Intensive care unit versus high-dependency care unit for mechanically ventilated patients with pneumonia: a nationwide comparative effectiveness study

Hiroyuki Ohbe,Yusuke Sasabuchi,Hayato Yamana,Hiroki Matsui,Hideo Yasunaga

doi:10.1016/j.lanwpc.2021.100185

Abstract

BackgroundMany mechanically ventilated patients in Japan are treated in high-dependency care units (HDUs) rather than intensive care units (ICUs). HDUs can provide intermediate-level care with reduced costs; however, there is limited evidence on whether mechanically ventilated patients should be treated in the ICU or HDU. MethodsThis was a comparative effectiveness study using a nationwide administrative database in Japan. We identified mechanically ventilated patients with pneumonia in ICU or HDU on the day of admission in the Japanese Diagnosis Procedure Combination inpatient database from April 2014 to March 2019. The primary outcome was 30-day in-hospital mortality. Propensity score matching analysis was performed to compare this outcome between patients treated in the ICU and HDU. The robustness of the analyses was evaluated with multivariable regression, overlap weighting, and instrumental variable analyses. FindingsOf 14,859 mechanically ventilated patients with pneumonia, 7,528 (51%) were treated in the ICU and 7,331 (49%) were treated in the HDU. After propensity score matching, patients treated in the ICU had significantly lower 30-day in-hospital mortality than did those treated in the HDU (24.0% vs. 31.2%; difference, −7.2%; 95% confidence interval, −10.0% to −4.4%). The multivariable regression, overlap weighting, and instrumental variable analyses showed a similar direction and magnitude of association. InterpretationCritical care for mechanically ventilated patients with pneumonia in the ICU was associated with a 7.2% decrease in 30-day in-hospital mortality vs. care in the HDU. Residual confounding may still play a role in the effect estimates. FundingThis study received funding from Ministry of Health, Labour and Welfare, Japan, and Ministry of Education, Culture, Sports, Science and Technology, Japan.

Highlights

Intensive care units (ICUs) are a limited and expensive resource
A total of 14,859 mechanically ventilated patients with pneumonia who were admitted to 689 hospitals with ICU and/or High-dependency care units (HDUs) beds were enrolled during the five years study period
Of the 14,859 patients in the 689 hospitals with ICU and/or HDU beds, 1,617 patients were in 159 hospitals with only ICU beds, and 1,683 patients were in 169 hospitals with only HDU beds; in the 361 hospitals with both ICU beds and HDU beds, 5,911 patients were treated in the ICU, and 5,648 were treated in the HDU

Summary

Introduction

Intensive care units (ICUs) are a limited and expensive resource. Appropriate utilization of ICU beds is essential but complex and difficult to achieve.[1] High-dependency care units (HDUs), called “intermediate care units” or “step-down units,” are areas where patient care levels and costs are between the levels found in the ICU and in the general ward.[1, 2, 3] HDUs may be used in different ways in the continuum of inpatient critical care, and, worldwide, HDUs are increasing widely to optimize critical care resource allocation.[2, 3, 4, 5, 6]. Many mechanically ventilated patients in Japan are treated in high-dependency care units (HDUs) rather than intensive care units (ICUs). HDUs can provide intermediate-level care with reduced costs; there is limited evidence on whether mechanically ventilated patients should be treated in the ICU or HDU

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Results

Conclusion