The Effect of Critical Care Transition Programs on the Short-Term Outcomes of Critically Ill Cancer Patients: A Propensity Score Matching Study

Xue-Zhong Xing; Hai-Jun Wang; Shi-Ning Qu; Chu-Lin Huang; Hao Zhang; Hao Wang

doi:10.4103/jtccm.jtccm_6_19

ORIGINAL ARTICLE

Year : 2019 | Volume : 1 | Issue : 3 | Page : 96-99

The Effect of Critical Care Transition Programs on the Short-Term Outcomes of Critically Ill Cancer Patients: A Propensity Score Matching Study

Xue-Zhong Xing, Hai-Jun Wang, Shi-Ning Qu, Chu-Lin Huang, Hao Zhang, Hao Wang
Department of Intensive Care Unit, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China

Date of Submission	05-Mar-2019
Date of Acceptance	09-May-2019
Date of Web Publication	28-Oct-2020

Correspondence Address:
Prof. Xue-Zhong Xing
Department of Intensive Care Unit, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17, Panjiayuan Nanli, Chaoyang District, Beijing
China

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jtccm.jtccm_6_19

Abstract

Objective: The objective of the study is to investigate the effect of critical care transition programs (TPs) on the short-term outcomes in critically ill cancer patients. Methods: Data of critically ill cancer patients admitted to the intensive care unit (ICU) at National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College between September 2017 and August 2018 were retrospectively reviewed and analyzed. Patients were grouped as TP group or non-TP (nTP) group according to whether patients received post-ICU follow-up. Results: In unmatched groups, compared with nTP group, patients in TP group were more severe with higher Acute Physiology and Chronic Health Evaluation (APACHE) II score, higher Simplified Acute Physiology Score 3 score, and higher Sequential Organ Failure Assessment score and decreased ICU mortality (0 vs. 3.1%, P = 0.001) and in-hospital mortality (0 vs. 3.2%, P = 0.001). After matching, there were no significant differences in readmission rate, in-hospital mortality, readmission/in-hospital mortality, ICU length of stay (LOS), and hospital LOS between TP and nTP groups (all P > 0.05). Subgroup analysis demonstrated that in severe group (APACHE II >15), compared with nTP group, patients in TP group had increased readmission rate (8.3% vs. 62.5%, P < 0.001) and increased duration of hospital LOS (13.92 ± 10.54 vs. 26.38 ± 15.46 days; P = 0.003). There is a trend that ICU mortality (23.6% vs. 0, P = 0.121) and hospital mortality (25.8% vs. 0, P = 0.108) were decreased in TP group than in nTP group. In less severe group (APACHE II ≤ 15), there were no significant differences in readmission rate (4.5% vs. 3.8%, P = 0.655), ICU LOS (3.00 ± 4.40 vs. 2.92 ± 3.23 days; P = 0.790), ICU mortality (1.0% vs. 0, P = 0.117), and hospital mortality (1.0% vs. 0, P = 0.117). Conclusions: Critical care TPs may decrease ICU mortality and hospital mortality in critically ill cancer patients with APACHE II >15. It has no role in less severe critically ill cancer patients with APACHE II ≤15.

Keywords: Cancer, critical care transition programs, critically ill, short-term outcome

How to cite this article:
Xing XZ, Wang HJ, Qu SN, Huang CL, Zhang H, Wang H. The Effect of Critical Care Transition Programs on the Short-Term Outcomes of Critically Ill Cancer Patients: A Propensity Score Matching Study. J Transl Crit Care Med 2019;1:96-9

How to cite this URL:
Xing XZ, Wang HJ, Qu SN, Huang CL, Zhang H, Wang H. The Effect of Critical Care Transition Programs on the Short-Term Outcomes of Critically Ill Cancer Patients: A Propensity Score Matching Study. J Transl Crit Care Med [serial online] 2019 [cited 2023 Mar 31];1:96-9. Available from: http://www.tccmjournal.com/text.asp?2019/1/3/96/299479

Introduction

Transition of critically ill patients who recovered to general hospital ward may expose patients at increased risk of readmission to intensive care unit (ICU) or death. Readmission to ICU was associated with a higher risk for hospital mortality and a longer hospital stay.^[1] As a result, how to decrease intensive care readmission is a key problem for healthcare providers. Critical care transition programs (TPs) may provide safe transition of patients who discharge from ICU to a general hospital ward.^[2] Indeed, a recent meta-analysis incorporating 16,433 patients found that patients who underwent critical care TPs had a readmission rate or mortality of 5.6%, which is significantly lower than that of 7.1% in usual care group.^[3] In another study, Kheir et al. performed a before and after study in medical ICU (MICU) and found that implementation of post-ICU transition of care significantly decreased duration of hospital stay after MICU transfer, although readmission and mortality rate was not changed.^[4]

However, in a larger sample study including 32,234 patients in Canada, implementation of critical care TPs in medical-surgical ICU was not associated with reduced readmission to ICU or mortality, which raised the question of usefulness of critical care TPs.^[5]

There is no study concerning the usefulness of critical care TPs in critically ill cancer patients. Therefore, we performed this study in a surgical ICU in a comprehensive cancer center to investigate whether critical care TPs decrease the readmission to ICU or mortality in critically ill cancer patients.

Methods

Data of patients who admitted to the ICU at National Cancer Center/National Clinical Research Center for Cancer, Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC). between September 2017 and August 2018 were retrospectively collected and reviewed. This study was approved by the Institutional Review Board of National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, CAMS and PUMC and performed in accordance with the ethical standards of the 1964 Declaration of Helsinki and its later amendments. Patients' consents were waived because of the observational nature of this study.

Patients were grouped as TP group or non-TP (nTP) group according to whether patients received post-ICU follow-up.

Critical care TPs in our center were defined as followed. After the patients were discharged from the ICU, an associate professor (Xing XZ) in the ICU evaluated patients within 24 h following discharge of ICU to the general ward. In addition to routine follow-up, the ICU physician would communicate with the attending doctor of general ward if needed and provide advice and support.

Primary outcome was readmission/in-hospital mortality, and secondary outcomes were ICU mortality rate, ICU length of stay (LOS), and hospital LOS.

Statistical analyses were carried out using SPSS software for Windows, Version 16.0 (SPSS Inc., Chicago, IL, USA). Continuous variables are presented as mean ± standard deviation and compared, respectively, using Student's t-test. Categorical variables were reported as absolute numbers (frequency and percentages) and analyzed using χ² test. To balance the confounding factors, we made propensity score analysis, according to Austin.^[6] For propensity score analysis, we first made the logistic regression model that calculated propensity scores receiving TPs (TP or nTP group) as outcome with age, sex, comorbidities (hypertension, coronary heart disease, diabetic mellitus, and chronic obstructive pulmonary disease), preoperative chemotherapy or radiotherapy, type of procedures (thoracic surgery, abdominal surgery, head surgery, other surgery, and nonoperation), and severity score on ICU admission (Acute Physiology and Chronic Health Evaluation II [APACHE II]; and Simplified Acute Physiology Score 3 [SAPS 3]; and Sequential Organ Failure Assessment [SOFA]). Patients with propensity scores lower than 0.10 (high chance of undergoing nTP) and higher than 0.90 (high chance of undergoing TP) were excluded. We then performed analysis for all matched patients. Patients were grouped as severe group with APACHE II score >15 and less severe group with APACHE II score ≤15. Subgroup analysis was made with comparison of primary and secondary outcomes between these two groups. The significant level was set as a P < 0.05.

Results

In unmatched groups, compared with patients in nTP group, patients in TP group had more thoracic surgeries (29.1% vs. 21.7%, P = 0.017) and were more severe with higher APACHE II score (8.85 ± 5.63 vs. 8.12 ± 3.67; P = 0.018), higher SAPS 3 score (37.15 ± 14.78 vs. 34.84 ± 11.16; P = 0.008), and higher SOFA (3.08 ± 2.97 vs. 2.57 ± 2.02; P = 0.002) score [Table 1]. Compared with patients in nTP group, patients in TP group had decreased ICU mortality (0 vs. 3.1%, P = 0.001) and decreased in-hospital mortality (0 vs. 3.2%, P = 0.001). There were no significant differences in readmission rate or readmission/in-hospital mortality (6.3% vs. 7.4%, P = 0.535) and ICU LOS (3.24 ± 4.67 vs. 3.10 ± 3.68; P = 0.662) between TP and nTP groups. However, patients in TP group had longer hospital LOS compared with patients in nTP group (20.07 ± 12.07 vs. 15.94 ± 12.09; P < 0.001) [Table 2].

Table 1: General characteristics of patients who received critical care transition programs or not before or after propensity score matching

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Table 2: Short-term outcomes of patients who received critical care transition programs or not before or after propensity score matching

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After matching, there were no significant differences in type of procedures and severity scores (all >0.05) between TP and nTP groups [Table 1]. There were no significant differences in readmission rate, in-hospital mortality, readmission/in-hospital mortality, ICU LOS, and hospital LOS between TP and nTP groups (all >0.05). Patients in TP group had longer hospital LOS compared with patients in nTP group (19.82 ± 11.59 vs. 14.66 ± 10.04; P < 0.001) [Table 2].

Subgroup analysis demonstrated that in severe group, compared with nTP group, patients in TP group had increased readmission rate (8.3% vs. 62.5%, P < 0.001) and increased duration of hospital LOS (13.92 ± 10.54 vs. 26.38 ± 15.46 days; P = 0.003). However, no significant differences were found in ICU LOS (5.56 ± 6.39 vs. 8.62 ± 9.31 days; P = 0.223). There is a trend that ICU mortality (23.6% vs. 0, P = 0.121) and hospital mortality (25.8% vs. 0, P = 0.108) were decreased in TP group than nTP group [Table 3]. In less severe group, there were no significant differences in readmission rate (4.5% vs. 3.8%, P = 0.655), ICU LOS (3.00 ± 4.40 vs. 2.92 ± 3.23 days; P = 0.790), ICU mortality (1.0% vs. 0, P = 0.117), and hospital mortality (1.0% vs. 0, P = 0.117). However, patients in TP group had increased duration of hospital LOS compared with nTP group (16.15 ± 11.23 vs. 19.87 ± 11.93 days; P < 0.001).

Table 3: Subgroup analysis of short term outcomes of severe and less severe patients who received critical care transition programs or not before or propensity score matching

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Discussion

In this study, we found that critical care TPs were not associated with a decrease in readmission/in-hospital mortality. However, there is trend that critical care TPs may decrease ICU mortality and hospital mortality in critically ill patients with APACHE II >15.

Readmission to ICU depends on several aspects including patient factors, process factors, provider factors, and organizational factors.^[7] Critical care TP belongs to process factors which may partly explained that implementation of critical care TP solely may not reduce readmission to ICU rate. In our study, to balance the patient factors such as severity scores, we made propensity score matching. However, no significant difference was found in readmission/in-hospital mortality between two groups. The reason may lie in organizational factors such as resource constrains and institutional policy. For example, a patient may readmit to ICU because of cardiac arrhythmias which doctors in the general ward may worry about patient situation and advice patient admission to ICU for further management. Our previous study found that 82% of readmission to ICU was unpreventable.^[8] Therefore, critical care TP may not reduce the risk of most ICU readmissions.

On the other hand, we found that patients who received critical care TP had longer hospital LOS compared with patients who did not receive critical care TP although there was no significant difference in ICU LOS between these two groups. It is well known that postoperative morbidity such as sepsis and complexity of procedures may prolong hospital LOS. For example, thoracic surgeries consist of esophagectomy and pulmonary lobectomy; abdominal surgeries consist of gastrectomy, colectomy, and duodenopancreatectomy. Grades of complications after these procedures varied which influence postoperative mortality and hospital LOS. In recent years, the development of enhanced recovery after surgery and minimally invasive surgery may also shorten hospital LOS.^[9] Further studies are needed to study the influencing factors of hospital LOS in oncologic surgical patients.

In this study, subgroup analysis demonstrated that there is a trend that patients in severe group with APACHE II score >15 who underwent TP had decreased ICU mortality and hospital mortality compared with nTP patients. Although, they had increased readmission rate and increased hospital length of stay compared with nTP patients. However, in less severe group with APACHE II score ≤15, whether TP or nTP had no influence on readmission rate, ICU mortality, and hospital mortality. Therefore, severe patients with APACHE II score >15 may benefit from TP. Further studies are needed to clarify the role of TP in critically ill patients with APACHE II score >15. In our study, severe patients may benefit from TP. The reason may lie in that severe patients readmitted to the ICU and received appropriate and timely treatment after TP. Therefore, severe patients had increased ICU readmission rates and prolonged hospital LOS after TP.

There are several limitations in this study. First, the results of this study are from a single cancer center, which may not be generalized to other cancer centers. Second, the sample of this study is relatively small. More studies are needed to validate our results. Finally, there are no long-term survival results.

conclusions

Critical care TPs may decrease ICU mortality and hospital mortality in critically ill cancer patients with APACHE II >15. It had no effect on readmission/in-hospital mortality in less severe critically ill cancer patients with APACHE II ≤15.

Financial support and sponsorship

The study was supported by Management Research Special Fund of Cancer Hospital of Chinese Academy of Medical Sciences (LC2017D06).

Conflicts of interest

There are no conflicts of interest.

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