McAlister, Finlay A.

Aims: Registries have reported large inter-hospital differences in intensive care unit admission rates for patients with acute heart failure, but little is known about the potential economic impact of over-admission of low-risk patients with heart failure to higher cost intensive care units. We described the variability in intensive care unit admission practices, the provision of critical care therapies, and estimated the potential national cost savings if all hospitals adopted low intensive care unit admission practices for patients admitted with heart failure. Methods: Using a national population health dataset, we identified 349,693 heart failure admission hospitalisations with a primary diagnosis of heart failure between 2007 and 2016. Hospitals were categorised as low (first quartile), medium (second and third quartile) and high (fourth quartiles) intensive care unit utilisation. Results: The mean intensive care unit admission rate was 16.4% (inter-hospital range 0.3–51%) including 5.4% in low, 14.5% in medium and 30% in high utilisation hospitals. Intensive care unit therapies in low, medium and high intensive care unit utilisation hospitals were 54.5%, 45.1% and 24.1% ( P<0.001), respectively and the inhospital mortality rate was not significantly different. The proportion of hospital costs incurred by intensive care unit care was 7.8% in low, 19.8% in medium and 28.2% in high ( P<0.001) admission hospitals. The potential cost savings of altering intensive care unit utilisation practices for patients with heart failure was CAN$234.8m over the study period. Conclusions: In a national cohort of patients hospitalised with heart failure, we observed that low intensive care unit utilisation centres had lower hospital costs with no differences in mortality rates. The development of standardised admission criteria for high-cost and high acuity intensive care unit beds could reduce costs to the healthcare system.

Abstract We examined the accuracy of preoperative assessment in predicting postoperative pulmonary risk in a prospective cohort of 272 consecutive patients referred for evaluation before nonthoracic surgery. Outcomes were assessed by an independent investigator who was blinded to the preoperative data. There were 22 (8%) postoperative pulmonary complications. Statistically significant predictors of pulmonary complications (all p ≤ 0.005) were as follows: hypercapnea of 45 mm Hg or more (odds ratio, 61.0), a FVC of less than 1.5 L/minute (odds ratio, 11.1), a maximal laryngeal height of 4 cm or less (odds ratio, 6.9), a forced expiratory time of 9 seconds or more (odds ratio, 5.7), smoking of 40 pack-years or more (odds ratio, 5.7), and a body mass index of 30 or more (odds ratio, 4.1). Multiple regression analyses revealed three preoperative clinical factors that are independently associated with pulmonary complications: an age of 65 years or more (odds ratio, 1.8; p = 0.02), smoking of 40 pack-years or more (odds ratio, 1.9; p = 0.02), and maximum laryngeal height of 4 cm or less (odds ratio, 2.0; p = 0.007). Thus, preoperative factors can identify those patients referred to pulmonologists or internists who are at increased risk for pulmonary complications after nonthoracic surgery.