Association between Critical Care Physician Management and Patient Mortality in the Intensive Care Unit

Association between Critical Care Physician Management and Patient Mortality in the Intensive Care Unit

From Brown University, Providence, Rhode Island; Mount Holyoke College, South Hadley, Massachusetts; Ohio State University College of Health, Columbus, Ohio; Albert Einstein College of Medicine, New York, New York; and National Institutes of Health, Bethesda, Maryland.

Abstract

Background: Critically ill patients admitted to intensive care units (ICUs) are thought to gain an added survival benefit from management by critical care physicians, but evidence of this benefit is scant.

Objective: To examine the association between hospital mortality in critically ill patients and management by critical care physicians.

Design: Retrospective analysis of a large, prospectively collected database of critically ill patients.

Setting: 123 ICUs in 100 U.S. hospitals.

Patients: 101 832 critically ill adults.

Measurements: Through use of a random-effects logistic regression, investigators compared hospital mortality between patients cared for entirely by critical care physicians and patients cared for entirely by non–critical care physicians. An expanded Simplified Acute Physiology Score was used to adjust for severity of illness, and a propensity score was used to adjust for differences in the probability of selective referral of patients to critical care physicians.

Results: Patients who received critical care management (CCM) were generally sicker, received more procedures, and had higher hospital mortality rates than those who did not receive CCM. After adjustment for severity of illness and propensity score, hospital mortality rates were higher for patients who received CCM than for those who did not. The difference in adjusted hospital mortality rates was less for patients who were sicker and who were predicted by propensity score to receive CCM.

Limitation: Residual confounders for illness severity and selection biases for CCM might exist that were inadequately assessed or recognized.

Conclusion: In a large sample of ICU patients in the United States, the odds of hospital mortality were higher for patients managed by critical care physicians than those who were not. Additional studies are needed to further evaluate these results and clarify the mechanisms by which they might occur.

Article and Author Information

Disclaimer: The opinions expressed in this paper are those of the authors and do not reflect policies of the National Institutes of Health or the U.S. Department of Health and Human Services.
Acknowledgment: The authors thank Rito Bergemann MD, PhD; Laura Katz, MPH; Lisa Siegartel, MPH; and J.J. Doyle, PhD, whose initial statistical support contributed to the initial observation, and Barbara Shott, who assisted in preparing the manuscript.
Grant Support: By the National Institutes of Health Clinical Center and an unrestricted educational grant from Eli Lilly.
Potential Financial Conflicts of Interest:Consultancies: D.B. Chalfin (Project IMPACT).
Reproducible Research Statement:Study protocol: Not available. Statistical code: Available from Mr. Phillips (gary.phillips{at}osumc.edu). Data set: Available for purchase from Cerner Corporation (http://www.cerner.com/piccm).
Requests for Single Reprints: Mitchell M. Levy, MD, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903; e-mail, Mitchell_Levy{at}brown.edu.
Current Author Addresses: Dr. Levy: Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903.
Dr. Rapoport: Department of Economics, Mount Holyoke College, 50 College Street, South Hadley, MA 01077.
Dr. Lemeshow: Ohio State University College of Health, M116 Starling Loving Hall, 320 West 10th Avenue, Columbus, OH 43210-1240.
Dr. Chalfin: Abbott Point of Care, 104 Windsor Center Boulevard, East Windsor, NJ 08520.
Mr. Phillips: Ohio State University Center for Biostatistics, M410 Starling Loving Hall, 320 West 10th Avenue, Columbus, OH 43210.
Dr. Danis: Department of Bioethics, National Institutes of Health, Building 10 Room 1C118, Bethesda, MD 20892-1156.
Author Contributions: Conception and design: J. Rapoport, D.B. Chalfin, M. Danis, M.M. Levy.
Analysis and interpretation of the data: J. Rapoport, S. Lemeshow, D.B. Chalfin, G. Phillips, M. Danis, M.M. Levy.
Drafting of the article: J. Rapoport, D.B. Chalfin, G. Phillips, M.M. Levy.
Critical revision of the article for important intellectual content: J. Rapoport, S. Lemeshow, D.B. Chalfin, G. Phillips, M. Danis, M.M. Levy.
Final approval of the article: J. Rapoport, S. Lemeshow, M. Danis, M.M. Levy.
Statistical expertise: J. Rapoport, S. Lemeshow, G. Phillips.
Obtaining of funding: M. Danis.

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