Abstract
BackgroundObservational studies on mechanical ventilation (MV) show practice variations across ICUs. We sought to determine, with a case-vignette study, the heterogeneity of processes of care in ICUs focusing on mechanical ventilation procedures, and whether organizational patterns or physician characteristics influence practice variations.MethodsWe conducted a cross-sectional multicenter study using the case-vignette methodology. Descriptive analyses were calculated for each organizational pattern and respondent characteristics. An Index of Qualitative Variation (IQV, from 0, no heterogeneity, to a maximum of 1) was calculated.ResultsForty ICUs from France (N = 33) and Switzerland (N = 7) participated; 396 physicians answered our case-vignettes. There was major heterogeneity of management processes related to MV within and across centers (mean IQV per center 0.51, SD 0.09). We observed the lowest variability (mean IQV per question < 0.4) for questions related to intubation procedure, ventilation of acute respiratory distress syndrome and the use of the semirecumbent position. We observed a high variability (mean IQV per question > 0.6) for questions related to management of endotracheal tube or suctioning, management of sedation and analgesia, and respect of autonomy. Heterogeneity was independent of respondent characteristics and of the presence of written procedures. There was a correlation between the processes associated with the highest variability (mean IQV per question > 0.6) and the annual volume of ICU admission (r = 0.32 (0.01 to 0.58)) and MV (r = 0.38 (0.07 to 0.63)). Within ICUs there was a large heterogeneity regarding knowledge of a local written procedure.ConclusionsLarge clinical practice variations were found among ICUs. High volume centers were more likely to have heterogeneous practices. The presence of a local written procedure or respondent characteristics did not influence practice variation.
Highlights
Observational studies on mechanical ventilation (MV) show practice variations across ICUs
We found no correlation between the questions with lowest variability and the total ICU admission volume (r = 0.17 −0.15 to 0.46)) or the MV volume (r = 0.04 (−0.35 to 0.28))
There were large variation between the answers of respondents and clinical research coordinators on the reports of incidents associated with MV (Table 4). In this cross-sectional multicenter study, we found a high level of practice variations for processes of care related to MV
Summary
Observational studies on mechanical ventilation (MV) show practice variations across ICUs. We sought to determine, with a case-vignette study, the heterogeneity of processes of care in ICUs focusing on mechanical ventilation procedures, and whether organizational patterns or physician characteristics influence practice variations. Several studies suggest that patients with similar demographic patterns, co-morbidities, diagnoses and severity of illness receive different levels of care depending on when, where or by whom they are treated [1,2]. Some variability may be justified by uncertainty in knowledge, need to individualize patient care and differences in case-mix, and can be related to how compelling individual clinicians find particular information [3]. Multicenter observational studies suggest practice variation in MV [5]. Case-mix and ICU organizational patterns such as MV annual volume and processes of care used may account for the variability observed
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