Stick to What You Know: Do Visiting Intensivists Worsen Outcomes?*

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Ever since the introduction of critical care as a discipline in the 1960s, the grouping of critically ill patients into ICUs has been recognized to carry several advantages. First, it allows the delivery of care by a multiprofessional team with expertise in the critically ill patient population (1). Second, it allows for the delivery of timely resuscitation and appropriate care to those who might benefit from disease or syndrome specific treatment. Which of these factors is more responsible for improvements in clinical outcomes, however, remains an open question. Zimmerman et al (2) found a 35% relative decrease in hospital mortality from 1988 to 2012 in the United States despite a concurrent shift toward older age and higher severity of illness in ICU admissions. Similar reductions in mortality have been observed in cohorts of critically ill participants with acute respiratory distress syndrome (ARDS) and in mechanically ventilated patients (3, 4). Big wins in critical care therapies such as lung protective mechanical ventilation in ARDS (5), early antibiotics, and volume resuscitation for sepsis (6, 7) may contribute to these improvements in mortality. However, many of the successes achieved in critical care outcomes over the last several decades probably have more to do with streamlining of structure (i.e., conditions under which care is provided) and processes of care (i.e., activities that constitute patient care) than with successes in novel therapies and treatments per se.
Recent studies have helped to characterize the organizational characteristics of an ICU that may help to reduce heterogeneity in care and lead to improved clinical outcomes (8, 9). For example, higher hospital case volume, effective team communication strategies, and a higher nurse-to-bed ratio are important determinants of outcomes in critically ill patients (8–10). In contrast, the use of protocols has not been found to be associated with improved clinical outcomes in both observational studies (11) and randomized clinical trials (12). High-intensity critical care physician staffing has had differing reports on clinical outcomes (13) with beneficial effects of such staffing more pronounced in surgical ICUs (14). Nighttime in-house intensivists are not associated with a lower hospital length of stay, lower mortality or higher ICU readmission when compared with periods when there was not a nighttime in-house intensivist (15).
The report by Whitehouse et al (16) in this issue of Critical Care Medicine brings attention to yet another potential driver of heterogeneity in delivery of care: that of visiting intensivists in an ICU. The authors postulated that intensivists unfamiliar with an ICU team and the context of that ICU would have worse outcomes when compared with intensivists who continued to work in their ICU. They used data of 9,981 admissions and 33 intensivists collected over 5 years in four ICUs of a large U.K. hospital. Of note, the types of geographically distinct ICUs that the authors examined in their analysis included liver specialty, neurology, cardiac, and general/trauma/burns ICUs. Using different types of analyses that controlled for clustering and adjusted for multiple confounders, the authors found that the odds of mortality was 18% higher with a visiting intensivist from another ICU when compared with a home intensivist. The association between visiting intensivist and a higher odds of mortality remained regardless of the type of analysis used: whether a marginal approach adjusted for clustering using generalized estimating equations, a hierarchical (random effects) model, or an analysis that adjusted for the likelihood (via a propensity score analysis) of being admitted by a visiting intensivist from another ICU.
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