Abstract
We aimed to measure the relation betwixt ICU diligent measurement earlier the COVID-19 pandemic and the outcomes of ventilated COVID-19 patients. We analyzed ventilated patients with COVID-19 aged > 17 years and enrolled successful the J-RECOVER study, a retrospective multicenter observational survey conducted successful Japan betwixt January and September 2020. Based connected the fig of patients admitted to the ICU betwixt January and December 2019, the apical 3rd institutions were defined arsenic high-volume centers, the mediate 3rd ones arsenic middle-volume centers, and the bottommost 3rd ones arsenic low-volume centers. The superior result measurement was in-hospital mortality. Multivariate logistic regression investigation for in-hospital mortality and ICU diligent measurement was performed aft adjusting for aggregate propensity scores. Among 461 patients, 158, 158, and 145 patients were admitted to low-volume (20 institutions), middle-volume (14 institutions), and high-volume (13 institutions) centers, respectively. Admission to middle- and high-volume centers was not importantly associated with in-hospital decease compared with admittance to low-volume centers (adjusted likelihood ratio, 1.11 [95% assurance interval (CI): 0.55–2.25] and adjusted likelihood ratio, 0.81 [95% CI: 0.31–1.94], respectively). In conclusion, organization intensive attraction diligent measurement anterior to the COVID-19 pandemic was not importantly associated with in-hospital decease successful ventilated COVID-19 patients.
Introduction
The coronavirus illness 2019 (COVID-19) pandemic caused by terrible acute respiratory syndrome coronavirus benignant 2 (SARS-CoV-2) has go a large load connected wellness attraction systems worldwide1. One-fifth to one-third of hospitalized patients with COVID-19 go critically ill, and two-thirds of critically sick patients necessitate invasive mechanical ventilation2,3,4,5. The case-fatality complaint for these patients connected mechanical ventilation has been reported to beryllium astir 45%6. The COVID-19 pandemic has resulted successful an utmost summation successful request for intensive attraction portion (ICU) resources. Improvements successful the wellness attraction strategy and endurance rates for terrible COVID-19 are urgent issues.
An summation successful the fig of aesculapian and surgical patients improves the prognosis of patients, particularly those who are critically sick oregon person undergone analyzable surgical procedures7,8. Many studies suggest that ICU diligent outcomes are related to the fig of patients treated and the fig of beds available8,9,10,11,12,13,14. Therefore, critically sick patients whitethorn beryllium champion treated successful the ICU, wherever much high-risk patients are treated. However, determination are besides reports that the volume-outcome narration was not observed15,16,17,18,19 and that diligent outcomes are worse successful hospitals with a precocious fig of ventilated patients oregon precocious ICU occupancy rate20,21. Few studies person examined whether the result of COVID-19 ICU patients is amended successful hospitals that are accustomed to treating a precocious measurement of ICU patients. The introspection of the volume-outcome narration successful presumption of the accustomed fig of ICU patients and terrible COVID-19 whitethorn assistance amended the care, outcomes, and wellness attraction strategy of COVID-19 ICU patients.
We hypothesized that regular attraction of a ample fig of ICU patients and proficiency successful ICU attraction would beryllium associated with amended outcomes successful COVID-19 ICU patients. To measure our hypothesis, we investigated the relation betwixt organization ICU diligent measurement earlier the COVID-19 pandemic and outcomes successful ventilated ICU COVID-19 patients.
Methods
Study plan and setting
The existent survey was 1 of the information analyses from the J-RECOVER study. The J-RECOVER survey was a retrospective multicenter observational survey conducted successful Japan betwixt January and September 2020. The design, information postulation methods, and protocols of the J-RECOVER survey person been antecedently reported successful detail22. The existent survey was performed successful accordance with the Declaration of Helsinki. The contiguous survey was approved by the organization reappraisal boards of Nippon Medical School Musashikosugi Hospital (representative institution, exertion number:561-2-26), and the request for informed consent was waived due to the fact that of the anonymous quality of the information used. Treatment protocols were near to each institution.
Patients
The J-RECOVER survey included COVID-19 patients admitted to the participating institutions during the survey period. The contiguous survey included ventilated patients with terrible COVID-19 aged > 17 years and were enrolled successful the J-RECOVER study. Patients were excluded if they had missing information connected the fig of ICU admissions successful 2019 astatine the institution.
Data collection
The patients’ objective accusation was obtained from diagnosis process operation (DPC) information and aesculapian records. The DPC strategy is comprehensively evaluated for acute inpatient attraction costs. Administrative billing information person been created and stored electronically astatine each instauration nether a broad outgo strategy based connected DPC22,23. DPC information included sex, day of birth, the superior intent of attraction during hospitalization, day of admission, day of discharge, proscription of the patient, way of admission, infirmary referral oregon outpatient section admission, scheduled oregon exigency attraction admission, exigency ambulance transport, discharge destination, and the outcomes of discharge. In addition, different indispensable accusation that was not disposable from the DPC information was obtained from the institutions’ aesculapian records and personnel.
Measurements and definitions
The superior result measurement was in-hospital decease owed to COVID-19 during hospitalization. Intensive attraction measurement was defined arsenic the fig of patients admitted to the ICU betwixt January and December 2019, the twelvemonth earlier the COVID-19 pandemic, and it was subdivided into 3 categories, arsenic per erstwhile studies12,24,25 to measure the dose–response relationship. A cutoff fig was defined to find the fig of patients arsenic evenly arsenic possible. The apical 3rd institutions were defined arsenic high-volume centers, the mediate 3rd ones arsenic middle-volume centers, and the bottommost 3rd ones arsenic low-volume centers. We utilized the Charlson comorbidity scale to measurement underlying disease26. We utilized the Sequential Organ Failure Assessment (SOFA) people arsenic an scale of severity27.
Statistical analysis
Demographic factors, diligent characteristics, infirmary care, and outcomes were compared among patients treated successful high-, middle-, and low-volume centers. We analyzed trends successful discrete variables among the 3 groups utilizing the Mantel–Haenszel inclination trial and analyzed continuous variables utilizing the Kruskal–Wallis test.
Regarding missing values, we performed aggregate imputations28. Twenty aggregate imputed datasets were generated. We performed multivariate logistic regression analyses to measure the relation betwixt ICU lawsuit measurement and in-hospital decease successful each dataset, and the estimates were past combined.
Multiple propensity people investigation was utilized successful the multivariate investigation to set for measurable prehospital confounding factors29,30. The propensity people indicates the conditional probability of a circumstantial vulnerability fixed a bid of measured baseline variables and is simply a well-established method for reducing confounding effects successful observational studies. The propensity people is utilized to comparison 2 groups; however, the aggregate propensity people was utilized since this was a examination of 3 groups30,31,32. Moreover, alternatively of matching and IPTW, which are often utilized successful the examination of 2 groups utilizing propensity scores, aggregate propensity scores were utilized arsenic covariates successful the multivariate investigation to set for confounding factors since this is simply a three-group comparison. A aggregate propensity people is the conditional probability of being classified into 3 oregon much circumstantial groups, fixed a acceptable of observed baseline covariates. We adapted a multinomial logistic regression exemplary to estimation the aggregate propensity people for the contiguous analysis. The exemplary fell into 1 of the 3 groups on with infirmary characteristics, including teaching status, fig of infirmary beds, fig of ICU beds, diligent demographics (age, sex, and Charlson comorbidity index), and prehospital factors (number of days from grounds onset to hospitalization, fig of days from affirmative polymerase concatenation absorption trial to hospitalization, transportation from different hospital, and SOFA score). Multivariate logistic regression was past utilized to analyse the relation betwixt ICU measurement and in-hospital mortality, adjusting for aggregate propensity scores and in-hospital variables specified arsenic favipiravir, remdesivir, ICU admission, usage of prone position, and usage of extracorporeal membrane oxygenation (ECMO), portion besides adjusting for within-hospital clustering utilizing a generalized estimating equation.
All statistical analyses were two-sided, and a level of 0.05 was considered statistically significant. We analyzed the information utilizing SPSS statistical bundle mentation 26 (IBM, New York, USA).
Results
Patients
The J-RECOVER survey enrolled 4,700 patients with COVID-19 from 66 institutions. Among them, 561 patients aged > 17 years required ventilator absorption (Fig. 1). After excluding 100 cases with missing information connected the fig of ICU admissions successful 2019 astatine the instauration wherever they were admitted, 461 patients were included successful the analyses. A full of 158, 158, and 145 patients were admitted to low-volume (20 institutions), middle-volume (14 institutions), and high-volume (13 institutions) centers, respectively. There were nary ventilated patients successful 11 institutions, and determination were nary information connected the fig of ICU admissions successful 2019 successful 8 institutions that had ventilated diligent admissions.
Flowchart of the study.
Institutional accusation and diligent characteristics
There were nary important differences successful the fig of world hospitals, infirmary beds, patients per institution, and ECMO patients per instauration among the 3 groups (Table 1). Higher ICU lawsuit measurement showed a important inclination of higher ICU beds (< 0.001).
Characteristics of the survey colonisation were described successful Table 2. The proportionality of men successful the high-volume halfway was importantly higher than that of men successful the different 2 groups (p = 0.04). Higher ICU lawsuit measurement showed a importantly little SOFA people connected admittance (p = 0.03). Patients successful middle-volume centers had a little probability of prone presumption (p < 0.001).
The differences successful outcomes among institutions
There were nary important differences successful transportation to different department, transportation to different hospital, magnitude of enactment successful the hospital, magnitude of enactment successful ICU, and in-hospital decease among the 3 groups (Table 3).
Multivariate logistic regression analyses for 1 month endurance adjusted by aggregate propensity score
Admission to middle-volume centers was not importantly associated with in-hospital mortality compared with admittance to low-volume centers (adjusted likelihood ratio, 1.11 [95% assurance interval (CI): 0.55–2.25]. In addition, high-volume centers were not importantly associated with in-hospital mortality compared to admittance to low-volume centers (adjusted likelihood ratio, 0.81 95% CI: 0.31–1.94) aft accommodation for aggregate propensity scores and in-hospital variables (Table 4).
Discussion
The existent survey evaluated the relation betwixt the organization ICU diligent measurement earlier the COVID-19 pandemic and in-hospital mortality successful ventilated COVID-19 patients. There was nary important relation betwixt the organization ICU lawsuit measurement successful 2019 and in-hospital decease aft adjusting for diligent characteristics, organization information, and prehospital and in-hospital confounding factors. Since determination was minimal bias successful the proportionality of world hospitals, staffing ratio, precocious treatments specified arsenic ECMO, prone ventilation among the groups, size effect of result, and nary dose–response narration of volume-outcome, low-volume halfway whitethorn not worsen the result for terrible COVID-19. The findings from the contiguous survey whitethorn beryllium utile successful processing a aesculapian strategy for patients with terrible COVID-19.
While galore erstwhile studies evaluated the volume-outcome relationships successful captious attraction and recovered that precocious diligent volumes whitethorn amended endurance outcomes8,9,10,11,12,13,14, respective studies recovered nary association15,16,17,18,19. Some studies observed that precocious diligent volumes whitethorn beryllium associated with worse outcomes20,21. These variances among survey findings whitethorn beryllium owed to differences successful wellness attraction systems and infirmary types, ICU absorption developments, oregon differences successful statistical methods. What differentiated this survey from erstwhile volume-outcome narration studies regarding the fig of ICU patients treated and their outcomes is that it examined the relation betwixt the fig of pre-pandemic ICU patients and the outcomes of COVID-19 ICU patients. In different words, our survey examined whether institutions accustomed to ICU attraction tin amended the outcomes of COVID-19 ICU patients. We hypothesized that severely sick COVID-19 patients would beryllium champion treated successful ICUs that person treated higher-risk patients. However, contrary to our hypothesis, our survey did not observe a important relation betwixt the organization ICU diligent measurement earlier the COVID-19 pandemic and in-hospital mortality.
Several reasons could explicate wherefore determination was nary important relation betwixt organization ICU diligent measurement and outcomes for COVID-19 ventilated cases. Many of the participating hospitals successful this survey were tertiary exigency centers. Both centers with precocious and debased ICU diligent measurement successful 2019 whitethorn person been habitually proficient successful ICU care. There was minimal bias among the groups successful staffing ratios of exigency medicine and intensive attraction specialists. In addition, the Ministry of Health, Labour and Welfare (MHLW) has acceptable a modular of (at least) 1 caregiver per 2 patients successful each ICU. Advanced treatments specified arsenic ECMO and prone positioning were arsenic oregon much often performed astatine the smaller institutions. The availability of unit resources, adjacent successful smaller institutions, whitethorn beryllium 1 of the factors that contributed to the lack of a volume-outcome relationship. The fig of COVID-19 patients during the survey play was besides little biased among the 3 groups, suggesting that the ICU load from COVID-19 was not unbalanced. In addition, ICU resources for terrible COVID-19 were maintained successful Japan during the survey period33. In an ICU specified arsenic that successful Japan, that is, a strategy successful which determination are much than a definite fig of exigency physicians, intensivists, and nurses astatine the installation for each patient, determination whitethorn not beryllium a volume-outcome relationship. Further large-scale survey is needed to measure this generated hypothesis.
Previous studies examining volume-outcome relationships for ICU attraction person included patients with varying diseases alternatively than patients with a circumstantial illness oregon intervention34. The wide interaction is truthful unclear. The survey included COVID-19 patients who were connected ventilator management, giving a comparatively wide depiction of the diligent population. Multiple propensity scores were besides utilized to set for galore confounding factors specified arsenic diligent characteristics, organization information, and prehospital and in-hospital factors. Few studies person examined the relation betwixt ICU diligent measurement anterior to the COVID-19 pandemic and the outcomes of COVID-19 ICU patients. These results are considered important for constructing a wellness attraction system.
There were respective limitations successful the contiguous study. First, this survey did not person a ample fig of eligible institutions and cases. Thus, though this survey did not find a important quality betwixt ICU diligent measurement and outcome, a volume-outcome narration could not beryllium ruled out. Further prospective large-scale studies are needed to measure the relation betwixt ICU diligent measurement and the outcomes of patients with terrible COVID-19. Second, the J-RECOVER survey was not a population-based survey and was conducted astatine a unpaid hospital. The generalization of the results whitethorn beryllium limited. Third, respective patients were excluded owed to missing ICU admittance information successful 2019. Since the information are per-institution, patients were missing connected a per-institution basis, and the interaction connected the results is unknown.
Conclusions
In the contiguous study, organization ICU diligent measurement anterior to the COVID-19 pandemic was not importantly associated with in-hospital decease successful ventilated COVID-19 patients aft adjusting for diligent demographics, organization information, and prehospital and in-hospital factors. In ICUs with capable unit resources, tiny instauration whitethorn not worsen the outcome. Further prospective large-scale survey is needed to find the relation betwixt organization ICU diligent volumes and terrible COVID-19 outcomes.
Data availability
The datasets generated and/or analyzed during the existent survey are not publically disposable due to the fact that the usage of the information was constricted to institutions that participated successful the registry. Datasets are disposable from the corresponding writer upon tenable request.
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Cite this article
Amagasa, S., Kashiura, M., Yasuda, H. et al. Relationship betwixt organization intensive attraction measurement anterior to the COVID-19 pandemic and in-hospital decease successful ventilated patients with terrible COVID-19. Sci Rep 12, 22318 (2022). https://doi.org/10.1038/s41598-022-26893-6
Received: 01 May 2022
Accepted: 21 December 2022
Published: 24 December 2022
DOI: https://doi.org/10.1038/s41598-022-26893-6
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