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Hospital-level variation in the development of persistent critical illness

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Abstract

Purpose

Patients with persistent critical illness may account for up to half of all intensive care unit (ICU) bed-days. It is unknown if there is hospital variation in the development of persistent critical illness and if hospital performance affects the incidence of persistent critical illness.

Methods

This is a retrospective analysis of Veterans admitted to the Veterans Administration (VA) ICUs from 2015 to 2017. Hospital performance was defined by the risk- and reliability-adjusted 30-day mortality. Persistent critical illness was defined as an ICU length of stay of at least 11 days. We used 2-level multilevel logistic regression models to assess variation in risk- and reliability-adjusted probabilities in the development of persistent critical illness.

Results

In the analysis of 100 hospitals which encompassed 153,512 hospitalizations, 4.9% (N = 7640/153,512) developed persistent critical illness. There was variation in the development of persistent critical illness despite controlling for patient characteristics (intraclass correlation: 0.067, 95% CI 0.049–0.091). Hospitals with higher risk- and reliability-adjusted 30-day mortality had higher probabilities of developing persistent critical illness (predicted probability: 0.057, 95% CI 0.051–0.063, p < 0.01) compared to those with lower risk- and reliability-adjusted 30-day mortality (predicted probability: 0.046, 95% CI 0.041–0.051, p < 0.01). The median odds ratio was 1.4 (95% CI 1.33–1.49) implying that, for two patients with the same physiology on admission at two different VA hospitals, the patient admitted to the hospital with higher adjusted mortality would have 40% greater odds of developing persistent critical illness.

Conclusion

Hospitals with higher risk- and reliability-adjusted 30-day mortality have a higher probability of developing persistent critical illness. Understanding the drivers of this variation may identify modifiable factors contributing to the development of persistent critical illness.

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Funding

This work was supported by Grants NHLBI T32 HL7749-25 (EMV), K12 HL138039 (EMV, TJI). Dr. Bagshaw is supported by a Canada Research Chair in Critical Care Nephrology.

Author information

Authors and Affiliations

  1. Department of Internal Medicine Division of Pulmonary and Critical Care, University of Michigan, 2800 Plymouth Road NCRC Building 14, G100-35, Ann Arbor, MI, 48109, USA

    Elizabeth M. Viglianti, Xiao Qing Wang & Theodore J. Iwashyna

  2. Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada

    Sean M. Bagshaw

  3. Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia

    Rinaldo Bellomo

  4. Department of Intensive Care, Alfred Hospital, Melbourne, VIC, Australia

    Rinaldo Bellomo

  5. School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, Scotland, UK

    Joanne McPeake

  6. Intensive Care Unit, Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, Scotland, UK

    Joanne McPeake

  7. Veterans Affairs Center for Clinical Management Research, HSR&D Center for Innovation, Ann Arbor, MI, USA

    Sarah Seelye & Theodore J. Iwashyna

  8. Institute for Social Research, Ann Arbor, MI, USA

    Theodore J. Iwashyna

Authors
  1. Elizabeth M. Viglianti
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  2. Sean M. Bagshaw
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  3. Rinaldo Bellomo
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  4. Joanne McPeake
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  5. Xiao Qing Wang
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  6. Sarah Seelye
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  7. Theodore J. Iwashyna
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Contributions

EMV designed the study, performed the statistical analyses, interpreted the results, compiled the manuscript, and is accountable for all aspects of the work. SMB interpreted the results and provided critical revisions for the manuscript. RB interpreted the results and provided critical revisions for the manuscript. JM interpreted the results and provided critical revisions for the manuscript. XQW performed statistical analyses and provided critical revisions for the manuscript. SS refined the analysis, assisted in interpreting the findings, and provided critical revisions for the manuscript. TJI consulted on the design of the study, refined the analyses, assisted in interpreting the findings, and provided critical revisions of the manuscript.

Corresponding author

Correspondence to Elizabeth M. Viglianti.

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The authors declare that they have no conflict of interest. This work does not represent the official views of the US Government or the US Department of Veteran Affairs.

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Viglianti, E.M., Bagshaw, S.M., Bellomo, R. et al. Hospital-level variation in the development of persistent critical illness. Intensive Care Med 46, 1567–1575 (2020). https://doi.org/10.1007/s00134-020-06129-9

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  • DOI: https://doi.org/10.1007/s00134-020-06129-9

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