Observational studyBMC infectious diseases2025
Impact of prefecture-level intensive care unit congestion on mortality in severe COVID-19 patients: a retrospective observational study in Japan.
Observational study in BMC infectious diseases, 2025. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
backgroundThe COVID-19 pandemic has placed unprecedented pressure on global healthcare systems, severely affecting the intensive care unit (ICU) capacity. Therefore, this study explored the association between prefecture-level ICU congestion and COVID-19 mortality in each prefecture of Japan.
methodsThis retrospective study analyzed data from the CRoss Icu Searchable Information System, covering all patients with COVID-19 who underwent mechanical ventilation with clearly documented initiation and cessation dates between January 1, 2020, and March 31, 2023. Prefecture-level ICU congestion was calculated as the total ventilator days over 2 weeks for severely ill patients with COVID-19, divided by the maximum potential ventilator days in the prefecture. Prefecture-level ICU congestion in each region was visualized by plotting time-series graphs capturing the temporal progression of congestion levels. Continuous variables were standardized, and missing data were imputed into 20 datasets by chained equations, assuming data missing at random. A mixed-effects logistic regression model was separately applied to each of the 20 multiply-imputed datasets generated during the imputation procedure to evaluate the association between prefecture-level ICU congestion and mortality. Estimates and standard errors from each model were pooled using Rubin's rules to obtain final combined results. A sensitivity analysis was performed using the same mixed-effects model, replacing the continuous congestion level with a categorical variable.
resultsA total number of 10,427 patients were included in this study, and the mortality rate was 22.7% in the original cohort, with 226 (1.9%) cases having missing data. Congestion levels varied by time and prefecture, ranging from 0 to over 1.5, indicating a strain beyond capacity. Median congestion level (interquartile range [IQR]) at admission was 0.3 (0.1, 0.7), and increased congestion level was statistically associated with increased mortality (odds ratio: 1.14; 95% confidential interval: 1.07-1.22). Sensitivity analysis showed consistent results, indicating the robustness of our findings.
conclusionsIncreased prefecture-level ICU congestion may be associated with increased COVID-19 mortality, warranting further investigation.
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