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Hospitals with the highest intensive care utilization provide lower quality pneumonia care to the elderly.

ABSTRACT: Quality of care for patients admitted with pneumonia varies across hospitals, but causes of this variation are poorly understood. Whether hospitals with high ICU utilization for patients with pneumonia provide better quality care is unknown. We sought to investigate the relationship between a hospital's ICU admission rate for elderly patients with pneumonia and the quality of care it provided to patients with pneumonia.Retrospective cohort study.Two thousand eight hundred twelve U.S. hospitals.Elderly (age?65 years) fee-for-service Medicare beneficiaries with either a (1) principal diagnosis of pneumonia or (2) principal diagnosis of sepsis or respiratory failure and secondary diagnosis of pneumonia in 2008.None.We grouped hospitals into quintiles based on ICU admission rates for pneumonia. We compared rates of failure to deliver pneumonia processes of care (calculated as 100-adherence rate), 30-day mortality, hospital readmissions, and Medicare spending across hospital quintile. After controlling for other hospital characteristics, hospitals in the highest quintile more often failed to deliver pneumonia process measures, including appropriate initial antibiotics (13.0% vs 10.7%; p<0.001), and pneumococcal vaccination (15.0% vs 13.3%; p=0.03) compared with hospitals in quintiles 1-4. Hospitals in the highest quintile of ICU admission rate for pneumonia also had higher 30-day mortality, 30-day hospital readmission rates, and hospital spending per patient than other hospitals.Quality of care was lower among hospitals with the highest rates of ICU admission for elderly patients with pneumonia; such hospitals were less likely to deliver pneumonia processes of care and had worse outcomes for patients with pneumonia. High pneumonia-specific ICU admission rates for elderly patients identify a group of hospitals that may deliver inefficient and poor-quality pneumonia care and may benefit from interventions to improve care delivery.

SUBMITTER: Sjoding MW

PROVIDER: S-EPMC4769869 | biostudies-literature | 2015 Jun

REPOSITORIES: biostudies-literature

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Hospitals with the highest intensive care utilization provide lower quality pneumonia care to the elderly.

Sjoding Michael W MW Prescott Hallie C HC Wunsch Hannah H Iwashyna Theodore J TJ Cooke Colin R CR

Critical care medicine 20150601 6

<h4>Objective</h4>Quality of care for patients admitted with pneumonia varies across hospitals, but causes of this variation are poorly understood. Whether hospitals with high ICU utilization for patients with pneumonia provide better quality care is unknown. We sought to investigate the relationship between a hospital's ICU admission rate for elderly patients with pneumonia and the quality of care it provided to patients with pneumonia.<h4>Design</h4>Retrospective cohort study.<h4>Setting</h4>T ...[more]

PMID: 25760660

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Project description:BackgroundDemographic change concurrent with medical progress leads to an increasing number of elderly patients in intensive care units (ICUs). Antibacterial treatment is an important, often life-saving, aspect of intensive care but burdened by the associated antimicrobial resistance risk. Elderly patients are simultaneously at greater risk of infections and may be more restrictively treated because, generally, treatment intensity declines with age. We therefore described utilization of antibacterials in ICU patients older and younger than 80 years and examined differences in the intensity of antibacterial therapy between both groups.MethodsWe analysed 17,464 valid admissions from the electronic patient data management system of our surgical ICU from April 2006 - October 2013. Antibacterial treatment rates were defined as days of treatment (exposed patient days) relative to patient days of ICU stay and calculated for old and young patients. Rates were compared in zero-inflated Poisson regression models adjusted for patients' sex, mean SAPS II- and TISS-scores, and calendar years yielding adjusted rate ratios (aRRs). Rate ratios exceeding 1 represent higher rates in old patients reflecting greater treatment intensity in old compared to younger patients.ResultsObserved antibacterial treatment rates were lower in patients 80 years and older compared to younger patients (30.97 and 39.73 exposed patient days per 100 patient days in the ICU, respectively). No difference in treatment intensity, however, was found from zero-inflated Poisson regression models permitting more adequate consideration of patient days with low treatment probability: for all antibacterials the adjusted rate ratio (aRR) was 1.02 (95%CI: 0.98-1.07). Treatment intensities were higher in elderly patients for penicillins (aRR 1.37 (95%CI: 1.26-1.48)), cephalosporins (aRR 1.20 (95%CI: 1.09-1.31)), carbapenems (aRR 1.35 (95%CI: 1.20-1.50)), fluoroquinolones (aRR 1.17 (95%CI: 1.05-1.30), and imidazoles (aRR 1.34 (95%CI: 1.23-1.46)).ConclusionsElderly patients were generally less likely to be treated with antibacterials. This observation, however, did not persist in patients with comparable treatment probability. In these, antibacterial treatment intensity did not differ between younger and older ICU patients, for some antibacterial classes treatment intensity was even higher in the latter. Patient-level covariates are instrumental for a nuanced evaluation of age-effects in antibacterial treatment in the ICU.

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Hospitals with the highest intensive care utilization provide lower quality pneumonia care to the elderly.

Publications

Hospitals with the highest intensive care utilization provide lower quality pneumonia care to the elderly.

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