Hospital ICU care found to be overused, according to study

Intensive care units (ICUs) may be used too often for patients who do not require the costly and invasive level of care provided there, according to a new study published online in theJournal of the American Medical Association Internal Medicine.

Researchers from the University of California Los Angeles (UCLA) and the Los Angeles Biomedical Institute conducted this study in 808 patients admitted to the ICU from July 1, 2015 through June 15, 2016. They categorized patients according to Society of Critical Care Medicine (SCCM) guidelines as priority 1 through priority 4. Patients who needed close monitoring but otherwise required care available outside of the ICU were categorized as priority 2, and those with a limited life expectancy or poor prospects for functional recovery as category 3.

In all, 48.9% of patients were considered priority 1, 23.4% priority 2, 20.9% priority 3, and 8.8% were priority 4.

“Our study found over 50% of patients admitted to the ICU were categorized into groups suggesting that they were potentially either too well or too sick to benefit from ICU care or could have received equivalent care in non-ICU settings,” said researcher Dong W. Chang, MD, MS, Los Angeles Biomedical Institute. “This research indicates that ICU care is inefficient because it is devoting substantial resources to patients who are less likely to benefit from this level of care. These findings are a concern for patients, providers, and the health care system because ICU care is frequently invasive and comes at a substantial cost.”

In patients categorized as priority 1, ICU mortality rates were 13.4% compared with 19.6% for hospital rates; in priority 2 patients, they were 4.2% and 10.6%, respectively; priority 3, 47.3% vs 61.9%; and priority 4, 2.8% and 7.0%.

In all, 56.0% of priority 1 and 62.4% of priority 2 patients were discharged compared with 6.0% of priority 3 patients.

Dr. Chang and fellow researchers calculated the lengths of stay for each ICU patient and found that almost 65% of these days were allocated to care considered discretionary monitoring, with a low likelihood of benefit despite critical illness, or care that should have been manageable in a non-ICU setting. Of 3,794 patients-days, 35.2% were given priority 1, 25.3% priority 2, 27.5% priority 3, 3.3% priority 4, and 8.7% priority 5.

“While this is a study of just one hospital and results may differ at other medical centers, we suspect that these characteristics of ICU utilization are commonplace and prevalent in many institutions,” said Dr. Chang.

In other facilities, ICU care may be appropriate in light of the absence of other appropriate levels of care outside the ICU, noted Dr. Chang and fellow researchers.

“However, there is likely to be a subset of patients in which ICU care leads to unwanted, invasive care without significant clinical benefit. Refining our ability to identify these patients and developing approaches to improve ICU utilization for those patients are important steps to assure the best care for patients and the most efficient use of the healthcare system’s limited resources,” he concluded.