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Background: Early reports suggest the number of cardiac intensive care unit (CICU) patients with primary noncardiac diagnoses is rising in the United States, but no national data currently exist. We examined changes in primary noncardiac diagnoses among elderly patients admitted to a CICU during the past decade.Methods and Results: Using 2003 to 2013 Medicare data, we grouped elderly patients admitted to CICUs into 2 categories based on principal diagnosis at discharge: (1) primary noncardiac diagnoses and (2) primary cardiac diagnoses. We examined changes in patient demographics, comorbidities, procedure use, and risk-adjusted in-hospital mortality. Among 3.4 million admissions with a CICU stay, primary noncardiac diagnoses rose in prevalence from 38.0% to 51.7% between 2003 and 2013. The fastest rising primary noncardiac diagnoses were infectious diseases (7.8%-15.1%) and respiratory diseases (6.0%-7.6%; P<0.001 for both), whereas the fastest declining primary cardiac diagnosis was coronary artery disease (32.3%-19.0%; P<0.001). Simultaneously, the prevalence of both cardiovascular and noncardiovascular comorbidities rose: heart failure (13.9%-34.4%), pulmonary vascular disease (1.2%-7.1%), valvular heart disease (5.0%-9.8%), and renal failure (7.1%-19.6%; P<0.001 for all). As compared with those with primary cardiac diagnoses, elderly CICU patients with primary noncardiac diagnoses had higher rates of noncardiac procedure use and risk-adjusted in-hospital mortality (P<0.001 for all). Risk-adjusted in-hospital mortality declined slightly in the overall cohort from 9.3% to 8.9% (P<0.001).Conclusions: More than half of all elderly patients with a CICU stay across the United States now have primary noncardiac diagnoses at discharge. These patients receive different types of care and have worse outcomes than patients with primary cardiac diagnoses. Our work has important implications for the development of appropriate training and staffing models for the future critical care workforce. [ABSTRACT FROM AUTHOR]

Rationale: Admission to an intensive care unit (ICU) may be beneficial to patients with pneumonia with uncertain ICU needs; however, evidence regarding the association between ICU admission and mortality for other common conditions is largely unknown.Objectives: To estimate the relationship between ICU admission and outcomes for hospitalized patients with exacerbation of chronic obstructive pulmonary disease (COPD), exacerbation of heart failure (HF), or acute myocardial infarction (AMI).Methods: We performed a retrospective cohort study of all acute care hospitalizations from 2010 to 2012 for U.S. fee-for-service Medicare beneficiaries aged 65 years and older admitted with COPD exacerbation, HF exacerbation, or AMI. We used multivariable adjustment and instrumental variable analysis to assess each condition separately. The instrumental variable analysis used differential distance to a high ICU use hospital (defined separately for each condition) as an instrument for ICU admission to examine marginal patients whose likelihood of ICU admission depended on the hospital to which they were admitted. The primary outcome was 30-day mortality. Secondary outcomes included hospital costs.Results: Among 1,555,798 Medicare beneficiaries with COPD exacerbation, HF exacerbation, or AMI, 486,272 (31%) were admitted to an ICU. The instrumental variable analysis found that ICU admission was not associated with significant differences in 30-day mortality for any condition. ICU admission was associated with significantly greater hospital costs for HF ($11,793 vs. $9,185, P < 0.001; absolute increase, $2,608 [95% confidence interval, $1,377-$3,840]) and AMI ($19,513 vs. $14,590, P < 0.001; absolute increase, $4,922 [95% confidence interval, $2,665-$7,180]), but not for COPD.Conclusions: ICU admission did not confer a survival benefit for patients with uncertain ICU needs hospitalized with COPD exacerbation, HF exacerbation, or AMI. These findings suggest that the ICU may be overused for some patients with these conditions. Identifying patients most likely to benefit from ICU admission may improve health care efficiency while reducing costs. [ABSTRACT FROM AUTHOR]

Rationale: The extent to which geographic variability in ICU admission across the United States is driven by patients with lower risk of death is unknown. Objectives: To determine whether patients at low to moderate risk of death contribute to geographic variation in ICU admission. Methods: Retrospective cohort of hospitalizations among Medicare beneficiaries (age > 64 years) admitted for ten common medical and surgical diagnoses (2004 to 2009). We examined population-adjusted rates of ICU admission per 100 hospitalizations in 304 health referral regions (HRR), and estimated the relative risk of ICU admission across strata of regional ICU and risk of death, adjusted for patient and regional characteristics. Measurement and Main Results: ICU admission rates varied nearly two-fold across HRR quartiles (quartile 1 to 4: 13.6, 17.3, 20.0, and 25.2 per 100 hospitalizations, respectively). Observed mortality for patients in regions (quartile 4) with the greatest ICU use was 17% compared to 21% in regions with lowest ICU use (quartile 1) (p<0.001). After adjusting for patient and regional characteristics, including regional differences in ICU, skilled nursing, and long-term acute care bed capacity, individuals’ risk of death modified the relationship between regional ICU use and an individual’s risk of ICU admission (p for interaction<0.001). Region was least important in predicting ICU admission among patients with high (quartile 4) risk of death (RR 1.27, 95% CI 1.22–1.31, for high versus low ICU use regions), and most important for patients with moderate (quartile 2; RR 1.63, 95% CI 1.53–1.72, quartile 3; RR 1.56 95% CI 1.47–1.65) and low (quartile 1) risk of death (RR 1.50, 95% CI 1.41–1.59). Conclusions: There is wide variation in in ICU use by geography, independent of ICU beds and physician supply, for patients with low and moderate risks of death. [ABSTRACT FROM AUTHOR]

Today, more than one half of older adults usetheinternetto obtain healthrelated information, and there is growing interest from governmental agencies in providing information online. The Centers for Medicare & Medicaid Services (CMS) provides guidance to Part D prescription drug plan sponsors about information to include on their websites. The current article examines compliance with the 2014 CMS guidance for Medication Therapy Management (MTM) program information on Part D plan sponsors' websites. There were 59.5% of plan sponsors that had a dedicated MTM program webpage, accessible within two clicks from the plan sponsor's home page and provided basic information, eligibility for MTM services, and access to a blank copy of a personalized medication list document. Although improvements in the provision of information about plan sponsors' MTM programs can be made, future work should evaluate the usability and effectiveness of the online MTM program information provided to Medicare beneficiaries. [ABSTRACT FROM AUTHOR]

Background: Quality of care for acute myocardial infarction (AMI) and heart failure (HF) varies across hospitals, but the factors driving variation are incompletely understood. We evaluated the relationship between a hospital's ICU or coronary care unit (CCU) admission rate and quality of care provided to patients with AMI or HF.Methods: A retrospective cohort study of Medicare beneficiaries hospitalized in 2010 with AMI or HF was performed. Hospitals were grouped into quintiles according to their risk- and reliability-adjusted ICU admission rates for AMI or HF. We examined the rates that hospitals failed to deliver standard AMI or HF processes of care (process measure failure rates), 30-day mortality, 30-day readmissions, and Medicare spending after adjusting for patient and hospital characteristics.Results: Hospitals in the lowest quintile had ICU admission rates < 29% for AMI or < 8% for HF. Hospitals in the top quintile had rates > 61% for AMI or > 24% for HF. Hospitals in the highest quintile had higher process measure failure rates for some but not all process measures. Hospitals in the top quintile had greater 30-day mortality (14.8% vs 14.0% [P = .002] for AMI; 11.4% vs 10.6% [P < .001] for HF), but no differences in 30-day readmissions or Medicare spending were seen compared with hospitals in the lowest quintile.Conclusions: Hospitals with the highest rates of ICU admission for patients with AMI or HF delivered lower quality of care and had higher 30-day mortality for these conditions. Hospitals with high ICU use may be targets to improve care delivery. [ABSTRACT FROM AUTHOR]

Rationale: Intermediate care (i.e., step-down or progressive care) is an alternative to the intensive care unit (ICU) for patients with moderate severity of illness. The adoption and current use of intermediate care is unknown.Objectives: To characterize trends in intermediate care use among U.S. hospitals.Methods: We examined 135 million acute care hospitalizations among elderly individuals (≥65 yr) enrolled in fee-for-service Medicare (U.S. federal health insurance program) from 1996 to 2010. We identified patients receiving intermediate care as those with intensive care or coronary care room and board charges labeled intermediate ICU.Measurements and Main Results: In 1996, a total of 960 of the 3,425 hospitals providing critical care billed for intermediate care (28%), and this increased to 1,643 of 2,783 hospitals (59%) in 2010 (P < 0.01). Only 8.2% of Medicare hospitalizations in 1996 were billed for intermediate care, but billing steadily increased to 22.8% by 2010 (P < 0.01), whereas the percentage billed for ICU care and ward-only care declined. Patients billed for intermediate care had more acute organ failures diagnoses codes compared with general ward patients (22.4% vs. 15.8%). When compared with patients billed for ICU care, those billed for intermediate care had fewer organ failures (22.4% vs. 43.4%), less mechanical ventilation (0.9% vs. 16.7%), lower mean Medicare spending ($8,514 vs. $18,150), and lower 30-day mortality (5.6% vs. 16.5%) (P < 0.01 for all comparisons).Conclusions: Intermediate care billing increased markedly between 1996 and 2010. These findings highlight the need to better define the value, specific practices, and effective use of intermediate care for patients and hospitals. [ABSTRACT FROM AUTHOR]

Importance: Among patients whose need for intensive care is uncertain, the relationship of intensive care unit (ICU) admission with mortality and costs is unknown.Objective: To estimate the relationship between ICU admission and outcomes for elderly patients with pneumonia.Design, Setting, and Patients: Retrospective cohort study of Medicare beneficiaries (aged >64 years) admitted to 2988 acute care hospitals in the United States with pneumonia from 2010 to 2012.Exposures: ICU admission vs general ward admission.Main Outcomes and Measures: Primary outcome was 30-day all-cause mortality. Secondary outcomes included Medicare spending and hospital costs. Patient and hospital characteristics were adjusted to account for differences between patients with and without ICU admission. To account for unmeasured confounding, an instrumental variable was used-the differential distance to a hospital with high ICU admission (defined as any hospital in the upper 2 quintiles of ICU use).Results: Among 1,112,394 Medicare beneficiaries with pneumonia, 328,404 (30%) were admitted to the ICU. In unadjusted analyses, patients admitted to the ICU had significantly higher 30-day mortality, Medicare spending, and hospital costs than patients admitted to a general hospital ward. Patients (n = 553,597) living closer than the median differential distance (<3.3 miles) to a hospital with high ICU admission were significantly more likely to be admitted to the ICU than patients living farther away (n = 558,797) (36% for patients living closer vs 23% for patients living farther, P < .001). In adjusted analyses, for the 13% of patients whose ICU admission decision appeared to be discretionary (dependent only on distance), ICU admission was associated with a significantly lower adjusted 30-day mortality (14.8% for ICU admission vs 20.5% for general ward admission, P = .02; absolute decrease, -5.7% [95% CI, -10.6%, -0.9%]), yet there were no significant differences in Medicare spending or hospital costs for the hospitalization.Conclusions and Relevance: Among Medicare beneficiaries hospitalized with pneumonia, ICU admission of patients for whom the decision appeared to be discretionary was associated with improved survival and no significant difference in costs. A randomized trial may be warranted to assess whether more liberal ICU admission policies improve mortality for patients with pneumonia. [ABSTRACT FROM AUTHOR]

Objectives To ascertain the absolute number of Medicare beneficiaries surviving at least 3 years after severe sepsis and to estimate their burden of cognitive dysfunction and disability. Design Retrospective cohort analysis of Medicare data. Setting All short-stay inpatient hospitals in the United States, 1996 to 2008. Participants Individuals aged 65 and older. Measurements Severe sepsis was detected using a standard administrative definition. Case-fatality, prevalence, and incidence rates were calculated. Results Six hundred thirty-seven thousand eight hundred sixty-seven Medicare beneficiaries were alive at the end of 2008 who had survived severe sepsis 3 or more years earlier. An estimated 476,862 (95% confidence interval ( CI) = 455,026-498,698) had functional disability, with 106,311 (95% CI = 79,692-133,930) survivors having moderate to severe cognitive impairment. The annual number of new 3-year survivors after severe sepsis rose 119% during 1998 to 2008. The increase in survivorship resulted from more new diagnoses of severe sepsis rather than a change in case-fatality rates; severe sepsis rates rose from 13.0 per 1,000 Medicare beneficiary-years to 25.8 ( P < .001), whereas 3-year case fatality rates changed much less, from 73.5% to 71.3% ( P < .001) for the same cohort. Increasing rates of organ dysfunction in hospitalized individuals drove the increase in severe sepsis incidence, with an additional small contribution from population aging. Conclusions Sepsis survivorship, which has substantial long-term morbidity, is a common and rapidly growing public health problem for older Americans. There has been little change in long-term case-fatality, despite changes in practice. Clinicians should anticipate more-frequent sequelae of severe sepsis in their patient populations. [ABSTRACT FROM AUTHOR]

Reports on the televised press conference denouncing the Medicare Prescription Drug and Modernization Act on January 28, 2004 in the U.S. Sponsors of the event; Remarks from Barbara Blakeney, president of the American Nurses Association, concerning the act; Vow of participants at the conference to work for legislation targeting the shortcomings of the new law.

Background: Use of intensive care after major surgical procedures and whether routinely admitting patients to intensive care units (ICUs) improve outcomes or increase costs is unknown.Methods: The authors examined frequency of admission to an ICU during the hospital stay for Medicare beneficiaries undergoing selected major surgical procedures: elective endovascular abdominal aortic aneurysm (AAA) repair, cystectomy, pancreaticoduodenectomy, esophagectomy, and elective open AAA repair. The authors compared hospital mortality, length of stay, and Medicare payments for patients receiving each procedure in hospitals admitting patients to the ICU less than 50% of the time (low use), 50 to 89% (moderate use), and 90% or greater (high use), adjusting for patient and hospital factors.Results: The cohort ranged from 7,878 patients in 162 hospitals for esophagectomies to 69,989 patients in 866 hospitals for endovascular AAA. Overall admission to ICU ranged from 35.6% (endovascular AAA) to 71.3% (open AAA). Admission to ICU across hospitals ranged from less than 5% to 100% of patients for each surgical procedure. There was no association between hospital use of intensive care and mortality for any of the five surgical procedures. There was a consistent association between high use of intensive care with longer length of hospital stay and higher Medicare payments only for endovascular AAA.Conclusions: There is little consensus regarding the need for intensive care for patients undergoing major surgical procedures and no relationship between a hospital's use of intensive care and hospital mortality. There is also no consistent relationship across surgical procedures between use of intensive care and either length of hospital stay or payments for care. [ABSTRACT FROM AUTHOR]

Objectives: To determine national readmission rates among sepsis survivors, variations in rates between hospitals, and determine whether measures of quality correlate with performance on sepsis readmissions.Design: Cross-sectional study of sepsis readmissions between 2008 and 2011 in the Medicare fee-for-service database.Setting: Acute care, Medicare participating hospitals from 2008 to 2011.Patients: Septic patients as identified by International Classification of Diseases, Ninth Revision codes using the Angus method.Interventions: None.Measurements and Main Results: We generated hospital-level, risk-standardized, 30-day readmission rates among survivors of sepsis and compared rates across region, ownership, teaching status, sepsis volume, hospital size, and proportion of underserved patients. We examined the relationship between risk-standardized readmission rates and hospital-level composite measures of quality and mortality. From 633,407 hospitalizations among 3,315 hospitals from 2008 to 2011, median risk-standardized readmission rates was 28.7% (interquartile range, 26.1-31.9). There were differences in risk-standardized readmission rates by region (Northeast, 30.4%; South, 29.6%; Midwest, 28.8%; and West, 27.7%; p < 0.001), teaching versus nonteaching status (31.1% vs 29.0%; p < 0.001), and hospitals serving the highest proportion of underserved patients (30.6% vs 28.7%; p < 0.001). The best performing hospitals on a composite quality measure had highest risk-standardized readmission rates compared with the lowest (32.0% vs 27.5%; p < 0.001). Risk-standardized readmission rates was lower in the highest mortality hospitals compared with those in the lowest (28.7% vs 30.7%; p < 0.001).Conclusions: One third of sepsis survivors were readmitted and wide variation exists between hospitals. Several demographic and structural factors are associated with this variation. Measures of higher quality in-hospital care were correlated with higher readmission rates. Several potential explanations are possible including poor risk standardization, more research is needed. [ABSTRACT FROM AUTHOR]