Icu study pa's vs residents

[deleted6669]

Impact of Nonphysician Staffing on Outcomes in a Medical ICU
Hayley B. Gershengorn, MD, Hannah Wunsch, MD, Romina Wahab, MD, David Leaf, MD, Daniel Brodie, MD, FCCP, Guohua Li, MD, DrPH and Phillip Factor, DO, FCCP
+ Author Affiliations

From the Division of Pulmonary, Critical Care, and Sleep Medicine (Drs Gershengorn and Factor), Beth Israel Medical Center; and the Department of Anesthesia (Drs Wunsch and Li), the Department of Medicine (Drs Wahab and Leaf), and the Division of Pulmonary, Allergy, and Critical Care (Dr Brodie), New York Presbyterian Hospital-Columbia, New York, NY.
Correspondence to:
Hayley B. Gershengorn, MD, Section of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Medical Center, 1st Ave at 16th St, New York, NY 10003; e-mail: [email protected]
Abstract
Background: As the number of ICU beds and demand for intensivists increase, alternative solutions are needed to provide coverage for critically ill patients. The impact of different staffing models on the outcomes of patients in the medical ICU (MICU) remains unknown. In our study, we compare outcomes of nonphysician provider-based teams to those of medical house staff-based teams in the MICU.

Methods: We conducted a retrospective review of 590 daytime (7:00 AM-7:00 PM) admissions to two MICUs at one hospital. In one MICU staffed by nurse practitioners and physician assistants (MICU-NP/PA) there were nonphysicians (nurse practitioners and physicians assistants) during the day (7:00 AM-7:00 PM) with attending physician coverage overnight. In the other MICU, there were medicine residents (MICU-RES) (24 h/d). The outcomes investigated were hospital mortality, length of stay (LOS) (ICU, hospital), and posthospital discharge destination.

Results: Three hundred two patients were admitted to the MICU-NP/PA and 288 to the MICU-RES. Mortality probability model III (MPM0-III) predicted mortality was similar (P = .14). There was no significant difference in hospital mortality (32.1% for MICU-NP/PA vs 32.3% for MICU-RES, P = .96), MICU LOS (4.22 ± 2.51 days for MICU-NP/PA vs 4.44 ± 3.10 days for MICU-RES, P = .59), or hospital LOS (14.01 ± 2.92 days for MICU-NP/PA vs 13.74 ± 2.94 days for MICU-RES, P = .86). Discharge to a skilled care facility (vs home) was similar (37.1% for MICU-NP/PA vs 32.5% for MICU-RES, P = .34). After multivariate adjustment, MICU staffing type was not associated with hospital mortality (P = .26), MICU LOS (P = .29), hospital LOS (P = .19), or posthospital discharge destination (P = .90).

Conclusions: Staffing models including daytime use of nonphysician providers appear to be a safe and effective alternative to the traditional house staff-based team in a high-acuity, adult ICU.

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[Instatewaiter]

I think that's pretty good news. As hours are restricted for residents, we need someone to fill in the gaps. It's not all that surprising since Attendings and fellows really run the show in the ICUs

 

[Maybeknot]

Why are there 2 MICU's (presumably identical, otherwise the point of the study is as moot as a cow's opinion) in the same hospital? Seems kinda wasteful to me.

 

[core0]

Why are there 2 MICU's (presumably identical, otherwise the point of the study is as moot as a cow's opinion) in the same hospital? Seems kinda wasteful to me.

Old hospitals have strange set ups. Most hospitals have ICUs squirreled into whatever area they could. We have two MICUs, two CVICUS, two CCUs. They all run on different models. Some are joined together and run as one unit and some are run as separate units. Its essentially a function of an old physical plant.

 

[Charles_Carmichael]

Thanks for the heads-up emedpa. I'll try to read it later tonight or tomorrow.

Keep in mind though that it's a single-institution retrospective study, which comes with its own share of advantages and disadvantages.

 

[Instatewaiter]

One thing to note is that attendings staffed the NP/PA MICU for half the time (7p-7a)

 

[Maybeknot]

It would, uh, actually be useful to have an actual reference to the quoted study. Specifically, it would be good to know the level of attending physician oversight over MICU-NP/PA and MICU-RES during the daytime hours.

 

[lapelirroja]

10 seconds on pubmed produced this... with link to full text...

http://www.ncbi.nlm.nih.gov/pubmed/21393397

 

[Maybeknot]

10 seconds on pubmed produced this... with link to full text...

http://www.ncbi.nlm.nih.gov/pubmed/21393397

Thank you. I'm just pointing out that it's common etiquette to properly reference what you're talking about.

Things to note about this study from my quick first read:
- Both the MICU-NP/PA and the MICU-RES had an on-site fellow and intensivist during the day and an intensivist at overnight.
- The MICU-RES was staffed by 1st and 2nd year medicine residents.
- The MICU-RES accepts new admissions 24/7 while MICU-NP/PA only admits from 7am-7pm.
- If there is bedboard problem (each unit has 12 beds), MICU-RES patients are transferred to MICU-NP/PA to allow for new admissions to MICU-RES... this was 14.2% of the patients in this study. While those patients admitted between 7pm-7am are excluded, the fact that 14.2% of the pts in this study were admitted and cared for by MICU-RES and THEN transferred to MICU-NP/PA is a huge confounding factor in this study, as I would assume that the most critically ill patients wouldn't be the ones transferred.
- There are a ton of Table 1 disparities that I think really weaken the validity of this study, such as an older and higher mortality risk group in MICU-NP/PA. Really, not a well designed study at all.

While this study gives support to the argument that midlevels have a place in the care of patients -- a fact that, really, no one is arguing against -- it doesn't say anything about independent midlevel equivalence to physicians. This study is comparing supervised midlevels to supervised junior residents.

(And I apologize in advance to emedpa if this wasn't his point; just given the climate of the DNP vs MD debate, I felt that these comments needed to be made before conclusions are jumped to.)

 

[deleted6669]

I just though it was an interesting study. I wasn't trying to make a pa vs md "point".

 

[FireCloud9]

So what you're saying EMEDPA is that people die regardless of who's watching?

 

[Maybeknot]

I just though it was an interesting study. I wasn't trying to make a pa vs md "point".

Out of curiousity, may I ask what you find so interesting about it?

 

[deleted6669]

Out of curiousity, may I ask what you find so interesting about it?

similar outcomes among critical care pts followed mostly by pa's and residents.
you may not be aware but critical care medicine is one of the new "hot fields" for pa's with several postgrad pa residencies( see www.appap.org) and many jobs for both new grads and experienced pa's. pa's have been covering icu's in this fashion( as well as night coverage as opposed to the day coverage in this study) for years and it's nice to see care provided by a pa was considered at least as good as that provided by residents.

 

[Maybeknot]

similar outcomes among critical care pts followed mostly by pa's and residents.

I don't really think resident care (by PGY-1 and PGY-2 residents) is the gold standard for ICU care.... and I don't think the conclusions of the authors is valid, particularly when...
- There were 10 NPs and 4 PA's working 36 hour weeks vs 6-8 residents (?, not clear from the text) working (presumably) 70-80 hrs.
- The NP's and PA's had 2-4 week training courses prior to starting in the MICU, which the residents did not have
- The overnight MICU-RES did NOT have an in-house intensivist, while MICU-NP/PA was staffed with an in-house intensivist overnight
- Both MICU's had higher than predicted mortality rates... in other words, both groups did equally as poor. Again, really, not the gold standard we should be striving for...
- Pt's who were admitted to MICU-RES and transferred to MICU-NP/PA had their data count in MICU-RES. Which in general would be a fair study design; however, they specifically excluded MICU-NP/PA admissions after 7pm to eliminate confounding factors; that they left THIS particular confounding factor seems to be a poor choice that was not explained within the text of the study
- The study looked at 2 12-bed MICU's for a period of 12 months... really, a low powered study which, as expected, failed to find a difference because of the study design (which was admitted by the authors)

If this paper was discussed in journal club, the study would have been chewed apart and spit out as a poorly designed one. I guess that's interesting...

It's really poorly designed studies like this that get published with misleading "conclusions" that have led the DNP's to believe that their care is equivalent to that of physicians. While that was not the intent of the OP, the fact that these studies get published without any commentary describing the glaringly huge holes in the study design and analysis of results really compounds the problem.

OK, time to step off the soapbox.

 

[ghost dog]

I don't really think resident care (by PGY-1 and PGY-2 residents) is the gold standard for ICU care.... and I don't think the conclusions of the authors is valid, particularly when...
- There were 10 NPs and 4 PA's working 36 hour weeks vs 6-8 residents (?, not clear from the text) working (presumably) 70-80 hrs.
- The NP's and PA's had 2-4 week training courses prior to starting in the MICU, which the residents did not have
- The overnight MICU-RES did NOT have an in-house intensivist, while MICU-NP/PA was staffed with an in-house intensivist overnight
- Both MICU's had higher than predicted mortality rates... in other words, both groups did equally as poor. Again, really, not the gold standard we should be striving for...
- Pt's who were admitted to MICU-RES and transferred to MICU-NP/PA had their data count in MICU-RES. Which in general would be a fair study design; however, they specifically excluded MICU-NP/PA admissions after 7pm to eliminate confounding factors; that they left THIS particular confounding factor seems to be a poor choice that was not explained within the text of the study
- The study looked at 2 12-bed MICU's for a period of 12 months... really, a low powered study which, as expected, failed to find a difference because of the study design (which was admitted by the authors)

If this paper was discussed in journal club, the study would have been chewed apart and spit out as a poorly designed one. I guess that's interesting...

It's really poorly designed studies like this that get published with misleading "conclusions" that have led the DNP's to believe that their care is equivalent to that of physicians. While that was not the intent of the OP, the fact that these studies get published without any commentary describing the glaringly huge holes in the study design and analysis of results really compounds the problem.

OK, time to step off the soapbox.

Another point to make here:

Junior residents are paid what : $ 45 - 50,000 / year

versus PA's: $ 95-100,000 / year?

Hardly cost effective. In fact, this is really crap bang for your buck.

 

[PharmBound2011]

Another point to make here:

Junior residents are paid what : $ 45 - 50,000 / year

versus PA's: $ 95-100,000 / year?

Hardly cost effective. In fact, this is really crap bang for your buck.

whats most important is the ability to bill for patients seen that tips the cost-effectiveness towards PAs, IMO. Its purely BS but even after the same workup/visit, the PA bils for 85% while the resident does not. Thus, the PA has "earned his keep" while the resident is at the job due to funding.

 

[Disinence2]

I was a med student who got assigned to the PA MICU at my hospital instead of the Resident run service.

The services were run drastically differently.

Agree this study is ridiculously underpowered.

 

[deleted87716]

similar outcomes among critical care pts followed mostly by pa's and residents.

All of whom were supervised by attending physicians.

 

[dilated]

Not dogpiling on you, emed, cause you can only post the studies people do. But my issue with this study is the presence of an in house fellow in the midlevel unit. I have to think like 95% of the midlevel ICU positions are out in the "real world" where there's no in-house fellow. Nobody doubts that it's the same if you have somebody standing there monitoring things, the only way there is a controversy to prove is if there is no on-site supervision (attending home backup for on-site midlevels at night is increasingly common).

 

[princekc]

whats most important is the ability to bill for patients seen that tips the cost-effectiveness towards PAs, IMO. Its purely BS but even after the same workup/visit, the PA bils for 85% while the resident does not. Thus, the PA has "earned his keep" while the resident is at the job due to funding.

+1

 

[Instatewaiter]

whats most important is the ability to bill for patients seen that tips the cost-effectiveness towards PAs, IMO. Its purely BS but even after the same workup/visit, the PA bils for 85% while the resident does not. Thus, the PA has "earned his keep" while the resident is at the job due to funding.

Actually, I am pretty sure this is wrong. The attending bills for both since you can't double bill and the attending can bill more. So the resident admits and the attending bills or the PA admits and the attending bills. The amount billed is the same.

So really you are paying double for the PA. Also, where I work, the caps for residents is higher than the caps for midlevels so you get more admissions out of the resident. So quite obviously, the resident is more cost effective even when you don't consider the hundred thousands dollars that the hospital gets per resident. So in effect, the resident's salary is paid for by medicare and then there is the money that is billed for per admission.

 

[core0]

Actually, I am pretty sure this is wrong. The attending bills for both since you can't double bill and the attending can bill more. So the resident admits and the attending bills or the PA admits and the attending bills. The amount billed is the same.

So really you are paying double for the PA. Also, where I work, the caps for residents is higher than the caps for midlevels so you get more admissions out of the resident. So quite obviously, the resident is more cost effective even when you don't consider the hundred thousands dollars that the hospital gets per resident. So in effect, the resident's salary is paid for by medicare and then there is the money that is billed for per admission.

Depending on how the PA is used you are not paying double. PAs bill for the encounter either under their own NPI or as part of a shared visit under the physicians NPI. If the PA bills under their NPI they need to have general supervision available (physician available by phone). If the physician wants to bill for the resident service they must either be present or perform the critical portion of the encounter.

The problem with the modern academic environment is that there are two issues. There are more patients in the hospital but there are not more residents to provide care. In addition the hours of the residents are being curtailed. If a hospital wants to provide care they have a couple of options.
1. They can hire more physicians. Replacing residents with physicians costs much more but rarely provide more billing. Also finding more physicians in many specialties is problematic.
2. They can hire more PAs. PAs can bill for the care they provide. The bill is paid at 85% of the physician fee. Medicare also requires that physician be involved in the care of any hospitalized patient. This will impact the physicians ability to see patients and bill. The usual accounting is from 10 to 25% of the physicians time. The PA is paid less than the physician. Dividing the patient load allows the team to see more patients and the extra income from the PA billing may pay the PAs salary depending on the payor mix.

In paper cited here there are a number of ways to structure the ICU. The unit could man both units with residents. Lets say you have 24 beds with 4 residents (to make some number up). Put the residents on q4 with each resident having 6-8 patients per day and covering overnight (PGY2 or better since interns can't take call). The attending rounds for 10 hours and bills for 12 hours of time (critical care time is billed in time). The attending must spend a minimum of 30 minutes per patient doing critical care work and teaching does not count in this time. In reality with 24 patients the attending will not spend 30 minutes on each so some will be billed E/M at a lesser pay. Usually totals 10 hours.

Now take the same unit and split it in half. 12 beds manned by two PAs on 12 hour shifts and the other unit manned by resident with one resident covering both units at night. The attending spends 6 hours rounding and some amount of time teaching and bills 6 hours. Each PA spends 12 hours managing 6 patients each. On average 50% of the time will be billable. This equals an additional 12 hours of billable time. Since this is discounted 85% the total billable time would equal 12x.85 = 10.2+6. So the billing is increased by 6 hours at the cost of two PA positions.

This also allows better care of the patients as each resident has less patients. It also allows for better teaching.

The model with an attending in house is probably used in less than 1/2 of academic medical centers. By adding night time PA coverage the center can provide better coverage while capturing more revenue (all night time admissions where the attending is not present cannot be billed). It takes 8-10 PAs to provide 24/7 coverage at a cost of $1-1.9 million. The revenue will depend on the payor mix. At a safety net hospital it will be pure loss. At most academic medical centers it will be net even to a slight profit. At most PP hospitals it will be a money machine.

I would maintain the current standard of care in MICUs is resident coverage with with attendings at home at night. This study is interesting in that it shows no disadvantages to adding daytime coverage in the MICU. To properly represent the model they would have to show 24/7 coverage with no difference.

 

[Instatewaiter]

In paper cited here there are a number of ways to structure the ICU. The unit could man both units with residents. Lets say you have 24 beds with 4 residents (to make some number up). Put the residents on q4 with each resident having 6-8 patients per day and covering overnight (PGY2 or better since interns can't take call). The attending rounds for 10 hours and bills for 12 hours of time (critical care time is billed in time). The attending must spend a minimum of 30 minutes per patient doing critical care work and teaching does not count in this time. In reality with 24 patients the attending will not spend 30 minutes on each so some will be billed E/M at a lesser pay. Usually totals 10 hours.

Where I have trained in the past (2 hospitals) the attendings see the patients the next morning and bill for the admission. Also from what I have experienced there are more than 1 team so the teams generally are no more than 12 patient and where I am now, are only 8-9 patients at a time (9 only if there is a MICU patient housed on a step down unit). Presentations take a minimum of 20-30 minutes which *I think* is counted in the billing time. So the time billed would still be more for the attending.

This also allows better care of the patients as each resident has less patients. It also allows for better teaching.

I'm not fighting you on this one. As the hours get cut more and more, someone is going to have to pick up the slack. Adding PAs is a good way to preserve teaching since that is the goal of residency.

On an unrelated note, I have to say core, I always find your posts to be level headed and reasonable. It is a nice contrast to others who feel defensive, myself included.

 

[core0]

Where I have trained in the past (2 hospitals) the attendings see the patients the next morning and bill for the admission. Also from what I have experienced there are more than 1 team so the teams generally are no more than 12 patient and where I am now, are only 8-9 patients at a time (9 only if there is a MICU patient housed on a step down unit). Presentations take a minimum of 20-30 minutes which *I think* is counted in the billing time. So the time billed would still be more for the attending.

Two issues here. One is that admissions that come in before midnight can't be billed. They can bill for the next day but you lose an entire days billing. By placing a PA in the ICU at night you can capture all that billing and critical care time that occurs at night. With 8-9 patients its hard to justify PA coverage during the day. Once you get above 12-14 its easiery. The absolute minimum time you can spend on the patient. So if you have twenty patients you have to spend 10 hours on patient care. Or the physician can cover 10 patients and bill for 10 hours and the PA can cover 10 patients and bill for 10 hours. Slightly less than doubling your billing without doubling the amount of physician coverage needed.

As for billing on rounds, the presentation can count as critical care time for the physician. On the other hand teaching is definitely not billable. There is no real way to check on this but if you are in a teaching institution and say you work 12 hours and bill for 11 when does the teaching occur?

I'm not fighting you on this one. As the hours get cut more and more, someone is going to have to pick up the slack. Adding PAs is a good way to preserve teaching since that is the goal of residency.

On an unrelated note, I have to say core, I always find your posts to be level headed and reasonable. It is a nice contrast to others who feel defensive, myself included.

The real problem that I see it, is where the residents go. Usually an academic program will have 2-3 hospitals one of which is a safety net. Safety net hospitals have horrible collections and can't really afford to hire additional personnel. As the work hours get cut the residents increasingly get shifted to the safety net hospital. More autonomy which is good but less teaching which is bad (at least the way that our residents explain it).