Intensivist Care Improves ICU Outcomes
Abstract & Commentary
Synopsis: This carefully done systematic review of the existing literature shows that overall mortality and ICU length of stay are better with increasing involvement of critical care physicians in patient care.
Source: Pronovost PJ, et al. JAMA. 2002;288: 2151-2162.
Pronovost and Associates performed a comprehensive review of reported studies on the effects of ICU physician staffing on mortality and length of stay (LOS). After screening all published articles captured by a large number of relevant medical subject heading terms, along with 2590 abstracts presented at meetings, Pronovost et al identified 26 studies that met their criteria, all of them observational in design. They grouped physician staffing into low-intensity (no intensivist or elective intensivist consultation at the discretion of the primary physician) vs high-intensity staffing [all care directed by intensivists (closed ICU) or mandatory intensivist consultation].
High-intensity staffing was associated with lower hospital mortality (pooled relative risk, 0.71; 95% confidence interval, 0.62-0.82) and lower ICU mortality (RR, 0.61; 95% CI 0.50-0.75). High-intensity staffing was also associated with reduced hospital LOS in 10 of 13 studies and reduced ICU LOS in 14 of 18 studies; in 4 studies that adjusted for case mix, 2 showed reduced hospital and ICU LOS and 2 did not. Although not every study showed positive effects, there were no studies that found increased LOS with high-intensity staffing after case-mix adjustment.
Comment by David J. Pierson, MD
Although it does not tell us why, this study pretty convincingly demonstrates that mortality and LOS are better the more intensivists are involved in the care of critically ill patients. An inherent problem with this literature is the inability to make care by intensivists vs nonintensivists the only variable. Pronovost et al were unable to find any randomized controlled trials of intensivist- vs nonintensivist ICU care. While such trials would be more scientifically rigorous than the observational studies currently available, it is pretty unlikely that they will be done. Thus we cannot be certain about the reasons for the improved outcomes in units heavily staffed by intensivists. In all probability it is not just the intensivist per se, but also the multiple organizational and system features present in ICUs with high-intensity intensivist exposure, that makes the difference.
This notion is especially important in interpreting "before-and-after" studies, in which there was typically less organization, standardization, and scrutiny of ICU care before the intensivists took over the unit. This is a limitation of the present study if the presence of an intensivist is the specific variable one is trying to study, but much less so if one’s interest is in the process of care. The intensivist is the catalyst, or at least a marker, for the constellation of things that happen with present-day ICU organization, which also appear to improve mortality and LOS.
Also of concern in "before-and-after" cohort studies is the possible effect of temporal trends. Outcomes may progressively improve over time because of things unrelated to ICU organization. At my institution, a substantial, progressive improvement in survival among patients with ARDS was documented during the decade ending in 1993, despite the absence of identifiable changes in patient population or approaches to management.1 The organization of our ICUs did not change during that time, but if it had—say, with adoption of a closed-ICU system midway through the study period—this temporal trend might have been interpreted as evidence of the positive effects of the new staffing system on ARDS survival.
These caveats notwithstanding, the Pronovost study is rigorous and strongly supportive of the conclusion that ICU care by intensivists improves outcomes. This paper is likely to be influential as discussions of healthcare organization, physician workforce, and ICU organization continue both locally and at the national policy level.
Dr. Pierson is Professor of Medicine University of Washington Medical Director Respiratory Care Harborview Medical Center, Seattle.
Reference
1. Milberg JA, et al. Improved survival of patients with acute respiratory distress syndrome (ARDS): 1983-1993. JAMA. 1995;273(4):306-309.
Synopsis: This carefully done systematic review of the existing literature shows that overall mortality and ICU length of stay are better with increasing involvement of critical care physicians in patient care.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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