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Critical Illness Outcomes in Specialty versus General Intensive Care Units

¹ University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; ² Division of Pulmonary & Critical Care Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan; ³ Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia; ⁴ Division of Pulmonary, Allergy & Critical Care; ⁵ Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; ⁶ Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania; ⁷ Cerner Corporation, Vienna, Virginia

Correspondence and requests for reprints should be addressed to Jeremy M. Kahn, M.D., M.Sc., Division of Pulmonary, Allergy & Critical Care, University of Pennsylvania School of Medicine, 723 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104. E-mail: jmkahn{at}mail.med.upenn.edu

Rationale: General intensive care units (ICUs) provide care across a wide range of diagnoses, whereas specialty ICUs provide diagnosis-specific care. Risk-adjusted outcome differences across such units are unknown.

Objectives: To determine the association between specialty ICU care and the outcome of critical illness.

Methods: We conducted a retrospective cohort study design analyzing patients admitted to 124 ICUs participating in the Acute Physiology and Chronic Health Evaluation IV from January 2002 to December 2005. We examined 84,182 patients admitted to specialty and general ICUs with an admitting diagnosis or procedure of acute coronary syndrome, ischemic stroke, intracranial hemorrhage, pneumonia, abdominal surgery, or coronary-artery bypass graft surgery. ICU type was determined by a local data coordinator at each site. Patients were classified by admission to a general ICU, a diagnosis-appropriate ("ideal") specialty ICU, or a diagnosis-inappropriate ("non-ideal") specialty ICU. The primary outcomes were in-hospital mortality and ICU length of stay.

Measurements and Main Results: After adjusting for important confounders, there were no significant differences in risk-adjusted mortality between general versus ideal specialty ICUs for all conditions other than pneumonia. Risk-adjusted mortality was significantly greater for patients admitted to non-ideal specialty ICUs. There was no consistent effect of specialization on length of stay for all patients or for ICU survivors.

Conclusions: Ideal specialty ICU care appears to offer no survival benefit over general ICU care for select common diagnoses. Non-ideal specialty ICU care (i.e., "boarding") is associated with increased risk-adjusted mortality.

Key Words: critical care • health services • organization • intensive care unit • hospital mortality

AT A GLANCE COMMENTARY Scientific Knowledge on the Subject The clinical benefits of organizing the delivery of critical care medicine into specialized intensive care units (ICUs) are widely assumed but unproven. What This Study Adds to the Field In a diverse group of United States hospitals, risk-adjusted in-hospital mortality did not differ between specialized and nonspecialized ICUs. Investment in ICU specialization may not improve mortality.