect those of ORG or Ministry of Government Services.


© 2020  The Authors. Pubblicato da Elsevier Masson SAS. Tutti i diritti riservati.
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