Grieve, R; O'Neill, S; Basu, A; Keele, L; Rowan, KM; Harris, S; (2019) Analysis of Benefit of Intensive Care Unit Transfer for Deteriorating Ward Patients: A Patient-Centered Approach to Clinical Evaluation. JAMA Network Open , 2 (2) , Article e187704. 10.1001/jamanetworkopen.2018.7704.

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Abstract

Importance It is unknown which deteriorating ward patients benefit from intensive care unit (ICU) transfer. Objectives To use an instrumental variable (IV) method that assesses heterogeneity and to evaluate estimates of person-centered treatment effects of ICU transfer and 28-day hospital mortality by age and illness severity. Design, Setting, and Participants An analysis of a prospective cohort study from November 1, 2010, to December 31, 2011. The dates of this analysis were June 1, 2017, to June 30, 2018. The setting was a multicenter study of 49 UK National Health Service hospitals. Participants were 9192 deteriorating ward patients assessed for ICU transfer (4596 matched pairs). The study matched on baseline characteristics to strengthen the IV and to balance observed confounders between the comparison groups. Exposures Transfer to the ICU or continued care on general wards. Main Outcomes and Measures Mortality at 28 days (primary outcome) and 90 days. To address unobserved confounding, ICU bed availability was the IV for whether or not a patient was transferred. The study used the IV approach to evaluate estimates of treatment effect of ICU transfer and mortality according to age and physiological severity alone and in combination. Results Both comparison groups included 4596 patients. In the group assessed with “many” ICU beds available (median, 7), 52.8% were male, and the mean (SD) age was 65.2 (17.7) years; in the group assessed with “few” ICU beds available (median, 2), 53.3% were male, and the mean (SD) age was 65.0 (17.3) years. The overall 28-day mortality estimates were 23.2% (2090 predicted deaths) if all of the matched patients were transferred vs 28.1% (2534 predicted deaths) if none of the matched patients were transferred, an estimated risk difference of −4.9% (95% CI, −26.4% to 16.6%). The estimated effects of ICU transfer differed by age and by physiological severity according to the National Early Warning Score (NEWS): the absolute risk differences in 28-day mortality after ICU transfer ranged from 7.7% (95% CI, −5.5% to 21.0%) for ages 18 to 23 years to −5.0% (95% CI -26.5% to 16.6%) for age 78 to 83 years and ranged from 3.7% (95% CI, −12.1% to 19.5%) for NEWS of 0 to −25.4% (95% CI, −50.6% to −0.2%) for NEWS of 19. The absolute risk differences for elderly patients (≥75 years) were −11.6% (95% CI, −39.0% to 15.8%) for those with high NEWS (>6), −4.8% (95% CI, −30.5% to 20.9%) for those with moderate NEWS (5-6), and −1.0% (95% CI, −24.8% to 22.8%) for those with low NEWS (<5). The corresponding estimates for subgroups of younger patients (<75 years) were −8.4% (95% CI, −31.0% to 14.1%), −2.1% (95% CI, −21.1% to 16.9%), and 1.4% (95% CI, −14.5% to 17.4%). Conclusions and Relevance This study using a this person-centered IV approach found that the benefits of ICU care may increase among patients at high levels of baseline physiological severity across different age groups, especially among elderly patients.

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