CHEST
Volume 146, Issue 4, October 2014, Pages 916-923
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Original Research
Aggressiveness of Intensive Care Use Among Patients With Lung Cancer in the Surveillance, Epidemiology, and End Results-Medicare Registry

https://doi.org/10.1378/chest.14-0477Get rights and content

BACKGROUND

Approximately 65% of elderly patients with lung cancer who are admitted to the ICU will die within 6 months. Efforts to improve end-of-life care for this population must first understand the patient factors that underlie admission to the ICU.

METHODS

We performed a retrospective cohort study examining all fee-for-service inpatient claims in the Surveillance, Epidemiology, and End Results (SEER)-Medicare registry for elderly patients (aged > 65 years) who had received a diagnosis of lung cancer between 1992 and 2005 and who were hospitalized for reasons other than resection of their lung cancer. We calculated yearly rates of ICU admission per 1,000 hospitalizations via room and board codes or International Classification of Diseases, Ninth Revision, Clinical Modification and diagnosis-related group codes for mechanical ventilation, stratified the rates by receipt of mechanical ventilation and ICU type (medical/surgical/cardiac vs intermediate), and compared these rates over time.

RESULTS

A total of 175,756 patients with lung cancer in SEER were hospitalized for a reason other than surgical resection of their tumor during the study period, 49,373 (28%) of whom had at least one ICU stay. The rate of ICU admissions per 1,000 hospitalizations increased over the study period from 140.7 in 1992 to 201.7 in 2005 (P < .001). The majority of the increase in ICU admissions (per 1,000 hospitalizations) between 1992 and 2005 occurred among patients who were not mechanically ventilated (118.2 to 173.3, P < .001) and among those who were in intermediate ICUs (20.0 to 61.9, P < .001), but increased only moderately in medical/surgical/cardiac units (120.7 to 139.9, P < .001).

CONCLUSIONS

ICU admission for patients with lung cancer increased over time, mostly among patients without mechanical ventilation who were largely cared for in intermediate ICUs.

Section snippets

Design

We conducted a retrospective cohort study examining the Surveillance, Epidemiology, and End Results (SEER)-Medicare registry, a publically available database provided by the National Cancer Institute.12 The SEER program collects extensive information, including cancer type, histology, and stage of disease, for patients given a diagnosis of cancer living in one of the SEER geographic regions. Through its links to Medicare, the SEER-Medicare registry provides a comprehensive way to assess

Results

Of the 175,756 patients with lung cancer, 49,373 patients (28%) had at least one ICU admission for reasons other than surgical resection of their lung cancer, and 90,675 patients (52%) had at least one non-ICU hospitalization (Table 1). Among patients with an ICU admission, 15,932 involved a stay in an intermediate ICU. Compared with patients hospitalized outside an ICU, patients in an ICU were more often younger, male, and of nonwhite race. Patients in an ICU also had a greater median annual

Discussion

We demonstrated that between 1992 and 2005, there was close to a 40% increase in the use of ICUs for the care of elderly patients with lung cancer hospitalized for reasons other than resection of their tumor. Increases in ICU admission were greatest among individuals not requiring MV, as well as among those hospitalized in intermediate units rather than in full-service ICUs. Most patients were hospitalized in an ICU for reasons directly related to their underlying lung cancer, but diagnoses of

Conclusions

In summary, we found that growth in the use of the ICU for patients with lung cancer over time is greatest among patients admitted to intermediate ICUs, a location where more elderly were admitted relative to other ICU types. Lung cancer was a common reason to be admitted to the ICU, but respiratory failure and sepsis as causes for ICU admission are increasing. ICU use was more common among patients who were younger and those who had greater comorbid illness, as well as those with nondistant

Acknowledgments

Author contributions: C. R. C. and C. G. S. contributed to the conception of the study and drafting or revision of the manuscript for important intellectual content and take full responsibility for the content of the manuscript, including the integrity of the data and the accuracy of the analysis. L. C. F. and R. S. W. contributed to the interpretation of the data and revision of the manuscript for important intellectual content; C. R. C., M. E. O., and C. G. S. contributed to the data

References (27)

  • RS Morrison et al.

    The growth of palliative care programs in United States hospitals

    J Palliat Med

    (2005)
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    FUNDING/SUPPORT: This work was supported in part by the Agency for Healthcare Research and Quality [Grant K08 HS020672 to Dr Cooke], the National Cancer Institute [Grant K07 CA138772 to Dr Wiener], the National Heart, Lung and Blood Institute [Grant K23 HL111116 to Dr Feemster], and the Department of Veterans Affairs [to Drs Wiener and Feemster].

    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.

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