Intensivists: don't quit your day job...yet!

Abstract

Management of critically ill patients by physicians with advanced training in critical care medicine has been associated with improved outcomes in a variety of disease states, such as acute lung injury [2] and intracranial hemorrhage [3], as well as following traumatic injury [4] and aortic [5] or esophageal [6] surgery. Additionally, a systematic review revealed that outcomes were better in a cohort of critically-ill patients managed by intensivists in high-intensity ICUs (defi ned as closed ICUs or ICUs with mandated intensivist consultation) as compared to low-intensity ICUs, with an overall reduction in the relative risk (RR) of both hospital and ICU mortality [7]. Furthermore, experts predict that there will be a shortage of critical care physicians in the very near future that is projected to increase dramatically as the population ages Expanded Abstract Citation Levy MM, Rapoport J, Lemeshow S, Chalfi n DB, Phillips G, and Danis M: Association between Critical Care Physician Management and Patient Mortality in the Intensive Care Unit. Ann Intern Med 2008 Jun 3, 148(11): 801-9 [1]. Background Critically ill patients admitted to intensive care units (ICUs) are thought to gain an added survival benefi t from management by critical care physicians, but evidence of this benefi t is scant. Methods 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. Subjects: 101,832 critically ill adults. Intervention: None. Outcomes: Through use of a random-eff ects 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 Simplifi ed Acute Physiology Score was used to adjust for severity of illness, and a propensity score was used to adjust for diff erences 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 diff erence in adjusted hospital mortality rates was less for patients who were sicker and who were predicted by propensity score to receive CCM. 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.