alexa Equity of Access to Critical Care Among Elderly Patients in Scotland: A National Cohort Study.


Emergency Medicine: Open Access

Author(s): Docherty AB, Anderson NH, Walsh TS, Lone NI

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Abstract OBJECTIVE: To compare elderly (≥ 80 yr), older (65-79 yr), and younger (< 65 yr) ICU admissions in Scotland in relation to trends in admission rates, regional variation in admissions, ICU treatment intensity, and ICU and 1-year mortality. DESIGN: National 5-year cohort study of ICU first admissions (January 1, 2005, to December 31, 2009). SETTING: All admissions to ICUs and combined units (level 2/3 care) in Scotland captured by the Scottish Intensive Care Society Audit Group database, linked with hospital discharge data and death records. PATIENTS: A total of 40,142 patients: 3,865 were 80 years old or older (9.6\%), 13,904 (34.6\%) were 65-79 years old; and 22,373 were younger than 65 years (55.7\%). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Between 2005 and 2009, elderly admission rates decreased from 36.6/10,000 (95\% CI, 34.0-39.2) in 2005 to 28.7/10,000 (95\% CI, 26.5-30.9) in 2009 (p < 0.001; relative decrease, 22.0\%); older admission rates also decreased, but less steeply (31.1 [95\% CI, 29.9-32.2] to 26.1 [95\% CI, 25.1-27.1] per 10,000 population; p < 0.001; relative decrease, 16.1\%). Rates were static for younger patients. Restricted to mechanically ventilated elderly patients, rates ranged from 13.9 to 30.1/10,000 between healthboard administrative regions (p < 0.001). Emergency surgical diagnoses were more prevalent for elderly patients (elderly, 39.8\%; older, 25.1\%; younger, 20.3\%; p < 0.001). Subgroup analyses limited to pneumonia admissions (elderly, n = 242; older, n = 1,226; younger, n = 1,836) indicated similar acute physiology scores, but fewer preexisting comorbidities among elderly patients (p = 0.007), who received a shorter duration of organ support and ICU stay. Mortality rates were higher in elderly patients at ICU discharge (elderly, 26.5\%; older, 25.0\%; younger, 17.0\%; p < 0.001; confounder adjusted odds ratio elderly vs younger, 2.33 [95\% CI, 2.11-2.58]; p < 0.001). Differences persisted at 1 year (elderly, 52.2\%; older, 43.8\%; younger, 27.6\%; adjusted odds ratio elderly vs younger, 3.72 [95\% CI, 3.42-4.06]; p < 0.001). CONCLUSIONS: In Scotland, elderly and older ICU admission rates are decreasing, with regional geographic variation. Although limited by an absence of a measure of frailty, patient characteristics and treatment intensity suggest selection of less comorbid elderly patients, indicating possible rationing based on chronologic age. This article was published in Crit Care Med and referenced in Emergency Medicine: Open Access

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