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Does Intensivist Care Harm Patients in the ICU?

Surprisingly, results of a large cohort study suggest that intensivist care is associated with higher mortality in critically ill patients.

Critical care units in the U.S. involve intensivists to varying degrees, ranging from mandatory handoff (closed intensive care unit [ICU] model) to no handoff (open-ICU model); outside the U.S., transfer of care to intensivists generally is mandatory. With a predicted shortage of intensivist physicians in the U.S., we are likely to see more open-ICU models, with elective or mandated consultation by intensivists. Prior evidence suggested that ICU outcomes are better when patients are managed by intensivists, but some experts (including the authors of this study) believe that these studies had methodologic limitations.

To examine this issue further, researchers extracted data on more than 100,000 patients in 123 ICUs in the U.S. from Project IMPACT, a U.S. national database that was not designed to address intensivists’ effects on patient outcomes in the ICU. Overall hospital mortality rates were derived by first applying a propensity score (the likelihood, based on clinical and environmental factors and illness severity, that a given patient would be managed by an intensivist) to each patient and then analyzing the groups who did or did not receive intensivist care.

Overall, patients who were managed by intensivists were sicker, underwent more procedures, and had higher hospital mortality rates than did patients who were not managed by intensivists. The higher hospital mortality rates among patients who received care from intensivists, compared with those who received care from only non–critical care physicians, persisted even after adjustment for severity of illness and other potential confounders.

Comment: The results of this study contradict previous findings and could bring into question our current models of provision of critical care in the U.S. Among this study’s many limitations, the chief caveat is that unrecognized confounders (factors that were not tracked by the Project IMPACT database and were not included in the propensity score) likely contributed to these unexpected findings. Probably, use of protocols and order sets, nursing-staff ratios, degree of staff training, number of physician transfers, and model of critical care physician management (full-time intensivists vs. office-based pulmonary critical care specialists) all had marked effects on patient outcomes.

For the care of critically ill patients, this study’s findings highlight the importance of identifying characteristics that are associated with superior-performing ICU teams and demonstrate that the involvement of intensivists does not guarantee better patient outcomes. Future efforts should focus on identifying factors that do lead to better outcomes.

— Aaron J. Calderon, MD, FACP

Published in Journal Watch Hospital Medicine June 9, 2008

Citation(s):

Levy MM et al. Association between critical care physician management and patient mortality in the intensive care unit. Ann Intern Med 2008 Jun 3; 148:801.

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• Medline abstract (Free)

Rubenfeld GD and Angus DC. Are intensivists safe? Ann Intern Med 2008 Jun 3; 148:877.

• Original article (Subscription may be required)
• Medline abstract (Free)