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Predictors of Mortality and Resource Utilization in Cirrhotic Patients Admitted to the Medical ICU^*

^* From the Department of Gastroenterology (Drs. Aggarwal, Ong, and Younossi), the Department of Biostatistics (Mr. Nelson), and the Department of Pulmonary and Critical Care Medicine (Ms. Hoffman-Hogg and Dr. Arroliga), The Cleveland Clinic Foundation, Cleveland, OH.

Correspondence to: Alejandro C. Arroliga, MD, FCCP, Head, Section of Critical Care Medicine, Department of Pulmonary and Critical Care Medicine, Cleveland Clinic Foundation, 9500 Euclid Ave, Desk G-62, Cleveland, OH 44195; e-mail: arrolia{at}ccf.org

Background and objective: Cirrhotic patients admitted to the medical ICU (MICU) are associated with high mortality rates and high resource utilization. This study identifies specific predictors of increased mortality and resource utilization and uses them to develop and validate prognostic models in cirrhotic patients admitted to the MICU.

Methods: Cirrhotic patients admitted to the MICU were identified from the Critical Care Section database (January 1993 to October 1998). Clinical data were extracted from chart review including hospital course variables, mortality, and length of stay (LOS). Total cost per case (TCPC) was obtained from the Transition System Inc. Multivariate logistic and linear regression analyses identified the independent predictors of increased mortality and resource utilization used for model building (MB) and model validation (MV).

Results: A total of 582 cases were randomized to the MB and MV groups. Each group contained 240 cases after exclusion criteria were applied. The MICU mortality rate was 36.6%, and the in-hospital mortality rate was 49.0%. Acute physiology, age, and chronic health evaluation (APACHE) III score (odds ratio [OR], 4.7; 95% confidence interval [CI], 2.70 to 8.16; p < 0.001), mechanical ventilation (OR, 4.57; 95% CI, 2.35 to 8.34); p < 0.001), and the use of pressors (OR, 7.57; 95% CI, 4.35 to 13.18; p < 0.001) were independent predictors of MICU mortality. APACHE III score (OR, 4.96; 95% CI, 2.97 to 8.29; p < 0.001), the use of pressors (OR, 6.55; 95% CI, 3.66 to 11.72; p < 0.001), and acute renal failure (ARF) (OR, 4.31; 95% CI, 2.41 to 7.71; p < 0.001) were independent predictors of in-hospital mortality. Increased LOS in the MICU was associated with mechanical ventilation, ARF, bronchoscopy, bacteremia, use of pressors, transjugular intrahepatic portosystemic shunt (TIPS), and never received cardiopulmonary resuscitation (CPR) (p < 0.005). Source of admission, platelet transfusion, bacteremia, pneumonia, and never received CPR were independently associated with increased total LOS (p < 0.001). Mechanical ventilation, platelet transfusion, bronchoscopy, TIPS, sepsis, and never received CPR were independent predictors of increased TCPC (p < 0.001).

Conclusion: Simple prognostic models for mortality and resource utilization have been developed for cirrhotic patients admitted to the MICU.

Key Words: cirrhosis • cost • end-stage liver disease • intensive care • length of stay • mortality • outcome • resource utilization

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