Outcome Variations
Admission to a neurologic/neurosurgical intensive care unit is associated with reduced mortality rate after intracerebral hemorrhage
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Summary
Posted By: Gordon S. Doig
E-Mail: gdoig@med.usyd.edu.au
Posted Date: 30Apr2001
Title: Admission to a neurologic/neurosurgical intensive care unit is associated with reduced mortality rate after intracerebral hemorrhage
Authors: Diringer MN and Edwards DF
Reference: Crit Care Med 2001;29:635-640
Link: Click here for a direct link to the paper. A password may be required for access to fulltext.
Abstract: Objective: To determine whether mortality rate after intracerebral hemorrhage (ICH) is lower in patients admitted to a neurologic or neurosurgical (neuro) intensive care unit (ICU) compared to those admitted to general ICUs.
Background: The utility of specialty ICUs is debated. From a cost perspective, having fewer larger ICUs is preferred. Alternatively, the impact of specialty ICUs on patient outcome is unknown. Patients with ICH are admitted routinely to both general and neuro ICUs and provide an opportunity to address this question.
Setting: Forty-two neuro, medical, surgical, and medical-surgical ICUs.
Measurements and Main Results: The study was an analysis of data prospectively collected by Project Impact over 3 yrs from 42 participating ICUs (including one neuro ICU) across the country. The records of 36,986 patients were merged with records of 3,298 patients from a second neuro ICU that collected the same data over the same period. The impact of clinical (age, race, gender, Glasgow Coma Scale score, reason for admission, insurance), ICU (size, number of ICH patients, full-time intensivist, clinical service, American College for Graduate Medical Education or Critical Care Medicine fellowship), and institutional (size, location, medical school affiliation) characteristics on hospital mortality rate of ICH patients was assessed by using a forward-enter multivariate analysis. Data from 1,038 patients were included. The 13 ICUs that admitted >20 patients accounted for 83% of the admissions with a mortality rate that ranged from 25% to 64%. Multivariate analysis adjusted for patient demographics, severity of ICH, and ICU and institutional characteristics indicated that not being in a neuro ICU was associated with an increase in hospital mortality rate (odds ratio [OR], 3.4; 95% confidence interval [CI], 1.657.6). Other factors associated with higher mortality rate were greater age (OR, 1.03/year; 95% CI, 1.011.04), lower Glasgow Coma Scale score (OR, 0.6/point; 95% CI, 0.580.65), fewer ICH patients (OR, 1.01/patient; 95% CI, 1.001.01), and smaller ICU (OR, 1.1/bed; 95% CI, 1.021.13). Having a full time intensivist was associated with lower mortality rate (OR, 0.388; 95% CI, 0.220.67).
Conclusions: For patients with acute ICH, admission to a neuro vs. general ICU is associated with reduced mortality rate.
 
Are the recommendations valid?
1. Are the outcome measures accurate and comprehensive?

"A randomized therapeutic trial must have valid and reliable outcome measures; so must any observational study assessing patients' outcomes. The easiest outcomes for health researchers to measure are those that are defined objectively and usually captured in large insurance data bases or computerized hospital administrative data, e.g. death, those in-hospital complications of surgery that are routinely coded, or readmissions to hospital."

This paper reports mortality and length of stay. In a group such as ICH patients, it may be more important to investigate quality of life or functional measures (such as SF-36 or GOS) than it would be in other groups.
2. Were the comparison groups similar with respect to important determinants of outcome, other than the one of interest, and were residual differences adjusted for in the analysis?
2a. Did the investigators measure all known important prognostic factors?
No. The investigators report that APACHE II was not available on all patients, so it could not be included in a multivariate model to control for severity of illness at the level of the individual patient (a severe limitation in an observational study!!!). Similarly, the investigators report that although the literature recognizes the importance of radiological findings in predicting outcome in ICH, radiological findings were NOT included in this study.
2b. Were measures of patients' prognostic factors reproducible and accurate?
The Glasgow Coma Scale score was the primary prognostic factor used in this study. The collection of GCS is highly reliable and accurate however, it is unclear as to which GCS would be the BEST predictor in ICH: GCS at hospital admission, GCS prior to surgery or worst GCS over the first 24 hours of ICU admission. The authors report using GCS 'at admission' (ICU admit???).
2c. Did the investigators show the extent to which patients differed on these factors?
No. Due to incomplete data collection, it was impossible to report differences in APACHE II at the patient level.
2d. Did the researchers use some form of multivariate analysis to adjust for all the important prognostic factors?
No. APACHE II could not be included in the multivariate model due to missing values. GCS however, could be included.
2e. Did additional analyses (particularly in low-risk subgroups) demonstrate the same results as the primary analysis?
Uncertain. Although GCS is included in a multivariate model, outcome by GCS (as a measure of risk) is not reported.
 
What are the recommendations?
1. What are the recommendations?
The suggestion that patients who are treated for ICH in a neuro ICU have a better outcome is interesting and could have important implications for decisions regarding the organization of critical care services provided by hospitals, HOWEVER the results of this paper should be considered 'preliminary' and require further study.
Will the recommendations help you in caring for your patients?
1. How will the recommendations help you?
Further study is required before concrete conclusions can be reached and acted upon.

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Admission to a neurologic/neurosurgical intensive care unit is associated with reduced mortality rate after intracerebral hemorrhage

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