Association Between Critical Care Physician Management and Patient Mortality in the Intensive Care Unit
Levy MM, Rapoport J, Lemeshow S, et al
Ann Intern Med. 2008;148:801-809
Critically ill patients admitted to intensive care units (ICUs) are thought to benefit from more intensive healthcare delivery from nurses, physicians, and other providers (eg, critical care pharmacists).[1-15] The authors examined data from Project Impact, including 101,832 patients from 123 ICUs in 100 US hospitals. The primary results show that patients cared for by critical care physicians were sicker than other patients and underwent more procedures. Notably, hospital mortality rates were higher for patients managed by critical care physicians, even after adjustment for severity of illness and other factors that may have influenced the probability of being cared for by a critical care physician. The authors concluded that hospital mortality was higher for patients managed by critical care physicians than those who were managed otherwise, and that additional studies are needed to confirm these results and clarify the responsible mechanisms.
Viewpoint
This article suggests, but does not confirm, that intensive care provided by critical care specialists does not improve outcomes and may in fact, be detrimental to patients. This study is observational in nature, making cause-and-effect conclusions impossible. As the authors noted, selection bias (differences in the individuals selected to take part in a study) and residual confounding (unmeasured factors that cannot be fully accounted for, but may influence the outcome of interest) could explain the results, as could indication bias (ie, that critical care physicians would be caring for sicker patients). The fact that the authors conducted extensive analyses that were robust to certain sensitivity tests sways the reader towards believing the results. Unfortunately, even the most elegant and powerful statistical analyses are incapable of dissecting and adjusting for all relevant factors that may influence the outcome of interest between the critical care and non-critical care groups. Thus, while observational data such as these may suggest a relationship between critical care-led patient care and survival, ascertaining the real relationship (ie, cause-and-effect) requires the conduct of a prospective, randomized trial.
Reviewed by Ramaz Mitaishvili, MD
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