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Association Between Intensive Care Unit Usage and Long-Term Medication Adherence, Mortality, and Readmission Among Initially Stable Patients With Non-ST-Segment-Elevation Myocardial Infarction.

ABSTRACT: Background Hospitals in the United States vary in their use of intensive care units (ICUs) for hemodynamically stable patients with non-ST-segment-elevation myocardial infarction (NSTEMI). The association between ICU use and long-term outcomes after NSTEMI is unknown. Methods and Results Using data from the National Cardiovascular Data Registry linked to Medicare claims, we identified 65 256 NSTEMI patients aged ≥ 65 years without cardiogenic shock or cardiac arrest on presentation between 2011 and 2014. We compared 1-year medication non-adherence, cardiovascular readmission, and mortality across hospitals by ICU use using multivariable regression models. Among 520 hospitals, 154 (29.6%) were high ICU users (>70% of stable NSTEMI patients admitted to ICU), 270 (51.9%) were intermediate (30%-70%), and 196 (37.7%) were low (<30%). Compared with low ICU usage hospitals, no differences were observed in the risks of 1-year medication non-adherence (adjusted odds ratio 1.08, 95% CI, 0.97-1.21), mortality (adjusted hazard ratio 1.06, 95% CI, 0.98-1.15), and cardiovascular readmission (adjusted hazard ratio 0.99, 95% CI, 0.95-1.04) at high usage hospitals. Patients hospitalized at intermediate ICU usage hospitals had lower rates of evidence-based therapy and diagnostic catheterization within 24 hours of hospital arrival, and higher risks of 1-year mortality (adjusted hazard ratio 1.07, 95% CI, 1.02-1.12) and medication non-adherence (adjusted odds ratio 1.09, 95% CI, 1.02-1.15) compared with low ICU usage hospitals. Conclusions Routine ICU use is unlikely to be beneficial for hemodynamically stable NSTEMI patients; medication adherence, long-term mortality, and cardiovascular readmission did not differ for high ICU usage hospitals compared with hospitals with low ICU usage rates.

SUBMITTER: Fanaroff AC

PROVIDER: S-EPMC7335514 | biostudies-literature | 2020 Mar

REPOSITORIES: biostudies-literature

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Association Between Intensive Care Unit Usage and Long-Term Medication Adherence, Mortality, and Readmission Among Initially Stable Patients With Non-ST-Segment-Elevation Myocardial Infarction.

Fanaroff Alexander C AC Chen Anita Y AY van Diepen Sean S Peterson Eric D ED Wang Tracy Y TY

Journal of the American Heart Association 20200315 6

Background Hospitals in the United States vary in their use of intensive care units (ICUs) for hemodynamically stable patients with non-ST-segment-elevation myocardial infarction (NSTEMI). The association between ICU use and long-term outcomes after NSTEMI is unknown. Methods and Results Using data from the National Cardiovascular Data Registry linked to Medicare claims, we identified 65 256 NSTEMI patients aged ≥ 65 years without cardiogenic shock or cardiac arrest on presentation between 2011 ...[more]

PMID: 32174210

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Project description:ImportanceIntensive care unit (ICU) utilization may have important implications for the care and outcomes of patients with non-ST-segment elevation myocardial infarction (NSTEMI).ObjectivesTo examine interhospital variation in ICU utilization in the United States for older adults with hemodynamically stable NSTEMI and outcomes associated with ICU utilization among patients with low, moderate, or high mortality risk.Design, setting, and participantsThis study was a retrospective analysis of 28 018 Medicare patients 65 years or older admitted with NSTEMI to 346 hospitals participating in the Acute Coronary Treatment and Intervention Outcomes Network (ACTION)-Get With the Guidelines from April 1, 2011, through December 31, 2012. Patients with cardiogenic shock or cardiac arrest on presentation were excluded. Data analysis was performed from May 7 through October 8, 2015.ExposuresHospitals with high (>70% of patients with NSTEMI treated in an ICU during the index hospitalization), intermediate (30%-70%), or low (<30%) ICU utilization.Main outcomes and measuresThirty-day mortality.ResultsOf 28 018 patients with NSTEMI 65 years or older (median age, 77 years [interquartile range, 71-84 years]; female, 13 055 [46.6%]; nonwhite race, 3931 [14.0%]), 11 934 (42.6%) had an ICU stay. The proportion of patients with NSTEMI treated in the ICU varied across hospitals (median, 38%; interquartile range, 26%-54%), but no significant differences were found in hospital or patient characteristics among high, intermediate, or low ICU utilization hospitals. Compared with high ICU utilization hospitals, low or intermediate ICU utilization hospitals were only marginally more selective of higher-risk patients, as determined by ACTION in-hospital mortality risk score or initial troponin level. The median ACTION risk score for patients treated in the ICU at low and intermediate ICU utilization hospitals was 34 compared with 33 for patients not treated in the ICU; at high ICU utilization hospitals, the median ACTION mortality risk score was 33 for patients treated in the ICU and 34 for patients not treated in the ICU. Thirty-day mortality rates did not significantly differ based on hospital ICU utilization (high vs low: 8.7% vs 8.7%; adjusted odds ratio, 0.91; 95% CI, 0.76-1.08; intermediate vs low: 9.6% vs 8.7%; adjusted odds ratio, 1.06; 95% CI, 0.94-1.20). The association between hospital ICU utilization and mortality did not change when considered among patients with ACTION risk scores greater than 40, 30 to 40, and less than 30 (adjusted interaction P = .86).Conclusions and relevanceUtilization of the ICU for older patients with NSTEMI varied significantly among hospitals. This variability was not explained by hospital characteristics or driven by patient risk. Mortality after myocardial infarction did not significantly differ among high, intermediate, or low ICU utilization hospitals.

Dataset Information

Association Between Intensive Care Unit Usage and Long-Term Medication Adherence, Mortality, and Readmission Among Initially Stable Patients With Non-ST-Segment-Elevation Myocardial Infarction.

Publications

Association Between Intensive Care Unit Usage and Long-Term Medication Adherence, Mortality, and Readmission Among Initially Stable Patients With Non-ST-Segment-Elevation Myocardial Infarction.

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