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(Chest. 2004;126:1583-1591.)
© 2004 American College of Chest Physicians

Hospital Discharge to Care Facility*

A Patient-Centered Outcome for the Evaluation of Intensive Care for Octogenarians

Mohamed Y. Rady, MD, PhD and Daniel J. Johnson, MD

* From the Department of Critical Care Medicine, Mayo Clinic Hospital, Mayo Clinic Scottsdale, Scottsdale, AZ.

Correspondence to: Mohamed Y Rady, MD, PhD, Mayo Clinic Hospital, 5777 East Mayo Blvd, Phoenix, AZ 85054


   Abstract
TOP
 Abstract
Introduction
 Patients and Methods
 Results
 Discussion
 Appendix
 References
 
Introduction: Hospital survival and length of stay are commonly used for the evaluation of intensive care outcome for the young and octogenarian patients (≥ 80 years old).

Hypothesis: Hospital discharge to a care facility should be considered for more accurate evaluation of intensive care outcome, especially for octogenarian patients.

Design: An observational descriptive study.

Patients: A total of 6,154 consecutive hospital admissions requiring intensive care over 4 years.

Measurements: Demographics, preadmission comorbidities, severity of illness, acute hospital diagnosis categories, charges and destination after discharge, and postdischarge survival for up to 42 months.

Results: Octogenarians represented 15% of intensive care admissions (900 admissions). The interventions performed in the ICU, the severity of illness measured by sequential organ failure assessment (SOFA), and hospital length of stay were similar for octogenarian and younger patients. Octogenarians had higher hospital mortality (10% vs 6%, p < 0.01) and discharge to care facility (35% vs 18%, p < 0.01) than younger patients. The average hospital charge per octogenarian hospital survivor discharged to home was $128,000, compared to $100,000 for a younger hospital survivor. At follow-up, octogenarian hospital survivors who were discharged to a care facility had higher mortality than hospital survivors discharged to home (31% vs 17%, p < 0.01). On multiple logistic regression, older age, female gender, preadmission comorbidities, type of admission, SOFA score ≥ 4, mechanical ventilation ≥ 96 h, requirement for tracheotomy, and hospital diagnosis categories were independent factors for discharge of hospital survivors to a care facility.

Conclusions: Hospital survival and length of stay did not accurately measure intensive care outcome for octogenarians. Care dependency among octogenarians who survived intensive care was prevalent and decreased their long-term survival. Care dependency and functional disability among hospital survivors should be considered for more accurate evaluation of intensive care outcome in that age group.

Key Words: care dependency • intensive care • long-term survival • octogenarians • outcome


   Introduction
TOP
 Abstract
 Introduction
Patients and Methods
 Results
 Discussion
 Appendix
 References
 
The growth and demands for health-care resources for the elderly population are projected to accelerate over the next decade.1 The rapid escalation of costs has prompted greater scrutiny of health-care delivery and benefits for that age group. Guidelines2 have emphasized the importance of capturing long-term survival and quality-adjusted survival associated with the type of care delivered in order to determine the impact on society as a whole.

ICUs provide advanced technology therapy including life-sustaining interventions.3 The benefits of intensive care have come under scrutiny because of the associated expenses.456 Social and economic pressures have demanded justification of this type of care, demonstration of its efficacy with simultaneous cost containment.7 Traditional measures for intensive care outcome have primarily focused on hospital survival and resource utilization adjusted for the severity of illness.89 These measures may be suitable for younger patients, for whom the majority of hospital survivors are discharged to home. It is uncertain if the same measures are equally accurate to evaluate intensive care outcome for patients aged ≥ 80 years old (octogenarians).10111213 The study was performed to test the hypothesis that hospital discharge to a care facility should be considered when evaluating intensive care outcome in that particular age group.


   Patients and Methods
TOP
 Abstract
 Introduction
 Patients and Methods
Results
 Discussion
 Appendix
 References
 
Study Population
The study was performed at a tertiary care teaching hospital. The Institutional Review Board approved the study. The study cohort consisted of all patients admitted to Mayo Clinic hospital and the ICU between January 1, 1999, and December 31, 2002. Mayo Clinic Hospital is a 250-bed tertiary care teaching hospital. Patients were admitted to a 20-bed multidisciplinary (medical, surgical, and coronary care) closed ICU.

Data Collection
Demographics, preadmission comorbidities, type of admission, ICU interventions, acute diagnosis during hospital stay, length of stay, and disposition after discharge were obtained from electronic medical records. Length of stay was calculated as hours from date and time and then expressed as fractions of days. Data extracted from electronic medical records were entered into an institutional clinical database. Hospital charges included the sum of all charges related to laboratory tests, pharmacy, radiology, diagnostic or therapeutic interventions, and surgical procedures during the hospital stay. Hospital charges excluded professional or ancillary charges. Preadmission comorbidities and acute hospital diagnosis categories obtained from the discharge medical records were coded using the International Classification of Diseases, Ninth Revision, Clinical Modification.14 For those patients with more than one hospital admission during the 4-year period, the initial admission was designated as the index admission. Preadmission comorbidities were determined using criteria proposed by Romano et al.15 All other diagnoses recorded for the index admission were used to develop the acute hospital diagnosis categories (see Appendix). Severity of illness in the ICU was determined by sequential organ failure assessment (SOFA) score.16 The SOFA score was calculated based on graded severity of six organ systems dysfunction: neurologic, pulmonary, cardiovascular, hepatic, renal, and coagulation as described by Vincent et al.17 The SOFA score was derived from daily laboratory data, vital signs, and medication infusions stored in structured Query Language electronic database.18 Maximal daily SOFA score was determined for the entire stay in the ICU. Care dependency, defined as discharge to acute, subacute, long-term nursing care, inpatient rehabilitation, long-term ventilation, or other types of extended-care facilities, was the primary outcome of the study. The average hospital charge per survivor discharged to home was calculated from the sum of hospital charges for the entire age group divided by the number of survivors discharged to home from that age group. Postdischarge survival was determined from the death file complied from state Medicare database until June 30, 2003. Patients who were not identified as deceased before that date were assumed to be alive as of June 30, 2003. Thus, the follow-up period after discharge ranged from 0 to 42 months.

Statistical Analysis
All continuous variables were presented as median and (10 to 90% percentile range) and analyzed by Student t test or Wilcoxon rank-sum test when appropriate. Categorical variables were expressed as actual numbers as well as percentages and analyzed by {chi}2 or Fisher exact test as appropriate. Comparison of length of stay was performed with a nonparametric test of the median (number of points above median) where appropriate. The dependent or outcome variable was hospital discharge to a care facility. Cutoff values for continuous variables were determined by likelihood ratio test. Variables from each of the three categories (preadmission comorbidities, ICU care, and hospital diagnosis categories) that reached significance at p = 0.1 on univariate analysis with the outcome variable were examined in multivariate analysis. Stepwise multiple regression analysis was performed on variables from each category. Variables that retained significance to a value of p = 0.1 were then entered together into a stepwise multivariate regression to determine the final logistic model. Calibration of the final logistic model was assessed using Hosmer-Lemeshow goodness-of-fit to evaluate the importance of the discrepancy between observed and expected outcome. Discrimination was assessed using the area under the receiver operating characteristic (ROC) curve to evaluate how well the model distinguished patients for the primary outcome. An ROC curve was constructed by plotting the sensitivity vs (1 – specificity) of the risk factors to outcome. All statistical tests were two tailed, and significance was accepted at p < 0.05. Statistical analysis was performed using JMP Statistical software version 5.1.1 (SAS Institute; Cary, NC).


   Results
TOP
 Abstract
 Introduction
 Patients and Methods
 Results
Discussion
 Appendix
 References
 
Cohort Description
The study cohort had 900 octogenarians and 5,254 younger patients. Preadmission characteristics, ICU interventions, hospital diagnosis, and discharge disposition by age group were shown in Table 1 . Certain preadmission comorbidities—congestive heart failure, hypertension, ischemic heart disease, peripheral arterial vascular disease, cerebral vascular disease, and degenerative brain disease—were prevalent in octogenarians. Fewer tracheotomies were performed for octogenarians than younger patients. Specific hospital diagnosis categories more frequent in octogenarians than younger patients were shown in Table 1. Both age groups had similar SOFA scores and ICU and hospital length of stay. Octogenarian nonsurvivors had slightly shorter hospital stay than younger nonsurvivors. Hospital death or discharge to a care facility were most frequent in octogenarians.


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  		Table 1. Characteristics of the Study Cohort by Age Group*

 
Preadmission characteristics and ICU interventions by discharge disposition were shown in Table 2 . Hospital survival and discharge to a care facility was characterized by older age, female gender, and multiple preadmission comorbidities. Discharge to a care facility was also associated with medical admission, mechanical ventilation for ≥ 96 h, performance of tracheotomy, slightly elevated SOFA score, and a relatively long stay in the ICU and hospital. Specific hospital diagnosis categories associated with discharge to a care facility are shown in Table 2.


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  		Table 2. Characteristics of the Study Cohort by Disposition at Hospital Discharge

 
The prevalence of different preadmission comorbidities in hospital nonsurvivors were similar to hospital survivors discharged to a care facility as shown in Table 2. Renal disease, malignancy, and hepatic cirrhosis were mostly seen among hospital nonsurvivors. Pulmonary artery catheter insertion and SOFA scores were highest for hospital nonsurvivors. Hospital nonsurvivors and survivors discharged to a care facility had the longest stay in the ICU and hospital. Hospital diagnosis categories frequently seen among hospital nonsurvivors were similar to that seen in hospital survivors discharged to a care facility (Table 2).

Postdischarge Outcome and Hospital Resources
Outcome at hospital discharge and postdischarge follow-up for the study cohort are summarized in Figure 1 . For hospital survivors discharged to a care facility, 97 of 315 octogenarians (31%) and 228 of 982 younger patients (23%) had died on follow-up after discharge (p < 0.01). For hospital survivors discharged to home, 87 of 499 octogenarians (17%) and 445 of 3,962 younger patients (11%) had died (p < 0.01). Considering all hospital survivors, the death rate for hospital survivors discharged to a care facility (325 of 1,297 survivors [25%]) was twice as high as that for hospital survivors discharged to home (532 of 4,461 survivors [12%]) [p < 0.01]. The death rate for octogenarians discharged to a care facility was approximately threefold higher than younger patients (Fig 1).



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  		Figure 1. Summary of hospital and postdischarge outcome by age group.

 
The median hospital charges were plotted against median SOFA scores for younger and octogenarian patients by disposition at hospital discharge (Fig 2 ). Patients discharged to home had the lowest SOFA scores and hospital charges in both age groups. The SOFA scores and hospital charges were highest for nonsurvivors in both age groups. Patients discharged to a care facility had low SOFA scores, and hospital charges as high as nonsurvivors for each of the age groups. The average hospital charge per octogenarian hospital survivor discharged to home was estimated at $128,000, vs $100,000 for a younger hospital survivor.



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  		Figure 2. Hospital charges and SOFA score by age group and destination at hospital discharge. A = home, B = discharge to a care facility, C = hospital death. *p < 0.05 vs home. {dagger}p < 0.05 vs discharge to a care facility. Dotted lines represent median and 25 to 75% percentile for SOFA score along x-axis. Solid lines represent median and 25 to 75% percentile for hospital charges per patient along y-axis.

 
Prediction Model for Hospital Discharge to a Care Facility
Multiple logistic regression analysis of factors associated with hospital discharge to a care facility for the entire cohort was depicted in Table 3 . Wald {chi}2 was shown to indicate the relative contribution of each factor to the final model. The final model had an excellent calibration (goodness-of-fit p = 0.2) and good discrimination characteristics (ROC area = 0.76, p < 0.01). Advanced age, certain preadmission comorbidities, medical or surgical admissions (compared to coronary care), requirement for tracheotomy, SOFA score ≥ 4, mechanical ventilation ≥ 96 h, and specific hospital diagnosis categories (Table 3) were associated with discharge to a care facility.


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  		Table 3. Multiple Logistic Regression Analysis of Factors Associated With Discharge to a Care Facility*

 

   Discussion
TOP
 Abstract
 Introduction
 Patients and Methods
 Results
 Discussion
Appendix
 References
 
The current study was different from previous reports in several ways.6101920212223 The study cohort was not limited to certain types of admissions, disease category, or a particular threshold of length of stay in the ICU or hospital. The delivery of care was in the setting of a closed unit under the direction of dedicated in-house intensivists. Octogenarians made up 15% of all admissions and received similar level of intensive care (eg, hemodynamic monitoring, mechanical ventilation, and length of stay) as younger patients. Therefore, advanced age was not considered a factor against the use of life-sustaining therapy in the ICU. This particular finding was different from a previous report by Hamel et al24 indicating that elderly patients received fewer intensive care interventions because of advanced age.

Influence of Age on Outcome and Resource Utilization
Our study findings indicated that an evaluation of intensive care outcome based on hospital survival and stay without consideration of care dependency at discharge would have portrayed an incomplete picture. Hospital survival and restoration of independent function were far less frequent for octogenarians than younger patients following intensive care. Discharge to a care facility was associated with twice the mortality rate as that for patients discharged to home. Advanced age added a compounding negative effect, such that the actual mortality following discharge to care facility was much higher for octogenarians at approximately 30%. Wright et al25 reported an increase in postdischarge mortality after recovery from intensive care compared to age-matched general population for up to 4 years of follow-up. Other researchers2026 indicted that postdischarge death among hospital survivors of intensive care was primarily related to the degree of functional disabilities at discharge, which was further exacerbated by residual health, mental, and neurocognitive problems.

Advanced age influenced the utilization of hospital resources that was discernable from disposition at hospital discharge. Octogenarians who died in the hospital or were discharged to a care facility had low severity of illness, but they still consumed disproportionately more resources than younger nonsurvivors who had much higher severity of illness. These findings suggested that hospital survival and discharge to a care facility should be considered as inseparable components of outcome to better define resources utilization adjusted for severity of illness and the economic performance of intensive care. The average hospital charge per octogenarian patient discharged to home was 28% higher than a younger patient. The higher hospital charge could be attributed to disproportionately more octogenarians discharged to care facility. Since the ratio of hospital charge to cost was fixed, it would be reasonable to propose that care dependency on hospital discharge increased the cost-benefit ratio for that hospitalization episode. The cost component was underweighted because it excluded added expenses associated with discharge to a care facility. The benefit component was exaggerated because of postdischarge death or persistent functional disability among hospital survivors was also excluded.

Risk Factors for Hospital Discharge to Care Facility
Octogenarians had multiple preadmission comorbidities and explained the low severity of illness associated with either hospital death or care dependency. Certain comorbidities such as degenerative brain disease, cerebral vascular disease, congestive heart failure, chronic pulmonary disease; diabetes mellitus, connective tissue disease, and malnutrition were particular risk factors for care dependency on hospital survival after intensive care. Previous investigators had emphasized the role of preadmission comorbidities on exacerbating postdischarge physical disability, the need for nursing care, and decreased long-term survival among the elderly.23272829

Specific events in the ICU also pertained to care dependency on hospital survival. A SOFA score of ≥ 4, mechanical ventilation for ≥ 96 h, and the need for tracheotomy were associated with discharge to a care facility. Long-term outcome after mechanical ventilation for the elderly had been previously examined.30313233 These studies agreed that care dependency was fairly common among the elderly survivors of mechanical ventilation and < 30% were alive at 1 year.

Care dependency on hospital discharge was also related to certain hospital diagnosis categories. The common feature among these diverse diagnosis categories was that recovery from such illness was often associated with significant physical and cognitive disabilities, diminished mobility, or global neuromuscular sequels that persisted at hospital discharge, and had greater impact in the elderly for the need of constant care. Miller et al34 and Halm et al35 reported a high prevalence of care dependency in the elderly who survived intensive care after traumatic injury. Others253637 reported profound disabilities and functional limitations in the elderly survivors of serious life-threatening infections. Octogenarians who acquired postoperative complications had an increased risk for subsequent discharge to a care facility. Our experience was not unlike others38 who reported major functional disabilities in approximately one third of survivors of major postoperative complications in that age group.

Study Implications
What are the implications of the study? While intensive care could result in hospital survival, that type of care did not necessarily translate to a quality-adjusted long-term survival for the elderly with multiple comorbidities and acute critical illness. Efforts should focus on the development and the use of risk assessment tool to predict the need for care dependency on hospital discharge. Elderly patients and surrogates could then be better informed on the potential risks for care dependency following intensive care, and promote their participation in decision making with regard to the types of treatment and care plans best suited. That would encourage patient autonomy with regard to decisions to stop or refuse certain kinds of aggressive treatment. Alternative options of nonaggressive medical care and palliation should also be offered to these elderly patients. Additional planning for provision of long-term care for the elderly after intensive care should be addressed to ensure continuity of patient-centered care delivery.

Study Limitations
Several limitations for the study should be mentioned. The study case mix consisted of admissions to a single ICU at a tertiary care teaching hospital, therefore limiting its application to other types of hospital practice such as rural, urban, or community. Hospital charges rather than direct cost were available for evaluation of intensive care and hospital expenses. Discharge to a care facility was the surrogate for profound disability or care dependency instead of objective assessment of activities of daily living or health-related quality of life. The latter types of assessment would have yielded more pertinent and useful information regarding disability among hospital survivors discharged to home. The source of admission, ie, home or long-term care facility, was not available for the study. The study follow-up of postdischarge survival was obtained from data compiled from the state database, and could have missed out-of-state deaths. Evaluation of recovery from functional disability and return to home was not addressed by the current study.

In conclusion, hospital survival, stay, and charges did not accurately evaluate the outcome of intensive care for octogenarians. Care dependency among octogenarian hospital survivors after intensive care was prevalent and decreased long-term survival. A measure of functional disability among hospital survivors should be considered for more accurate evaluation of intensive care outcome in that age group.


   Appendix
TOP
 Abstract
 Introduction
 Patients and Methods
 Results
 Discussion
 Appendix
References
 
International Classification of Diseases, Ninth Revision, Clinical Modification Acute Hospital Diagnosis at Discharge
Cardiovascular:
Acute myocardial infarction (410–411), angina pectoris (413), acute pericarditis (420), acute and subacute endocarditis (421), acute myocarditis (422), conduction disorders (426), cardiac arrhythmias (427), aortic dissection (441.0x), rupture of aorta (441.1, 441.3, 441.5, 441.6), acute arterial embolism and thrombosis (444), acute arterial rupture (447.2), and shock (785.51, 785.59, 995.0).

Respiratory:
Acute pulmonary embolism (415), acute respiratory infections (460–466), pneumonia (480–487, 514, 518.6), acute exacerbation of COPD (491.21, 493.01–493.91), acute inhalation or aspiration pneumonitis (506, 507), pleural effusions (511.1–511.9), pneumothorax (512), pulmonary collapse (518.0), acute pulmonary insufficiency (518.4–518.5), acute respiratory failure (518.81, 518.84), and ARDS (518.82).

Neurologic:
Acute organic brain syndrome (291–293), inflammatory disease of the CNS (320–329, 338–389), intractable epilepsy (345.x1), encephalopathy (348.3), brain compression (348.4), cerebral edema (348.5), disorder of peripheral nervous system (350–359), intracranial hemorrhage (430–432), acute cerebral-vascular accident (433.x1, 434.x1, 435, 436, 437.2, 437.4), head injury (800–804, 850–854), and vertebral and spinal cord injury (805–806, 952–957).

GI:
Hemorrhage, obstruction, perforation, fistula of stomach, duodenum (531–537, 578), appendicitis (540–543), complications of hernia of abdominal cavity (550–553), noninfectious enteritis and colitis (555–558); other diseases of intestine (560–569), acute and subacute liver necrosis (570), gall bladder and biliary tact disorder (574–576), acute pancreatitis (577).

Acute Renal Failure:
(584).

Infections:
Infectious and parasitic disease (001–139), empyema (510), lung mediastinal abscess (513), mediastinitis (519.2), infections of urinary tract (590, 595, 597, 599), genital tract infections (601,604), skin and subcutaneous tissue infections (680–686), joint infections (711), bone infection (730), prosthetic or implant devices infections (996.6), and postoperative infections (998.51–998.59).

Fluid and Electrolyte Abnormalities:
Disorders of mineral metabolism (275), and disorder of fluid, electrolyte, and acid base (276).

Trauma:
Torso and extremities injury (807–848), internal injury to thorax, abdomen, and pelvis (860–869), and open or blood vessel injury (870–904).

Musculoskeletal Disorder:
Disorders of joint (715), dorsopathies (720–724), disorder of muscle and tendon (726–729), and disorder of bone and cartilage (733).

Anemia:
(285.1)

Poisoning:
(960–989)

Complications of Surgical and Other Procedures:
(996–998.4, 998.6–999.9)


   Footnotes
 
Abbreviations: ROC = receiver operating characteristic; SOFA = sequential organ failure assessment

Accepted for presentation at the 33rd Critical Care Congress of the Society of Critical Care Medicine, February 2004, Orlando, FL.

Received for publication December 18, 2003. Accepted for publication May 20, 2004.


   References
TOP
 Abstract
 Introduction
 Patients and Methods
 Results
 Discussion
 Appendix
 References
 

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