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Among patients whose need for intensive care is uncertain, the relationship of intensive care unit (ICU) admission with mortality and costs is unknown.

To estimate the relationship between ICU admission and outcomes for elderly patients with pneumonia.

Retrospective cohort study of Medicare beneficiaries (aged >64 years) admitted to 2988 acute care hospitals in the United States with pneumonia from 2010 to 2012.

ICU admission vs general ward admission.

Primary outcome was 30-day all-cause mortality. Secondary outcomes included Medicare spending and hospital costs. Patient and hospital characteristics were adjusted to account for differences between patients with and without ICU admission. To account for unmeasured confounding, an instrumental variable was used—the differential distance to a hospital with high …