Relationship between Volume and Survival in Closed Intensive Care Units Is Weak and Apparent Only in Mechanically Ventilated Patients

• Published in: Anesthesiology (Philadelphia) 2013-10, Vol.119 (4), p.871-879
• Main Authors: FERNANDEZ, Rafael, ALTABA, Susana, GOMEZ-TELLO, Vicente, CURIEL, Emilio, FERNANDEZ-MONDEJAR, Enrique, OLIVA, Joan-Carles, CABRE, Lluis, LACUEVA, Victoria, SANTOS, Antonio, SOLSONA, Jose-Felipe, ANON, Jose-Manuel, CATALAN, Rosa-Maria, GUTIERREZ, Maria-Jose, FERNANDEZ-CID, Ramon
• Format: Article
• Language: English
• Subjects: Aged; Anesthesia; Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Biological and medical sciences; Cohort Studies; Female; Hospital Mortality; Humans; Intensive Care Units - statistics & numerical data; Length of Stay - statistics & numerical data; Male; Medical sciences; Middle Aged; Patient Outcome Assessment; Prospective Studies; Respiration, Artificial - mortality; Spain; Survival Analysis
• ISSN: 0003-3022; 1528-1175
• DOI: 10.1097/ALN.0b013e31829c3029

Recent studies have found an association between increased volume and increased intensive care unit (ICU) survival; however, this association might not hold true in ICUs with permanent intensivist coverage. Our objective was to determine whether ICU volume correlates with survival in the Spanish healthcare system. Post hoc analysis of a prospective study of all patients admitted to 29 ICUs during 3 months. At ICU discharge, the authors recorded demographic variables, severity score, and specific ICU treatments. Follow-up variables included ICU readmission and hospital mortality. Statistics include logistic multivariate analyses for hospital mortality according to quartiles of volume of patients. The authors studied 4,001 patients with a mean predicted risk of death of 23% (range at hospital level: 14-46%). Observed hospital mortality was 19% (range at hospital level: 11-35%), resulting in a standardized mortality ratio of 0.81 (range: 0.5-1.3). Among the 1,923 patients needing mechanical ventilation, the predicted risk of death was 32% (14-60%) and observed hospital mortality was 30% (12-61%), resulting in a standardized mortality ratio of 0.96 (0.5-1.7). The authors found no correlation between standardized mortality ratio and ICU volume in the entire population or in mechanically ventilated patients. Only mechanically ventilated patients in very low-volume ICUs had slightly worse outcome. In the currently studied healthcare system characterized by 24/7 intensivist coverage, the authors found wide variability in outcome among ICUs even after adjusting for severity of illness but no relationship between ICU volume and outcome. Only mechanically ventilated patients in very low-volume centers had slightly worse outcomes.