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Hospitals With the Highest Intensive Care Utilization Provide Lower Quality Pneumonia Care to the Elderly*

Sjoding, Michael W. MD1; Prescott, Hallie C. MD, MSc1; Wunsch, Hannah MD, MSc2,3; Iwashyna, Theodore J. MD, PhD1,4,5; Cooke, Colin R. MD, MSc, MS1,6

doi: 10.1097/CCM.0000000000000925
Clinical Investigations

Objective: Quality of care for patients admitted with pneumonia varies across hospitals, but causes of this variation are poorly understood. Whether hospitals with high ICU utilization for patients with pneumonia provide better quality care is unknown. We sought to investigate the relationship between a hospital’s ICU admission rate for elderly patients with pneumonia and the quality of care it provided to patients with pneumonia.

Design: Retrospective cohort study.

Setting: Two thousand eight hundred twelve U.S. hospitals.

Patients: Elderly (age ≥ 65 years) fee-for-service Medicare beneficiaries with either a (1) principal diagnosis of pneumonia or (2) principal diagnosis of sepsis or respiratory failure and secondary diagnosis of pneumonia in 2008.

Interventions: None.

Measurements and Main Results: We grouped hospitals into quintiles based on ICU admission rates for pneumonia. We compared rates of failure to deliver pneumonia processes of care (calculated as 100 – adherence rate), 30-day mortality, hospital readmissions, and Medicare spending across hospital quintile. After controlling for other hospital characteristics, hospitals in the highest quintile more often failed to deliver pneumonia process measures, including appropriate initial antibiotics (13.0% vs 10.7%; p < 0.001), and pneumococcal vaccination (15.0% vs 13.3%; p = 0.03) compared with hospitals in quintiles 1–4. Hospitals in the highest quintile of ICU admission rate for pneumonia also had higher 30-day mortality, 30-day hospital readmission rates, and hospital spending per patient than other hospitals.

Conclusions: Quality of care was lower among hospitals with the highest rates of ICU admission for elderly patients with pneumonia; such hospitals were less likely to deliver pneumonia processes of care and had worse outcomes for patients with pneumonia. High pneumonia-specific ICU admission rates for elderly patients identify a group of hospitals that may deliver inefficient and poor-quality pneumonia care and may benefit from interventions to improve care delivery.

1The Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI.

2Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.

3Department of Anesthesia, University of Toronto, Toronto, ON, Canada.

4VA Center for Clinical Management Research, Ann Arbor, MI.

5Institute for Social Research, Ann Arbor, MI.

6Center for Healthcare Outcomes and Policy, Institute for Healthcare Innovation and Policy, University of Michigan, Ann Arbor, MI.

* See also p. 1329.

Drs. Sjoding and Cooke contributed to the study design, analysis and interpretation of data, writing and revising the article and approval of the final article. Drs. Prescott, Wunch, and Iwashyna contributed to the analysis and interpretation of data, revising the article for important intellectual content and approval of the final article.

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Drs. Sjoding and Prescott received support for article research from the National Institutes of Health (NIH). Dr. Sjoding and Prescott and their institution received grant support from the NIH T32HL007749 Training Grant. Dr. Wunsch received grant support from NIH (K08AG038477) and from the CIHR and received support for article research from the NIH. Dr. Iwashyna received support for article research from the Department of Veterans Affairs Health Services Research and Development Services—IIR 11–109, National Institutes of Health R21AG044752 and disclosed government work. Dr. Cooke received support for article research from the NIH. His institution received grant support from the Agency for Healthcare Research and Quality (K08HS020672).

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