Randomised trial of systematic ICU admission for critically ill elderly patients

EJRC ARTICLE REVIEW

The demand for intensive care for elderly patients is increasing as the population ages (1). Elderly patients account for a growing proportion of ICU admissions, but the benefit of intensive care to this group has not been established by observational studies (2).

The ICE-CUB 2 study (3), led by Bertrand Guidet, aimed to establish whether a programme promoting systematic admission of critically ill elderly patients to ICU improved mortality. Results from this study were first presented at LIVES 2017, the 30^th Annual Congress of ESICM in late September 2017.

Methods

3037 patients assessed at the emergency departments (ED) of 24 French hospitals were included in the study. All were aged 75 years or older, had preserved functional and nutritional status and were free of any known cancer.

This study utilised a cluster randomisation design. The hospitals were randomised to use either an intervention programme promoting systematic ICU admission (with bedside ICU physician assessment) of these patients, or a control programme of usual standard care.

The primary outcome was mortality at six months.

Results

• The crude risk of death at six months was higher in the systematic ICU admission group (RR 1.16), though this did not differ significantly between the two groups after adjustment for baseline characteristics (RR 1.05 95% CI 0.96-1.14).
• The ICU admission rate among patients in the systematic ICU admission group was 61%, compared to 34% in the control group.
• In-hospital mortality was significantly higher in the systematic ICU admission group than the control group (30% vs 21%).
• There were no significant differences in measures of quality of life at six months or change in functional status of patients in the two groups.

Discussion

This study’s findings confirm those of ICE-CUB 1 (2), a prospective observational study, which showed no mortality improvement at six months after ICU admission among elderly patients.

Its cluster randomisation design provided an achievable methodology to investigate the intervention, and a large number of patients were successfully randomised. The direct involvement of ICU physicians at the bedside to share decision making with the ED physicians may have reduced selection bias.

Limitations of the study included the potential distorting effect of the admission to ICU of patients that were more critically unwell in the systematic admission (i.e. intervention) group. The single country setting of the trial also limits its external validity.

Take Home Message

A programme promoting the systematic ICU admission of critically ill elderly patients in French hospitals was found to result in no significant difference in mortality at six months compared to standard practice, confirming the findings of previous observational studies.

Article review prepared and submitted by Ehsan Ahmadnia and Duncan Baily (London, UK) on behalf of the EJRC.

References

1. Flaatten H, de Lange DW, Artigas A, et al. The status of intensive care medicine research and a future agenda for very old patients in the ICU. Intensive Care Med. 2017;43(9):1319-1328.
2. Boumendil A, Angus DC, Guitonneau AL, et al; ICE-CUB study group. Variability of intensive care admission decisions for the very elderly. PLoS One. 2012;7(4):e34387
3. Guidet B, Leblanc G, Simon T et al; ICE-CUB 2 study network. Effect of Systematic Intensive Care Unit Triage on Long-term Mortality Among Critically Ill Elderly Patients in France – A Randomised Clinical Trial. JAMA. 2012017;318(15):1450-1459