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Potential Value of Regionalized Intensive Care for Mechanically Ventilated Medical Patients

¹ Division of Pulmonary, Allergy, and Critical Care, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine; ² Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania; ³ ZD Associates, LLC, Perkasie, Pennsylvania; ⁴ Department of Anesthesiology, Columbia Presbyterian Medical Center, Columbia University, New York, New York; ⁵ Section of Decision Sciences and Clinical Systems Modeling, Division of General Internal Medicine, University of Pittsburgh School of Medicine; ⁶ Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh; ⁷ Department of Industrial Engineering, University of Pittsburgh School of Engineering; and ⁸ Clinical Research, Investigation, and Systems Modeling of Acute Illness Laboratory, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania

Correspondence and requests for reprints should be addressed to Jeremy M. Kahn, M.D., M.Sc., Division of Pulmonary, Allergy, and 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: Regionalization has been proposed as a method to improve outcomes for medical patients receiving mechanical ventilation in the intensive care unit.

Objectives: To determine the number of patients who would be affected by regionalization and the potential mortality reduction under a regionalized system of care.

Methods: We performed a retrospective cohort study with Monte Carlo simulation, using 2001 state discharge data from eight states representing 42% of the U.S. population. Adult medical patients undergoing invasive mechanical ventilation were identified. Patient location and hospital mortality rates were obtained from the discharge data; estimates of the relative risk reduction in hospital mortality for high-volume hospitals compared with low-volume hospitals were obtained from the published literature and applied to the cohort.

Measurements and Main Results: Of 180,976 adult medical patients who underwent mechanical ventilation at 1,170 nonfederal hospitals, 83,050 (46%) received mechanical ventilation at 887 (76%) hospitals with low annual volumes (fewer than 275 patients per year). Using published risk estimates, approximately 4,720 lives per year (95% range, 2,522–6,744) could potentially be saved in the 8 states by routinely transferring patients from low- to high-volume hospitals, representing a number needed to treat of 15.7. The median distance that patients would need to travel to reach a high-volume hospital was 8.5 miles (interquartile range, 4.0–21.2 mi).

Conclusions: Regionalization of intensive care could potentially improve survival for patients undergoing mechanical ventilation. Transfer distances are modest for most patients.

Key Words: mechanical ventilation • triage • transportation of patients • critical care • Monte Carlo method

AT A GLANCE COMMENTARY Scientific Knowledge on the Subject Regionalization of care has been proposed as a method to improve outcomes for critically ill patients at small hospitals. Little is known about the relative number of small hospitals or the potential mortality benefit for patients under regionalization. What This Study Adds to the Field Many medical patients undergoing mechanical ventilation receive care at low-volume hospitals. Regionalization has the potential to improve the survival for these patients.

 

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