Intensive care unit versus high-dependency care unit for mechanically ventilated patients with pneumonia: a nationwide comparative effectiveness study.

comparative effectiveness high-dependency care unit intensive care unit mechanical ventilation pneumonia

Journal

The Lancet regional health. Western Pacific
ISSN: 2666-6065
Titre abrégé: Lancet Reg Health West Pac
Pays: England
ID NLM: 101774968

Informations de publication

Date de publication:
Aug 2021
Historique:
received: 18 02 2021
revised: 13 05 2021
accepted: 26 05 2021
entrez: 16 9 2021
pubmed: 17 9 2021
medline: 17 9 2021
Statut: epublish

Résumé

Many mechanically ventilated patients in Japan are treated in high-dependency care units (HDUs) rather than intensive care units (ICUs). HDUs can provide intermediate-level care with reduced costs; however, there is limited evidence on whether mechanically ventilated patients should be treated in the ICU or HDU. This was a comparative effectiveness study using a nationwide administrative database in Japan. We identified mechanically ventilated patients with pneumonia in ICU or HDU on the day of admission in the Japanese Diagnosis Procedure Combination inpatient database from April 2014 to March 2019. The primary outcome was 30-day in-hospital mortality. Propensity score matching analysis was performed to compare this outcome between patients treated in the ICU and HDU. The robustness of the analyses was evaluated with multivariable regression, overlap weighting, and instrumental variable analyses. Of 14,859 mechanically ventilated patients with pneumonia, 7,528 (51%) were treated in the ICU and 7,331 (49%) were treated in the HDU. After propensity score matching, patients treated in the ICU had significantly lower 30-day in-hospital mortality than did those treated in the HDU (24.0% vs. 31.2%; difference, -7.2%; 95% confidence interval, -10.0% to -4.4%). The multivariable regression, overlap weighting, and instrumental variable analyses showed a similar direction and magnitude of association. Critical care for mechanically ventilated patients with pneumonia in the ICU was associated with a 7.2% decrease in 30-day in-hospital mortality vs. care in the HDU. Residual confounding may still play a role in the effect estimates. This study received funding from Ministry of Health, Labour and Welfare, Japan, and Ministry of Education, Culture, Sports, Science and Technology, Japan.

Sections du résumé

BACKGROUND BACKGROUND
Many mechanically ventilated patients in Japan are treated in high-dependency care units (HDUs) rather than intensive care units (ICUs). HDUs can provide intermediate-level care with reduced costs; however, there is limited evidence on whether mechanically ventilated patients should be treated in the ICU or HDU.
METHODS METHODS
This was a comparative effectiveness study using a nationwide administrative database in Japan. We identified mechanically ventilated patients with pneumonia in ICU or HDU on the day of admission in the Japanese Diagnosis Procedure Combination inpatient database from April 2014 to March 2019. The primary outcome was 30-day in-hospital mortality. Propensity score matching analysis was performed to compare this outcome between patients treated in the ICU and HDU. The robustness of the analyses was evaluated with multivariable regression, overlap weighting, and instrumental variable analyses.
FINDINGS RESULTS
Of 14,859 mechanically ventilated patients with pneumonia, 7,528 (51%) were treated in the ICU and 7,331 (49%) were treated in the HDU. After propensity score matching, patients treated in the ICU had significantly lower 30-day in-hospital mortality than did those treated in the HDU (24.0% vs. 31.2%; difference, -7.2%; 95% confidence interval, -10.0% to -4.4%). The multivariable regression, overlap weighting, and instrumental variable analyses showed a similar direction and magnitude of association.
INTERPRETATION CONCLUSIONS
Critical care for mechanically ventilated patients with pneumonia in the ICU was associated with a 7.2% decrease in 30-day in-hospital mortality vs. care in the HDU. Residual confounding may still play a role in the effect estimates.
FUNDING BACKGROUND
This study received funding from Ministry of Health, Labour and Welfare, Japan, and Ministry of Education, Culture, Sports, Science and Technology, Japan.

Identifiants

DOI: 10.1016/j.lanwpc.2021.100185 PMID: 34527980 PMC: PMC8350066
pubmed: 34527980
doi: 10.1016/j.lanwpc.2021.100185
pii: S2666-6065(21)00094-8
pmc: PMC8350066
doi:

Types de publication

Journal Article

Langues

eng

Pagination

100185

Informations de copyright

© 2021 The Author(s). Published by Elsevier Ltd.

Déclaration de conflit d'intérêts

This work was supported by grants from the Ministry of Health, Labour and Welfare, Japan (19AA2007 and H30-Policy-Designated-004) and the Ministry of Education, Culture, Sports, Science and Technology, Japan (17H04141). The authors report no potential conflicts of interest.

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Auteurs

Hiroyuki Ohbe (H)

Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 1130033, Japan.

Yusuke Sasabuchi (Y)

Data Science Centre, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi Prefecture, 3290498, Japan.

Hayato Yamana (H)

Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 1130033, Japan.

Hiroki Matsui (H)

Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 1130033, Japan.

Hideo Yasunaga (H)

Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 1130033, Japan.

Classifications MeSH