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Original Research: Pulmonary Vascular Disease |

Hospital-Level Variation in ICU Admission and Critical Care Procedures for Patients Hospitalized for Pulmonary EmbolismVariation in ICU Use for Pulmonary Embolism

Andrew J. Admon, MD, MPH; Christopher W. Seymour, MD; Hayley B. Gershengorn, MD; Hannah Wunsch, MD; Colin R. Cooke, MD
Author and Funding Information

From the Department of Internal Medicine (Drs Admon and Cooke), the Division of Pulmonary and Critical Care Medicine (Dr Cooke), and the Center for Healthcare Outcomes and Policy (Dr Cooke), University of Michigan, Ann Arbor, MI; the Department of Critical Care (Dr Seymour), the Department of Emergency Medicine (Dr Seymour), and the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center (Dr Seymour), University of Pittsburgh, Pittsburgh, PA; the Division of Critical Care Medicine (Dr Gershengorn), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; and the Department of Anesthesiology (Dr Wunsch) and the Department of Epidemiology (Dr Wunsch), Columbia University, New York, NY.

CORRESPONDENCE TO: Colin R. Cooke, MD, University of Michigan, Center for Healthcare Outcomes and Policy, 2800 Plymouth Rd, Bldg 16, Rm 127W, Ann Arbor, MI 48109; e-mail: cookecr@umich.edu


FUNDING/SUPPORT: This work was supported in part by the Agency for Healthcare Research and Quality [Grant K08HS020672, Dr Cooke], the National Institutes of Health [Grant K23GM104022, Dr Seymour], and the National Institute on Aging [Grant K08AG038477, Dr Wunsch].

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;146(6):1452-1461. doi:10.1378/chest.14-0059
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BACKGROUND:  Variation in the use of ICUs for low-risk conditions contributes to health system inefficiency. We sought to examine the relationship between ICU use for patients with pulmonary embolism (PE) and cost, mortality, readmission, and procedure use.

METHODS:  We performed a retrospective cohort study including 61,249 adults with PE discharged from 263 hospitals in three states between 2007 and 2010. We generated hospital-specific ICU admission rate quartiles and used a series of multilevel models to evaluate relationships between admission rates and risk-adjusted in-hospital mortality, readmission, and costs and between ICU admission rates and several critical care procedures.

RESULTS:  Hospital quartiles varied in unadjusted ICU admission rates for PE (range, ≤ 15% to > 31%). Among all patients, there was a small trend toward increased use of arterial catheterization (0.6%-1.1%, P < .01) in hospital quartiles with higher levels of ICU admission. However, use of invasive mechanical ventilation (14.4%-7.9%, P < .01), noninvasive ventilation (6.6%-3.0%, P < .01), central venous catheterization (14.6%-11.3%, P < .02), and thrombolytics (11.0%-4.7%, P < .01) in patients in the ICU declined across hospital quartiles. There was no relationship between ICU admission rate and risk-adjusted hospital mortality, costs, or readmission.

CONCLUSIONS:  Hospitals vary widely in ICU admission rates for acute PE without a detectable impact on mortality, cost, or readmission. Patients admitted to ICUs in higher-using hospitals received many critical care procedures less often, suggesting that these patients may have had weaker indications for ICU admission. Hospitals with greater ICU admission may be appropriate targets for improving efficiency in ICU admissions.

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