Impact on 6-month outcomes of hospital trajectory in critically ill older patients: analysis of the ICE-CUB2 clinical trial
Authors: Thietart Sara , Boumendil Ariane , Pateron Dominique , Guidet Bertrand , Vallet Hélène ,   the ICE-CUB2 Study Network, Guidet Bertrand , Pateron Dominique , Debuc Erwan , Yordanov Youri , Boumendil Ariane , Thomas Caroline , Dreyfuss Didier , Ricard Jean-Damien , Brun Patrick , Leroy Christophe , Cohen Yves , Adnet Frédéric , Woimant Maguy , Mira Jean-Paul , Doumenc Benoît , Tku Khalil , Similowski Thomas , Riou Bruno , Hausfater Pierre , Delerme Samuel , Quenot Jean-Pierre , Honnart Didier , Timsit Jean-François , Guérin Pierrick , Carpentier Françoise , Maignan Maxime , Makhlou Foued , Poussel Jean-François , Picard Yohann , Braun François , Trognon Pauline , Fourrier François , Goldstein Patrick , Girot Marie , Gosselin Pierre , Santoli Francesco , Charestan Pierre , Poly Claire , Mentec Hervé , Le Gall Catherine , Sahraoui Karima , Baillard Christophe , Javaud Nicolas , Misset Benoît , Garrouste-Orgeas Maité , Ganansia Olivier , Rooryck François-Xavier , Aim Jean Luc , El Rifai Abudlrazak , Reignier Jean , Martin-Lefevre Laurent , Fradin Philippe , Mauriat Claire , Cwicklinski Emelyne , Slama Michel , Dupont Hervé , Ammirati Christine , Gallou Justine , Fartoukh Muriel , Djibre Michel , Ray Patrik , Rouff Edwin , Souweine Bertrand , Hssain Ali Ait , Schmidt Jeannot , Pic Daniel , Moustafa Farès , Mercat Alain , Lerolle Nicolas , Roy Pierre-Marie , Baud Frédéric , Plaisance Patrick , Montagnon Sophie , Galichon Bertrand , Wolff Michel , Mourvillier Bruno , Casalino Enrique , Choquet Christophe , Bernard Julien , Juillien Gaëlle , Fagon Jean-Yves , Guerot Emmanuel , Juvin Philippe , Patzak Anabela , Verdière Bruno , Ioos Vincent , Kouka Marie-Clément , Berthoumieu Audrey , Richard Christian , Maurice Raphael , Sarnel Sophie , Diez Stéphane , Vieillard Baron Antoine , Beaune Sébastien , Grenet Julie , Azerad Sylvie , Leblanc Guillaume , Simon Tabassome 
Published: July 2022

Background

Little is known about the impact of hospital trajectory on survival and functional decline of older critically ill patients. We evaluate 6-month outcomes after admission to: intensive care units (ICU), intermediate care units (IMCU) or acute medical wards (AMW).

Methods

Data from the randomised prospective multicentre clinical trial ICE-CUB2 was secondarily analysed. Inclusion criteria were: presenting at emergency departments in critical condition; age ≥ 75 years; activity of daily living (ADL) ≥ 4; preserved nutritional status; and no active cancer. A Cox model was fitted to compare survival according to admission destination adjusting for patient characteristics. Sensitivity analysis using multiple imputation for missing data and propensity score matching were performed.

Results

Among 3036 patients, 1675 (55%) were women; median age was 85 [81–99] years; simplified acute physiology score (SAPS-3) 62 [55–69]; 1448 (47%) were hospitalised in an ICU, 504 in IMCU (17%), and 1084 (36%) in AMW. Six-month mortality was 629 (44%), 155 (31%) and 489 (45%) after admission in an ICU, IMCU and AMW (p < 0.001), respectively. In multivariate analysis, AMW admission was associated with worse 6-month survival (HR 1.31, 95% CI 1.04–1.63) in comparison with IMCU admission, after adjusting for age, gender, comorbidities, ADL, SAPS-3 and diagnosis. Survival was not significantly different between patients admitted in an ICU and an IMCU (HR 1.17, 95% CI 0.95–1.46). Sensitivity analysis using multiple imputation for missing data and propensity score matching found similar results. Hospital destination was not significantly associated with the composite criterion loss of 1-point ADL or mortality. Physical and mental components of the 12-Item Short-Form Health Survey were significantly lower in the acute medical ward group (34.3 [27.5–41.7],p = 0.037 and 44.3 [38.6–48.6],p = 0.028, respectively) than in the ICU group (34.7 [28.4–45.3] and 45.5 [40.0–50.0], respectively) and IMCU group (35.7 [29.7–43.8] and 44.5 [39.7–48.4], respectively).

Conclusions

Admission in an AMW was associated with worse 6-month survival in older critically ill patients in comparison with IMCU admission, with no difference of survival between ICU and IMCU admission. There were no clinically relevant differences in quality of life in each group. These results should be confirmed in specific studies and raise the question of dedicated geriatric IMCUs.