Impact on 6-month outcomes of hospital trajectory in critically ill older patients: analysis of the ICE-CUB2 clinical trial
Sara Thietart, Ariane Boumendil, Dominique Pateron, Bertrand Guidet, Hélène Vallet, Bertrand Guidet, Dominique Pateron, Erwan Debuc, Youri Yordanov, Ariane Boumendil, Caroline Thomas, Didier Dreyfuss, Jean-Damien Ricard, Patrick Brun, Christophe Leroy, Yves Cohen, Frédéric Adnet, Maguy Woimant, Jean-Paul Mira, Benoît Doumenc, Khalil Tku, Thomas Similowski, Bruno Riou, Pierre Hausfater, Samuel Delerme, Jean-Pierre Quenot, Didier Honnart, Jean-François Timsit, Pierrick Guérin, Françoise Carpentier, Maxime Maignan, Foued Makhlou, Jean-François Poussel, Yohann Picard, François Braun, Pauline Trognon, François Fourrier, Patrick Goldstein, Marie Girot, Pierre Gosselin, Francesco Santoli, Pierre Charestan, Claire Poly, Hervé Mentec, Catherine Le Gall, Karima Sahraoui, Christophe Baillard, Nicolas Javaud, Benoît Misset, Maité Garrouste-Orgeas, Olivier Ganansia, François-Xavier Rooryck, Jean Luc Aim, Abudlrazak El Rifai, Jean Reignier, Laurent Martin-Lefevre, Philippe Fradin, Claire Mauriat, Emelyne Cwicklinski, Michel Slama, Hervé Dupont, Christine Ammirati, Justine Gallou, Muriel Fartoukh, Michel Djibre, Patrik Ray, Edwin Rouff, Bertrand Souweine, Ali Ait Hssain, Jeannot Schmidt, Daniel Pic, Farès Moustafa, Alain Mercat, Nicolas Lerolle, Pierre-Marie Roy, Frédéric Baud, Patrick Plaisance, Sophie Montagnon, Bertrand Galichon, Michel Wolff, Bruno Mourvillier, Enrique Casalino, Christophe Choquet, Julien Bernard, Gaëlle Juillien, Jean-Yves Fagon, Emmanuel Guerot, Philippe Juvin, Anabela Patzak, Bruno Verdière, Vincent Ioos, Marie-Clément Kouka, Audrey Berthoumieu, Christian Richard, Raphael Maurice, Sophie Sarnel, Stéphane Diez, Antoine Vieillard Baron, Sébastien Beaune, Julie Grenet
Abstract
BACKGROUND: Little is known about the impact of hospital trajectory on survival and functional decline of older critically ill patients. We evaluate 6-month outcomes after admission to: intensive care units (ICU), intermediate care units (IMCU) or acute medical wards (AMW). METHODS: Data from the randomised prospective multicentre clinical trial ICE-CUB2 was secondarily analysed. Inclusion criteria were: presenting at emergency departments in critical condition; age ≥ 75 years; activity of daily living (ADL) ≥ 4; preserved nutritional status; and no active cancer. A Cox model was fitted to compare survival according to admission destination adjusting for patient characteristics. Sensitivity analysis using multiple imputation for missing data and propensity score matching were performed. RESULTS: Among 3036 patients, 1675 (55%) were women; median age was 85 [81-99] years; simplified acute physiology score (SAPS-3) 62 [55-69]; 1448 (47%) were hospitalised in an ICU, 504 in IMCU (17%), and 1084 (36%) in AMW. Six-month mortality was 629 (44%), 155 (31%) and 489 (45%) after admission in an ICU, IMCU and AMW (p < 0.001), respectively. In multivariate analysis, AMW admission was associated with worse 6-month survival (HR 1.31, 95% CI 1.04-1.63) in comparison with IMCU admission, after adjusting for age, gender, comorbidities, ADL, SAPS-3 and diagnosis. Survival was not significantly different between patients admitted in an ICU and an IMCU (HR 1.17, 95% CI 0.95-1.46). Sensitivity analysis using multiple imputation for missing data and propensity score matching found similar results. Hospital destination was not significantly associated with the composite criterion loss of 1-point ADL or mortality. Physical and mental components of the 12-Item Short-Form Health Survey were significantly lower in the acute medical ward group (34.3 [27.5-41.7], p = 0.037 and 44.3 [38.6-48.6], p = 0.028, respectively) than in the ICU group (34.7 [28.4-45.3] and 45.5 [40.0-50.0], respectively) and IMCU group (35.7 [29.7-43.8] and 44.5 [39.7-48.4], respectively). CONCLUSIONS: Admission in an AMW was associated with worse 6-month survival in older critically ill patients in comparison with IMCU admission, with no difference of survival between ICU and IMCU admission. There were no clinically relevant differences in quality of life in each group. These results should be confirmed in specific studies and raise the question of dedicated geriatric IMCUs.