Outcomes and Costs in Elderly Ventilated Patients
Abstract & Commentary
In this study conducted at wake forest university, ely and associates use logistic regression analysis in two groups of prospectively followed, mechanically ventilated patients in their medical and coronary ICUs—those 75 years of age or older, and those younger than 75—to determine the effect of age on outcomes. Sixty-three patients 75 or older were compared to 237 patients younger than 75 who were enrolled during a nine-month period. Severity of illness was assessed by APACHE II score and by a modification that omitted age and by Murray Acute Lung Injury score. Ely et al examined demographics, mortality, duration of mechanical ventilation and ICU care, and costs associated with the ICU and the whole hospital stay in the two groups of patients.
Patients included in the study had a variety of medical diagnoses resulting in the need for mechanical ventilation, including pulmonary (48%) and cardiac (27%) disease in 75% of them. The distribution of diagnoses was not different in the elderly vs. the younger patients. There were fewer men among the elderly patients (38% vs 54%), and those in the older age group had greater mean severity of illness as measured by APACHE II scores.
There was no overall difference in duration of mechanical ventilation in older vs. younger patients: median duration of mechanical ventilation was 4.2 days (interquartile range, 2.1-9.3 days) in patients 75 or older, as compared to 6.4 days (3.4-11.4) for those younger than 75 (P = 0.14). However, when readiness for weaning according to standardized screening criteria was used as a measure of the duration of need for ventilatory support, the older patients met the criteria earlier. Overall costs of ICU care were lower in the elderly patients than in the younger patients: mean $12,822 (95% CI, $9821-$26,313) vs. $19,316 (95% CI, $9699-$39,950; P = 0.03). Median overall hospital costs also tended to be lower in the older patients, although this trend was not statistically significant. Multivariate logistic regression analysis adjusting for ethnicity, sec, and severity of illness showed that patients’ age of 75 years or older was predictive of one less day on the ventilator. In-hospital mortality rates were approximately 38% in both age groups and were not statistically different. (Ely EW, et al. Ann Intern Med 1999;131:96-104.)
COMMENT BY DAVID J. PIERSON, MD, facp, fccp
This prospective cohort study shows that, in an unselected general medical and cardiology ICU population and after adjustment for severity of illness, elderly patients spent similar time on mechanical ventilation and in the ICU but had a lower cost of care than younger patients. These findings were not accounted for by differences in mortality, protocol management, or other identifiable factors. On the basis of their findings, Ely et al conclude that chronological age should not be used to restrict the use of mechanical ventilation in elderly patients with acute respiratory failure.
As health care costs continue to soar in the United States, our aging population accounts for ever-greater proportions of total expenditures. However, as the data of Ely et al demonstrate, age in and of itself is not a predictor of outcome or costs among patients admitted to medical and coronary ICUs. Thus, any policy that prohibits or restricts ICU access or other aspects of critical care solely on the basis of a patient’s age would appear to be unwise and unjustified.
Which of the following statements is true about patients 75 years of age or older who require mechanical ventilation in a medical or coronary ICU, as compared to younger patients?
a. They are less likely to survive the hospitalization.
b. They meet standardized criteria for ventilator weaning earlier.
c. Their ICU care costs more.
d. They tend to have lower APACHE II scores.
e. More of them tend to be men.
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