Intensive Care Unit Admitting Patterns in the Veterans Affairs Health Care System

Background: Critical care resource use accounts for almost 1% of US gross domestic product and varies widely among hospitals. However, we know little about the initial decision to admit a patient to the intensive care unit (ICU). Methods: To describe hospital ICU admitting patterns for medical patients after accounting for severity of illness on admission, we performed a retrospective cohort study of the first nonsurgical admission of 289 310 patients admitted from the emergency department or the outpatient clinic to 118 Veterans Affairs acute care hospitals between July 1, 2009, and June 30, 2010. Severity (30-day predicted mortality rate) was measured using a modified Veterans Affairs ICU score based on laboratory data and comorbidities around admission. The main outcome measure was direct admission to an ICU. Results: Of the 31 555 patients (10.9%) directly admitted to the ICU, 53.2% had 30-day predicted mortality at admission of 2% or less. The rate of ICU admission for this low-risk group varied from 1.2% to 38.9%. For high-risk patients (predicted mortality >30%), ICU admission rates also varied widely. For a 1-SD increase in predicted mortality, the adjusted odds of ICU admission varied substantially across hospitals (odds ratio =0.85-2.22). As a result, 66.1% of hospitals were in different quartiles of ICU use for low- vs high-risk patients (weighted kappa=0.50). Conclusions: The proportion of low- and high-risk patients admitted to the ICU, variation in ICU admitting patterns among hospitals, and the sensitivity of hospital rankings to patient risk all likely reflect a lack of consensus about which patients most benefit from ICU admission.