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Medical ICU Admission Diagnoses and Outcomes in Human Immunodeficiency VirusInfected and VirusUninfected Veterans in the Combination Antiretroviral Era*

Akgün, Kathleen M. MD1,2; Tate, Janet P. ScD, MPH1,2; Pisani, Margaret MD, MPH2; Fried, Terri MD2,3; Butt, Adeel A. MD, MS4,5; Gibert, Cynthia L. MD, MSc6; Huang, Laurence MD7; Rodriguez-Barradas, Maria C. MD8; Rimland, David MD9; Justice, Amy C. MD, PhD1,2; Crothers, Kristina MD10

Critical Care Medicine:
doi: 10.1097/CCM.0b013e31827caa46
Clinical Investigations
Abstract

Objectives: Human immunodeficiency virus (HIV)–infected (HIV+) patients on combination antiretroviral therapy are living longer but have increased risk for aging-associated disease which may lead to increasing critical care requirements. We compare medical ICU admission characteristics and outcomes among HIV infected and demographically similar uninfected patients (uninfected) and considered whether an index which combines routine clinical biomarkers (the Veterans Aging Cohort Study Index) predicts 30-day medical ICU mortality.

Design: Observational data analyses (Veterans Aging Cohort Study).

Setting: Eight Veterans Affairs medical centers nationwide.

Patients: HIV infected and uninfected with a medical ICU admission between 2002 and 2010.

Intervention: None.

Measurements and Main Results: Medical ICU admission was determined using bedsection (Veterans Affairs) and revenue center codes (Medicare). For Veterans Affairs admissions, we used clinical data to calculate Veterans Aging Cohort Study Index scores and multivariable logistic regression to determine factors associated with 30-day mortality. Overall, 539 of 3,620 (15%) HIV infected and 375 of 3,639 (10%) uninfected had a medical ICU admission; 72% and 78%, respectively, were Veterans Affairs based. HIV+ patients were younger at admission (p < 0.0001). Although most HIV+ patients were on antiretroviral therapy (71%) with undetectable HIV-1 RNA (54%), compared with uninfected they were more commonly admitted with respiratory diagnoses or infections (21% vs. 12%), were more likely to require mechanical ventilation (17% vs. 9%; p = 0.001), and had a higher mortality rate (18.6% vs. 11.2%, p = 0.003). Cardiovascular diagnoses were less common among HIV infected (18% vs. 29%; p < 0.0001). In logistic regression (c-statistic 0.87), a 5-point increment in Veterans Aging Cohort Study Index was associated with an odds ratio of death of 1.22 (95% confidence interval 1.14–1.30) among HIV infected and of 1.50 (95% confidence interval 1.29–1.76) among uninfected; infection/sepsis and respiratory diagnoses were also associated with mortality.

Conclusions: Medical ICU admission was frequent, 30-day mortality higher, and mechanical ventilation more common in HIV infected compared with uninfected. The Veterans Aging Cohort Study Index calculated at medical ICU admission predicted 30-day mortality for HIV infected and uninfected. As more individuals age with HIV, their requirements for medical ICU care may be greater than demographically similar uninfected individuals.

Author Information

1 Department of Internal Medicine, VA Connecticut Healthcare System, West Haven, CT.

2 Department of Internal Medicine, Yale University School of Medicine, New Haven, CT.

3 Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, CT.

4 Department of Medicine, University of Pittsburgh School of Medicine and VA Pittsburgh Healthcare System, Pittsburgh, PA.

5 Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates.

6 Department of Medicine, VAMC & George Washington University, Washington, DC.

7 Department of Medicine, University of California, San Francisco, CA.

8 Infectious Diseases Section, Michael E. De Bakey VAMC and Department of Medicine, Baylor College of Medicine, Houston, TX.

9 Department of Medicine, Atlanta VA & Emory University, Decatur, GA.

10 Department of Medicine, University of Washington School of Medicine, Seattle, WA.

*See also p. 1579.

This work was completed at VA Connecticut West Haven campus, West Haven, CT, and Yale University School of Medicine, New Haven, CT.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).

Supported, in part, by Association of Subspecialty Physicians and CHEST Foundation of the American College of Chest Physicians T. Franklin Williams Award (KMA); National Institutes of Health, National Heart, Lung, and Blood Institute K24 HL087713 (LH); National Institute on Alcohol Abuse and Alcoholism 5U01AA013566-05 (AJ); and National Institutes of Health, National Heart, Lung, and Blood Institute R01 HL090342 (KC).

Drs. Akgün, Tate, Gibert, Huang, Rodriguez-Barradas, Rimland, Justice, and Crothers received grant support from the National Institutes of Health. Dr. Akgün received grant support from ASP-ACCP (T Franklin Williams Award). Dr. Butt received grant support from Merck. Dr. Rodriguez-Barradas received support for travel from NIH. Dr. Butt lectured for Gilead. Dr. Crothers received educational presentation funding from ATS.

The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: kathleen.akgun@yale.edu

© 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins