1. Home>
2. Specialties>
3. Emergency Medicine>
4. Summary and Comment

Patient Outcomes from Intensivist Care

A stunning and counterintuitive finding

Prior studies consistently have shown better patient outcomes when critical care specialists are substantially involved in care of patients in intensive care units (ICUs), but these studies all had methodological limitations. These authors reviewed data from a national ICU database to compare hospital mortality rates in more than 100,000 patients who were cared for either entirely by intensivists or entirely by nonintensivist physicians. Intensivists were defined as physicians who were board certified in critical care medicine, trained in a critical care fellowship, or recognized by the institution as critical care specialists (e.g., burn surgeons).

The standardized mortality ratio (ratio of actual mortality to expected mortality measured by the Simplified Acute Physiology Score) was 1.09 for patients who were managed by intensivists and 0.91 for those who were managed by nonintensivists. A significant difference persisted after logistic regression analysis that included adjustment for illness severity (odds ratio for death, 1.40). The authors note that the startling results could be explained by the confounding effects of unrecognized, unmeasured contributors to illness severity or that, alternatively, the findings could be accurate and reflect, for example, that intensivists’ greater use of procedures might lead to more complications, with increased morbidity and mortality.

Editorialists emphasize the substantial evidence showing that patients cared for by intensivists have better outcomes and note the mechanistic explanations for the improved outcomes, whereas the authors of the current study provide no evidence to support an explanation for their findings. The editorialists also note that the specialty of the caregiver might not be as important as the mode in which the care is delivered (e.g., use of protocols).

Comment: Common wisdom takes a real hit from this study, so much so that the results are hard to believe. The findings are as stunning as if a similar retrospective database study of emergency departments identified decreased mortality when nonemergency physicians provided emergency care. As an emergency physician, I breathe easier knowing that when I admit a patient to our ICU, a qualified intensivist is on the receiving end.

— J. Stephen Bohan, MD, MS, FACP, FACEP

Published in Journal Watch Emergency Medicine June 20, 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.

• Original article (Subscription may be required)
• 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)