Do intensivists increase mortality?

[Planktonmd]

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An interesting study although not very strong:
http://www.annals.org/cgi/content/abstract/148/11/801

Who causes patients to die more critical illnesses or critical care doctors?

 

[pd4emergence]

I think any time you have to numerically adjust for severity of illness in comparing outcomes between two groups of practioners, there is alot of room for error. If you don't have a similiar patient population, comparing outcomes even with statistical "correction" is questionable. The CCM guys get the patients that are the sickest. A better study would be to take the same unit and have the ccm guys run it for 6 months and then have them leave and then compare outcomes after six months. I would not want to be in the second six month group.

pd4

 

[cchoukal]

yeah, that was an interesting article. A couple things stood out to me. First, I think the interpretation of the findings depends on how faithfully the propensity scores encompass the patients' illness severity. That could be debated forever, and reasonably people will be on both sides. Second, since it's an SCCM sample, the intensivists were predominantly pulmonologists. Maybe single-organ-doctor intensivists just aren't that good! Third, it's one contrary study in a background of many that show a benefit. Still... it's thought-provoking.

 

[Winged Scapula]

Second, since it's an SCCM sample, the intensivists were predominantly pulmonologists. Maybe single-organ-doctor intensivists just aren't that good! Third, it's one contrary study in a background of many that show a benefit. Still... it's thought-provoking.

It begs the question, "what is an intensivist"? Is it someone who does full time critical care, or someone who spends a week/month in the ICU, and the rest of the month doing academic stuff coupled with ward or OR duties?

I thought the requirement for participation in the study was only that the physician was identified as a "critical care specialist" who cares for the entire patient rather than a single organ system without being BE or BC; be critical care BE or BC; or have trained in a CC fellowship.

I can get behind #s 2 and 3 but 1? "Lookee me, I'm a critical care specialist!" Is that really a criteria?

 

[Surfer]

to "beg the question" does not mean to raise the question. it means to avoid it altogether. i've noticed this saying has become increasingly popular, even in the media, but used incorrectly each time. the other definition is to use circular logic, ie: "i know the bible is God's word, because God says so in the bible."

sorry, didn't mean to be grammar nazi, but this saying has got to die.

 

[Winged Scapula]

to "beg the question" does not mean to raise the question. it means to avoid it altogether. i've noticed this saying has become increasingly popular, even in the media, but used incorrectly each time. the other definition is to use circular logic, ie: "i know the bible is God's word, because God says so in the bible."

sorry, didn't mean to be grammar nazi, but this saying has got to die.

I understand your frustration but that was not how I was using it. My comment was meant to highlight the following:

"intensivists take care of critically care patients"
"critically care patients die a lot"
"intensivists kill patients"

Thus, begging the question does not mean to "avoid the question" but rather a type of circular reasoning and without adequately defining what an intensivist is (ie, you can just apparently be hired as a critical care physician without the training, in this study, and be one), the study is guilty of this, IMHO.

 

[goodoc]

As it was pointed out, perhaps some of the interventions that we think should be helpful really are harmful.

 

[Danbo1957]

Who causes patients to die more critical illnesses or critical care doctors?

The illnesses.

 

[Planktonmd]

Who causes patients to die more critical illnesses or critical care doctors?

The illnesses.

Are you sure?

 

[Danbo1957]

Are you sure?

From the numbers that I've seen, the recent move to full-time intensivists (board-certified critical care) running "closed unit" MICUs have reduced mortality rates.

Intensivists are a part of a system of care. Careful dissection of patterns of treatment in the MICU is required to draw specific conclusions as to the causes of patient mortalities.

I would argue that intensivists do not generally make more "mistakes" than do other physicions - it's just that there are immediate mortal consequences of mistakes made to baseline risk patients in the MICU.

 

[Planktonmd]

From the numbers that I've seen, the recent move to full-time intensivists (board-certified critical care) running "closed unit" MICUs have reduced mortality rates.

Intensivists are a part of a system of care. Careful dissection of patterns of treatment in the MICU is required to draw specific conclusions as to the causes of patient mortalities.

I would argue that intensivists do not generally make more "mistakes" than do other physicions - it's just that there are immediate mortal consequences of mistakes made to baseline risk patients in the MICU.

I think the point is: The more "things" we do to patients the more likely that one of these things is going to be the wrong thing.
So, if your specialty involves doing many things (procedures, medications, diagnostic studies....) then you have a higher likelihood of hurting someone than if you didn't do many things.
History has demonstrated repeatedly that many things that we used to do in the past were not in the best interest of patients and I have no doubt that in the future many of the things that we consider life saving right now will be considered dangerous by our successors.
So, if you want to do less harm than the others only do the "things" that are absolutely necessary in your best judgment.

 

[goodoc]

Plankton has a significant point. We do not really KNOW what is benificial in all cases, hell beta blockade is an excellent point. Good, not good, maybe? Large tidal volume, small tidal volume , intermittent sigh?
These are just 2 things we KNEW and now we know we do not know.

 

[Surfer]

the other problem with this study is that often times the best thing an intensivist does for a patient and their family is have "the talk." you know the one where you convince them it's not worth keeping them on machines for 8 more months. so that might technically increase mortality rates, but actually be a benefit to the patient, their family, and society as a whole.

 

[Idiopathic]

The study Ive always wanted to do is: Put ICU patients in a building with round the clock nursing, an always functioning IV, q1h vitals, a system to treat vital sign abnormalities based on protocol and full time nutritionists.

I dont think your outcomes across the board would be dramatically different.

 

[Planktonmd]

The study Ive always wanted to do is: Put ICU patients in a building with round the clock nursing, an always functioning IV, q1h vitals, a system to treat vital sign abnormalities based on protocol and full time nutritionists.

I dont think your outcomes across the board would be dramatically different.

You are describing the way ICU's are currently managed in the majority of our small community hospitals.
They don't have full time physicians and most of the management is done by nurses with occasional phone calls from Pulmonologists, surgeons and primary physicians.