title: Hospital-level variation in ICU admission and critical care procedures for patients hospitalized for pulmonary embolism.
abstract: BACKGROUND
  Variation in the use of ICUs for low-risk conditions contributes to health system inefficiency. We sought to examine the relationship between ICU use for patients with pulmonary embolism (PE) and cost, mortality, readmission, and procedure use.
  
  
  METHODS
  We performed a retrospective cohort study including 61,249 adults with PE discharged from 263 hospitals in three states between 2007 and 2010. We generated hospital-specific ICU admission rate quartiles and used a series of multilevel models to evaluate relationships between admission rates and risk-adjusted in-hospital mortality, readmission, and costs and between ICU admission rates and several critical care procedures.
  
  
  RESULTS
  Hospital quartiles varied in unadjusted ICU admission rates for PE (range, ≤ 15% to > 31%). Among all patients, there was a small trend toward increased use of arterial catheterization (0.6%-1.1%, P < .01) in hospital quartiles with higher levels of ICU admission. However, use of invasive mechanical ventilation (14.4%-7.9%, P < .01), noninvasive ventilation (6.6%-3.0%, P < .01), central venous catheterization (14.6%-11.3%, P < .02), and thrombolytics (11.0%-4.7%, P < .01) in patients in the ICU declined across hospital quartiles. There was no relationship between ICU admission rate and risk-adjusted hospital mortality, costs, or readmission.
  
  
  CONCLUSIONS
  Hospitals vary widely in ICU admission rates for acute PE without a detectable impact on mortality, cost, or readmission. Patients admitted to ICUs in higher-using hospitals received many critical care procedures less often, suggesting that these patients may have had weaker indications for ICU admission. Hospitals with greater ICU admission may be appropriate targets for improving efficiency in ICU admissions.
authors.affiliation: Department of Internal Medicine, University of Michigan, Ann Arbor, MI.
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Admon
authors.affiliation: Department of Critical Care, Department of Emergency Medicine, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, University of Pittsburgh, Pittsburgh, PA.
authors.forename: Christopher W
authors.initials: CW
authors.lastname: Seymour
authors.affiliation: Division of Critical Care Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY.
authors.forename: Hayley B
authors.initials: HB
authors.lastname: Gershengorn
authors.affiliation: Department of Anesthesiology, Department of Epidemiology, Columbia University, New York, NY.
authors.forename: Hannah
authors.initials: H
authors.lastname: Wunsch
authors.affiliation: Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI. Electronic address: cookecr@umich.edu.
authors.forename: Colin R
authors.initials: CR
authors.lastname: Cooke
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D003362:Cost-Benefit Analysis; D003422:Critical Care / Q000379:methods; D003695:Delivery of Health Care / Q000458:organization & administration; D005260:Female; D006301:Health Services Needs and Demand; D006761:Hospitals / Q000639:trends*; D006801:Humans; D015994:Incidence; D007362:Intensive Care Units / Q000191:economics / Q000706:statistics & numerical data*; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D010343:Patient Admission / Q000706:statistics & numerical data*; D011655:Pulmonary Embolism / Q000175:diagnosis* / Q000628:therapy; D012189:Retrospective Studies; D012737:Sex Factors; D017749:Total Quality Management; D014481:United States