Intensive care contributes to a substantial part of health care expenses. Admission to intensive care units is associated with a high mortality rate and a high risk of long-term disability. Data from several studies suggest that suboptimal standards of intensive care are relatively common. Lack of knowledge regarding the use of intensive care and long-term outcome as well as the effectiveness and adverse effects of intensive care impede a systematic and evidence-based development and quality improvement. An initiative to establish a Danish national clinical database for intensive care has been launched.
To examine whether there is geographical variation in the use of intensive care resources in Denmark concerning both intensive care unit (ICU) admission and use of specific interventions. Substantial variation in use of intensive care has been reported between countries and within the US, however, data on geographical variation in use within more homogenous tax-supported health care systems are sparse.
We conducted a population-based cross-sectional study based on linkage of national medical registries including all Danish residents between 2008 and 2012 using population statistics from Statistics Denmark. Data on ICU admissions and interventions, including mechanical ventilation, noninvasive ventilation, acute renal replacement therapy, and treatment with inotropes/vasopressors, were obtained from the Danish Intensive Care Database. Data on patients' residence at the time of admission were obtained from the Danish National Registry of Patients.
The overall age- and gender standardized number of ICU patients per 1000 person-years for the 5-year period was 4.3 patients (95 % CI, 4.2; 4.3) ranging from 3.7 (95 % CI, 3.6; 3.7) to 5.1 patients per 1000 person-years (95 % CI, 5.0; 5.2) in the five regions of Denmark and from 2.8 (95 % CI, 2.8; 3.0) to 23.1 patients per 1000 person-years (95 % CI, 13.0; 33.1) in the 98 municipalities. The age-, gender-, and comorbidity standardized proportion of use of interventions among ICU patients also differed across regions and municipalities.
There was only minimal geographical variation in the use of intensive care admissions and interventions at the regional level in Denmark, but more pronounced variation at the municipality level.
We examined rates of first hospitalization for COPD, rates of 5-year mortality among patients hospitalized for COPD, and comparisons of mortality between COPD patients and a matched cohort free of COPD. We computed standardized rates of first COPD hospitalization. Using Cox regression, we compared 180- and 181-day to 5-year mortality among COPD patients with the comparison cohort. We used medical databases in Denmark (population 5.4 million) from 1997 to 2006. We included patients 40 years or older with first hospitalization for COPD (64,499) and an age- and gender-matched comparison cohort of persons without COPD hospitalization (322,495). We examined the incidence of COPD hospitalization and risks and rates of mortality in the 5 years after hospitalization. Standardized rates of first hospitalization for COPD declined from 276 per 100,000 person-years in 1999 to 231 per 100,000 person-years in 2006. Within 180 days of hospitalization, 16% of COPD patients and 2.4% of persons in the matched cohort died (adjusted hazard ratio = 7.00, 95% CI = 6.79-7.22). Between 181 days and 5 years, 46% of COPD patients who survived the first 180 days and 19% of persons in the comparison cohort died (adjusted hazard ratio = 2.91, 95% CI = 2.86-2.95). COPD and comorbid diseases interacted to increase mortality in the first 180 days, but not thereafter. COPD continues to be a major public health problem causing substantial mortality in the 5 years after hospitalization, particularly in the first 180 days and in patients with comorbid diseases.
COPD is associated with an increased risk of peptic ulcer disease, but limited data exist on whether COPD influences short-term mortality among patients with bleeding and a perforated peptic ulcer. We examined the association between COPD and 30-day mortality following bleeding and perforation of a peptic ulcer.
We identified all patients who had been hospitalized with a first-time diagnosis of peptic ulcer perforation (n = 2,033) or bleeding (n = 7,486) in northern Denmark between 1991 and 2004. Information on COPD, comorbidities, and filled prescriptions was obtained from medical databases. Mortality was ascertained using the Danish Civil Registration System. We computed the cumulative 30-day mortality rates for ulcer patients with COPD and for other ulcer patients, and used regression analysis to obtain the 30-day mortality rate ratios (MRRs), controlling for potential confounding factors.
Among patients who were hospitalized with perforated peptic ulcers, 218 (10.7%) had previously been hospitalized with COPD. The 30-day mortality rate was 44.0% among perforated ulcer patients with COPD vs 25.5% among other ulcer patients (adjusted MRR, 1.48; 95% confidence interval [CI], 1.18 to 1.85). Among patients hospitalized with a bleeding peptic ulcer, 759 (10.1%) had previously been hospitalized with COPD. The 30-day mortality rate was 16.5% among bleeding peptic ulcer patients with COPD vs 10.8% among other ulcer patients (adjusted MRR, 1.38; 95% CI, 1.14 to 1.68). The use of oral glucocorticoids among COPD patients was associated with higher MRRs for both perforated and bleeding peptic ulcers.
COPD substantially increased 30-day mortality among patients with bleeding and perforated peptic ulcers.
Multiple sclerosis (MS) patients may be at increased risk of venous thromboembolism (VTE), but evidence is limited.
To examine long-term risk of VTE among MS patients.
We conducted a population-based cohort study among 17,418 Danish MS patients and 87,090 comparison cohort members from the general population. Data on MS, VTE and comorbidities were obtained from the Danish National Registry of Patients including all admissions to Danish hospitals since 1977. We computed cumulative risks for VTE and adjusted incidence rate ratios (IRRs).
A total of 34 (0.2%) MS patients and 36 (0.04%) comparison cohort members had a deep venous thrombosis (DVT) within 1 year following the date of initial MS diagnosis/index date [adjusted IRR = 3.02 (95% CI: 2.14-4.27)]. During this period, 16 (0.09%) MS patients and 26 (0.03%) comparison cohort members had a documented pulmonary embolism (PE) [adjusted IRR = 2.85 (95% CI: 1.72-4.70)]. During the subsequent up to 29 years, 315 (1.9% of MS patients alive at year 1) MS patients had a record of a DVT [adjusted IRR = 2.28 (95% CI: 2.01-2.59)] and 129 (0.8%) had PE [IRR = 1.58 (95% CI: 1.31-1.92].
MS is a risk factor for VTE, but the absolute risk is low.
Beta-blockers have cardioprotective, metabolic and immunomodulating effects that may be beneficial to patients in intensive care. We examined the association between preadmission beta-blocker use and 30-day mortality following intensive care.
We identified 8,087 patients over age 45 admitted to one of three multidisciplinary intensive care units (ICUs) between 1999 and 2005. Data on the use of beta-blockers and medications, diagnosis, comorbidities, surgery, markers of socioeconomic status, laboratory tests upon ICU admission, and complete follow-up for mortality were obtained from medical databases. We computed probability of death within 30 days following ICU admission for beta-blocker users and non-users, and the odds ratio (OR) of death as a measure of relative risk using conditional logistic regression and also did a propensity score-matched analysis.
Inclusion of all 8,087 ICU patients in a logistic regression analysis yielded an adjusted OR of 0.82 (95% confidence interval (CI): 0.71 to 0.94) for beta-blocker users compared with non-users. In the propensity score-matched analysis we matched all 1,556 beta-blocker users (19.2% of the entire cohort) with 1,556 non-users; the 30-day mortality was 25.7% among beta-blocker users and 31.4% among non-users (OR 0.74 (95% CI: 0.63 to 0.87)]. The OR was 0.69 (95% CI: 0.54 to 0.88) for surgical ICU patients and 0.71 (95% CI: 0.51 to 0.98) for medical ICU patients. The OR was 0.99 (95% CI: 0.67 to 1.47) among users of non-selective beta-blockers, and 0.70 (95% CI: 0.58 to 0.83) among users of cardioselective beta-blockers.
Preadmission beta-blocker use is associated with reduced mortality following ICU admission.
Cites: Ann Surg. 1998 Aug;228(2):146-589712558
Cites: N Engl J Med. 1998 Aug 20;339(8):489-979709041
Cites: Dan Med Bull. 1999 Jun;46(3):263-810421985
Cites: Cytokine. 2005 Mar 7;29(5):208-1415760677
Cites: N Engl J Med. 2005 Jul 28;353(4):349-6116049209
INTRODUCTION: Statins reduce risk of cardiovascular events and have beneficial pleiotropic effects; both may reduce mortality in critically ill patients. We examined whether statin use was associated with risk of death in general intensive care unit (ICU) patients. METHODS: Cohort study of 12,483 critically ill patients > 45 yrs of age with a first-time admission to one of three highly specialized ICUs within the Aarhus University Hospital network, Denmark, between 2001 and 2007. Statin users were identified through population-based prescription databases. We computed cumulative mortality rates 0-30 days and 31-365 days after ICU admission and mortality rate ratios (MRRs), using Cox regression analysis controlling for potential confounding factors (demographics, use of other cardiovascular drugs, comorbidity, markers of social status, diagnosis, and surgery). RESULTS: 1882 (14.3%) ICU patients were current statin users. Statin users had a reduced risk of death within 30 days of ICU admission [users: 22.1% vs. non-users 25.0%; adjusted MRR = 0.76 (95% confidence interval (CI): 0.69 to 0.86)]. Statin users also had a reduced risk of death within one year after admission to the ICU [users: 36.4% vs. non-users 39.9%; adjusted MRR = 0.79 (95% CI: 0.73 to 0.86)]. Reduced risk of death associated with current statin use remained robust in various subanalyses and in an analysis using propensity score matching. Former use of statins and current use of non-statin lipid-lowering drugs were not associated with reduced risk of death. CONCLUSIONS: Preadmission statin use was associated with reduced risk of death following intensive care. The associations seen could be a pharmacological effect of statins, but unmeasured differences in characteristics of statin users and non-users cannot be entirely ruled out.
OBJECTIVE. Use of selective serotonin reuptake inhibitors (SSRIs) increases the risk of upper gastrointestinal bleeding and this risk is amplified by concomitant use of non-steroidal anti-inflammatory drugs (NSAIDs). The aim of the study was to examine the impact of SSRI use alone or in combination with NSAIDs on 30-day mortality after peptic ulcer bleeding (PUB). MATERIAL AND METHODS. A population-based cohort study of patients with a first hospitalization with PUB in three Danish counties was carried out between 1991 and 2005 using medical databases. We calculated 30-day mortality rate ratios (MRRs) associated with the use of SSRIs, alone or in combination with NSAIDs, adjusted for important covariates. RESULTS. Of 7415 patients admitted with PUB, 5.9% used SSRIs only, and 3.8% used SSRIs in combination with NSAIDs, with a 30-day mortality of 11.8% and 11.3%, respectively. Compared with patients who used neither SSRIs nor NSAIDs, the adjusted 30-day MRR was 1.02 (95% CI: 0.76-1.36) for current users of SSRIs and 0.89 (0.62-1.28) for the combined use of SSRIs with NSAIDs. There was a 2.11-fold (95% CI 1.35-3.30) increased risk of death associated with SSRI use starting within 60 days of admission; for those younger than 80 years, the adjusted MRR was 1.54 (0.72-3.29), and 2.57 (1.47-4.49) for those older than 80 years. CONCLUSIONS. Use of SSRIs, alone or in combination with NSAIDs, was not associated with increased 30-day mortality following PUB. However, increased mortality was found in patients who started SSRI therapy, particularly among those older than 80 years. We can only speculate on whether this finding is due to pharmacological action or confounding factors.
While some experimental and clinical research suggests that statins improve outcomes after severe infections, the evidence for pneumonia is conflicting. We examined whether preadmission statin use decreased risk of death, bacteremia, and pulmonary complications after pneumonia.
We conducted a population-based cohort study of 29,900 adults hospitalized with pneumonia for the first time between January 1, 1997, and December 31, 2004 in northern Denmark. Data on statin and other medication use, comorbidities, socioeconomic markers, laboratory findings, bacteremia, pulmonary complications, and death were obtained from medical databases. We used regression analyses to compute adjusted mortality rate ratios within 90 days and relative risks of bacteremia and pulmonary complications after hospitalization in both statin users and nonusers.
Of patients with pneumonia, 1371 (4.6%) were current statin users. Mortality among statin users was lower than among nonusers: 10.3% vs 15.7% after 30 days and 16.8% vs 22.4% after 90 days, corresponding to adjusted 30- and 90-day mortality rate ratios of 0.69 (95% confidence interval, 0.58-0.82) and 0.75 (0.65-0.86). Decreased mortality associated with statin use remained robust in various subanalyses and in a supplementary analysis using propensity score matching. In contrast, former use of statins and current use of other prophylactic cardiovascular drugs were not associated with decreased mortality from pneumonia. In statin users, adjusted relative risk for bacteremia was 1.07 (95% confidence interval, 0.69-1.67) and for pulmonary complications was 0.69 (0.42-1.14).
The use of statins is associated with decreased mortality after hospitalization with pneumonia.
Comment In: Arch Intern Med. 2009 Jun 8;169(11):107419506180
Comment In: Arch Intern Med. 2008 Oct 27;168(19):2067-818955634