ICU Care Differences Reflect Extremes of Bed Availability

Patients who receive services in intensive care units (ICUs) fare differently in the United States than in the United Kingdom, according to a new study.

Researchers at Columbia University (New York, NY, USA) analyzed all medical admissions to ICUs from 2002 to 2004 from Project IMPACT (PI) in the US, and the Case Mix Program (CMP) in the UK, both large prospective datasets abstracted from clinical records of voluntarily participating ICUs. They then compared admission and mortality statistics from ICUs in each country, merging datasets and using variables that were confirmed to be defined similarly in both countries. The researchers excluded surgical admissions, patients younger than 16 years, and readmissions to the ICU during the same hospital stay, and calculated the relative degree of illness of patients, length of stay, and hospital mortality and discharge status.

The results showed that UK admissions were less likely to be admitted directly from the emergency room (ER), had longer hospital stays before ICU admission, and fewer were older than 85 years old. UK patients were more frequently mechanically ventilated within 24 hours after ICU admission, were sicker, and had higher primary hospital mortality. There was no mortality difference for mechanically ventilated patients admitted from the ER. Comparisons of hospital mortality were confounded by differences in case mix, hospital length of stay (UK median of 10 days compared to only 6 in the US), and discharge practices, with more US patients discharged to skilled care facilities (29% of survivors compared to 6% in the UK). The study was published early online on March 25, 2011, in the American Journal of Respiratory and Critical Care Medicine.

"The US has about seven times as many ICU beds available per capita than the UK; We wanted to compare the two because they represent extremes of ICU availability in developed countries,” said lead author, Hannah Wunsch, MD, an assistant professor of anesthesiology and epidemiology at Columbia University. "The US and the UK have very different discharge patterns, and the trend in the US has been to shorten hospital length of stay and discharge people earlier to other types of facilities.”

"If you look at hospital length-of-stay information it looks like the US is very efficient, but many of these patients are actually going to a skilled care facility where the mortality is a lot higher than among those who go home,” added Dr. Wunsch. "The effect is that for studies of ICU patients, there is a fair amount of mortality that occurs after intensive care that is outside of the hospital. This practice makes it hard to compare US hospital mortality to other countries that tend to keep people in the hospital until they either die or are able to go home.”

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