Patients on respiratory support in rural intermediate care units have higher death rates

A new study finds that patients receiving ventilator life support in intermediate care units of rural hospitals had significantly higher death rates than patients in the same type of unit at urban hospitals.

Intermediate care units are a potentially less costly alternative for people not sick enough for the intensive care units (ICUs) but too ill for the general ward.  The study also found that patients with respiratory failure in the ICUs at rural and urban hospitals fare similarly. 

Published in the journal Annals of the American Thoracic Society, this study highlights the need for more careful evaluations of patients with breathing problems who are assigned to intermediate care units. 

“This study underscores the importance of learning more about how to best use intermediate care units and highlights the need to continue investing in rural hospitals to make sure all who need it have access to life saving care,” said Emily Harlan, M.D., of the Division of Pulmonary and Critical Care Medicine at University of Michigan Health. 

“There is a common belief that rural hospitals may have a lower quality of care, but that’s not what we saw for the ICU patients in our study.”

Patients on respiratory support studied

The research team, led by Harlan, collected data from 2010 to 2019 on 2.75 million hospitalizations of Medicare patients (65 years or older) who were on respiratory support at rural and urban hospitals across the country. 

The researchers conducted separate analyses for patients admitted to the general, intermediate, and ICU wards, and another analysis of patients in all the wards combined. 

When they compared patients in all the wards, they found that those receiving mechanical ventilation in rural hospitals had significantly higher 30-day death rates than those in urban hospitals. 

Difference in outcomes

However, when the researchers broke down the data by level of care, patients in the ICUs of rural and urban hospitals had a similar chance of dying. The difference in outcomes, the researchers discovered, was singularly explained by the higher mortality rates for patients in the rural intermediate care units – 37% died within 30 days compared to 31.3% in urban hospitals. 

When patients are admitted to a hospital, the least sick are taken to the general ward and the sickest go to the ICU. However, U.S. hospitals are increasingly shifting toward a model that incorporates intermediate care units, which use fewer resources and can be less expensive to operate than ICUs. These units may help a rural hospital’s financial bottom line, but how rural patients fared in them compared to their urban counterparts, was largely unknown.

Important implications

“This study has important implications for rural hospitals when determining how to care for their sickest patients on mechanical ventilation, as rural hospitals tend to be smaller and less resourced,” said Gustavo Matute-Bello, M.D., deputy director for the Division of Lung Diseases at the National Heart, Lung, and Blood Institute (NHLBI), part of NIH. 

“It emphasizes the need to assess whether rural intermediate care units can meet the complex demands of critically ill patients, and the importance of carefully evaluating the processes designed to care for them.”

Funding: This study is supported by NHLBI grants K23HL140165 and T32HL007749.

Citation: “Rural-urban differences in mortality among mechanically ventilated patients in intensive and intermediate care” Ann Am Thorac Soc., 2024. DOI: https://www.atsjournals.org/doi/abs/10.1513/AnnalsATS.202308-684OC 

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