Thietart Sara, Boumendil Ariane, Pateron Dominique, Guidet Bertrand, Vallet Hélène
Department of Intensive Care, APHP, Hôpital Saint-Antoine, Sorbonne Université, 184, rue du Faubourg Saint-Antoine, 75012, Paris, France.
EBMT LWP, Paris Office, Hôpital Saint-Antoine, Paris, France.
Ann Intensive Care. 2022 Jul 11;12(1):65. doi: 10.1186/s13613-022-01042-4.
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).
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.
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).
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.
关于医院治疗轨迹对老年危重症患者生存及功能衰退的影响，目前所知甚少。我们评估了入住重症监护病房（ICU）、中级护理病房（IMCU）或急性内科病房（AMW）6个月后的预后情况。
对随机前瞻性多中心临床试验ICE-CUB2的数据进行二次分析。纳入标准为：在急诊科处于危急状态；年龄≥75岁；日常生活活动能力（ADL）≥4；营养状况良好；无活动性癌症。采用Cox模型，根据入院目的地比较生存情况，并对患者特征进行校正。使用多重填补法处理缺失数据及倾向评分匹配进行敏感性分析。
在3036例患者中，1675例（55%）为女性；中位年龄为85[81 - 99]岁；简化急性生理学评分（SAPS-3）为62[55 - 69]；1448例（47%）入住ICU，504例入住IMCU（17%），1084例（36%）入住AMW。入住ICU、IMCU和AMW后6个月死亡率分别为629例（44%）、155例（31%）和489例（45%）（p<0.001）。多因素分析显示，与入住IMCU相比，入住AMW与6个月生存率较差相关（风险比1.31，95%置信区间1.04 - 1.63），校正了年龄、性别、合并症、ADL、SAPS-3和诊断等因素。入住ICU和IMCU的患者生存率无显著差异（风险比1.17，95%置信区间0.95 - 1.46）。使用多重填补法处理缺失数据及倾向评分匹配的敏感性分析得出了类似结果。医院目的地与ADL评分降低1分或死亡率的综合标准无显著相关性。急性内科病房组12项简短健康调查问卷的身体和心理成分得分（分别为34.3[27.5 - 41.7]，p = 0.037和44.3[38.6 - 48.6]，p = 0.028）显著低于ICU组（分别为34.7[28.4 - 45.3]和45.5[40.0 - 50.0]）和IMCU组（分别为35.7[29.7 - 43.8]和44.5[39.7 - 48.4]）。
与入住IMCU相比，入住AMW的老年危重症患者6个月生存率较差，入住ICU和IMCU的患者生存率无差异。各组生活质量在临床上无相关差异。这些结果应在特定研究中得到证实，并引发了关于设立专门老年IMCU的问题。
