Despite a sizable financial disadvantage, ST-segment elevation MI (STEMI) patients who could be treated effectively in an intensive or non-intensive care unit fare better in the ICU, according to research published June 4 in The BMJ.
Right now, three-quarters of STEMI patients in the U.S. are admitted to an intensive or coronary care unit, first author Thomas S. Valley, MD, of the University of Michigan, and colleagues wrote in the journal, typically after receiving reperfusion treatment. And that has significant economic implications—ICU admissions are on average 2.5 times pricier than non-ICU admissions, and critical care services in the U.S. now account for nearly 1% of the country’s total gross domestic product.
Valley and co-authors said it’s unknown whether ICU admission is necessary for all STEMI patients, especially since CV innovations over the past two decades have inflated STEMI survival by almost 20%. It doesn’t help that clinical guidelines on the subject contradict one another, either. European guidelines recommend all STEMI patients be admitted to the ICU, while more lax American guidelines suggest lower-risk patients might not need ICU-level care.
“This uncertainty is reflected in practice,” Valley and colleagues wrote. “Wide variation exists among hospitals in the use of ICUs for STEMI, both in the U.S. and worldwide.”
The researchers’ study focused on the situation stateside, pulling data from 109,375 STEMI patients admitted to 1,727 acute care hospitals across the U.S. between January 2014 and October 2015. Valley et al. tracked 30-day mortality rates in the patients, all Medicare beneficiaries aged 65 and up.
The team found hospitals in the top quarter of ICU admission rates in the country admitted at least 85% of STEMI patients to an ICU. Those who received ICU care solely because they were closest to a hospital in the top quarter of ICU admission rates—also known as marginal patients—saw lower 30-day mortality than non-ICU patients (an absolute survival benefit of 6.1%).
“Clinically, these patients likely have borderline or discretionary ICU needs,” Valley and co-authors wrote. “In other words, they may be admitted to an ICU in some but not all hospitals because clinicians may disagree about the optimal location of care. Thus, the borderline patients in this study represent a group of patients for whom there is clinical equipoise and unwarranted variation that exists in care.”
In a separate analysis of patients with non-STEMI—a group that historically hasn’t benefited from routine ICU care—ICU admission wasn’t associated with any significant difference in mortality (an absolute increase of 1.3%), the authors said.
Valley et al. said marginal patients might benefit from ICU admission in part due to the unit’s enhanced nursing care, which means patients are watched more closely and monitored for early detection of complications or decompensation. They said their results could also reflect the “growing complexity of STEMI patients,” who increasingly present to hospitals with additional, non-cardiac complications.
The authors said that moving forward, it will be important to develop methods to separate STEMI patients who might benefit from ICU care from those who likely wouldn’t, especially because of the costly implications for healthcare systems and patients themselves.
“Conventional wisdom in the U.S. suggests that ICU care is generally overused and that efforts must be made to reduce the number of patients receiving ICU care,” they wrote. “However, this study, in combination with others, indicates instead that ICU care may often be misdirected, with some patients experiencing underuse while others experience overuse.”