PMID- 31164326 OWN - NLM STAT- MEDLINE DCOM- 20190610 LR - 20200411 IS - 1756-1833 (Electronic) IS - 0959-8138 (Print) IS - 0959-8138 (Linking) VI - 365 DP - 2019 Jun 4 TI - Intensive care use and mortality among patients with ST elevation myocardial infarction: retrospective cohort study. PG - l1927 LID - 10.1136/bmj.l1927 [doi] LID - l1927 AB - OBJECTIVE: To evaluate the effect of intensive care unit (ICU) admission on mortality among patients with ST elevation myocardial infarction (STEMI). DESIGN: Retrospective cohort study. SETTING: 1727 acute care hospitals in the United States. PARTICIPANTS: Medicare beneficiaries (aged 65 years or older) admitted with STEMI to either an ICU or a non-ICU unit (general/telemetry ward or intermediate care) between January 2014 and October 2015. MAIN OUTCOME MEASURE: 30 day mortality. An instrumental variable analysis was done to account for confounding, using as an instrument the additional distance that a patient with STEMI would need to travel beyond the closest hospital to arrive at a hospital in the top quarter of ICU admission rates for STEMI. RESULTS: The analysis included 109 375 patients admitted to hospital with STEMI. Hospitals in the top quarter of ICU admission rates admitted 85% or more of STEMI patients to an ICU. Among patients who received ICU care dependent on their proximity to a hospital in the top quarter of ICU admission rates, ICU admission was associated with lower 30 day mortality than non-ICU admission (absolute decrease 6.1 (95% confidence interval -11.9 to -0.3) percentage points). In a separate analysis among patients with non-STEMI, a group for whom evidence suggests that routine ICU care does not improve outcomes, ICU admission was not associated with differences in mortality (absolute increase 1.3 (-0.9 to 3.4) percentage points). CONCLUSIONS: ICU care for STEMI is associated with improved mortality among patients who could be treated in an ICU or non-ICU unit. An urgent need exists to identify which patients with STEMI benefit from ICU admission and what about ICU care is beneficial. CI - Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions. FAU - Valley, Thomas S AU - Valley TS AUID- ORCID: 0000-0002-5766-4970 AD - Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA. AD - Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA. AD - Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, USA. FAU - Iwashyna, Theodore J AU - Iwashyna TJ AD - Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA. AD - Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA. AD - VA Center for Clinical Management Research, Ann Arbor, MI, USA. FAU - Cooke, Colin R AU - Cooke CR AD - Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA. AD - Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA. AD - Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA. FAU - Sinha, Shashank S AU - Sinha SS AD - Cardiac Intensive Care Unit, Inova Heart and Vascular Institute, Inova Fairfax Medical Center, Falls Church, VA, USA. AD - Cardiovascular Critical Care Research, Inova Heart and Vascular Institute, Inova Fairfax Medical Center, Falls Church, VA, USA. FAU - Ryan, Andrew M AU - Ryan AM AD - Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA. AD - Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA. FAU - Yeh, Robert W AU - Yeh RW AD - Richard and Susan Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA. AD - Department of Medicine, Harvard Medical School, Boston, MA, USA. FAU - Nallamothu, Brahmajee K AU - Nallamothu BK AD - Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA. AD - VA Center for Clinical Management Research, Ann Arbor, MI, USA. AD - Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA. AD - Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA. LA - eng GR - K23 HL140165/HL/NHLBI NIH HHS/United States GR - L30 HL133988/HL/NHLBI NIH HHS/United States GR - R01 HL137816/HL/NHLBI NIH HHS/United States PT - Journal Article PT - Research Support, N.I.H., Extramural DEP - 20190604 PL - England TA - BMJ JT - BMJ (Clinical research ed.) JID - 8900488 SB - IM MH - Aged MH - *Critical Care/methods/organization & administration MH - Female MH - Health Services Accessibility/statistics & numerical data MH - *Hospital Mortality MH - Hospitalization/statistics & numerical data MH - Humans MH - Intensive Care Units/*statistics & numerical data MH - Male MH - Medicare/statistics & numerical data MH - Mortality MH - Needs Assessment MH - Outcome and Process Assessment, Health Care MH - *ST Elevation Myocardial Infarction/economics/mortality/therapy MH - United States/epidemiology PMC - PMC6547840 COIS- Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organization for the submitted work other than that described above; no financial relationships with any organizations that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work. Ethical approval: The Institutional Review Board for the University of Michigan approved the study and provided a waiver of consent (HUM00053488). EDAT- 2019/06/06 06:00 MHDA- 2019/06/14 06:00 PMCR- 2019/01/01 CRDT- 2019/06/06 06:00 PHST- 2019/06/06 06:00 [entrez] PHST- 2019/06/06 06:00 [pubmed] PHST- 2019/06/14 06:00 [medline] PHST- 2019/01/01 00:00 [pmc-release] AID - valt048284 [pii] AID - 10.1136/bmj.l1927 [doi] PST - epublish SO - BMJ. 2019 Jun 4;365:l1927. doi: 10.1136/bmj.l1927.