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.

中文翻译：

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对重症老年患者住院轨迹 6 个月结果的影响：ICE-CUB2 临床试验分析

背景

关于医院轨迹对老年危重患者生存和功能衰退的影响知之甚少。我们评估入院后 6 个月的结果：重症监护病房 (ICU)、中级监护病房 (IMCU) 或急性内科病房 (AMW)。

方法

对随机前瞻性多中心临床试验 ICE-CUB2 的数据进行了二次分析。纳入标准是：在紧急情况下出现在急诊室；年龄≥75岁；日常生活活动（ADL）≥4；保持营养状况；并且没有活动性癌症。根据针对患者特征调整的入院目的地，拟合 Cox 模型以比较生存率。对缺失数据和倾向评分匹配进行了使用多重插补的敏感性分析。

结果

在 3036 名患者中，1675 名（55%）为女性；中位年龄为 85 [81-99] 岁；简化急性生理评分 (SAPS-3) 62 [55–69]；1448 人（47%）在 ICU 住院，504 人在 IMCU 住院（17%），1084 人（36%）在 AMW 住院。入住 ICU、IMCU 和 AMW 后的 6 个月死亡率分别为 629（44%）、155（31%）和 489（45%）（p < 0.001)，分别。在多变量分析中，在调整年龄、性别、合并症、ADL、SAPS-3 和诊断后，与 IMCU 入院相比，AMW 入院与更差的 6 个月生存率相关（HR 1.31, 95% CI 1.04-1.63）。入住 ICU 和 IMCU 的患者的生存率没有显着差异（HR 1.17, 95% CI 0.95–1.46）。对缺失数据和倾向得分匹配使用多重插补的敏感性分析发现了相似的结果。医院目的地与 1 分 ADL 或死亡率的复合标准损失没有显着相关性。12 项简短健康调查的身体和精神成分在急性病房组中显着降低（34.3 [27.5–41.7]，p  = 0.037 和 44.3 [38.6–48.6]，p = 0.028，分别比 ICU 组（分别为 34.7 [28.4-45.3] 和 45.5 [40.0-50.0]）和 IMCU 组（分别为 35.7 [29.7-43.8] 和 44.5 [39.7-48.4]）。

结论

与 IMCU 入院相比，AMW 入院与老年重症患者的 6 个月生存率较差相关，ICU 和 IMCU 入院之间的生存率没有差异。各组的生活质量没有临床相关的差异。这些结果应在具体研究中得到证实，并提出专用老年 IMCU 的问题。