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Prioritizing the organization and management of intensive care services in the United States: The PrOMIS Conference*

Barnato, Amber E. MD, MPH, MS; Kahn, Jeremy M. MD, MSc; Rubenfeld, Gordon D. MD, MSc; McCauley, Kathleen PhD, RN, BC; Fontaine, Dorrie RN, DNSc; Frassica, Joseph J. MD, FCCP; Hubmayr, Rolf MD; Jacobi, Judith PharmD; Brower, Roy G. MD; Chalfin, Donald MD, MS; Sibbald, William MD, MPH†; Asch, David A. MD, MBA; Kelley, Mark MD; Angus, Derek C. MD, MPH

doi: 10.1097/01.CCM.0000259535.06205.B4
Feature Articles

Objective: Adult critical care services are a large, expensive part of U.S. health care. The current agenda for response to workforce shortages and rising costs has largely been determined by members of the critical care profession without input from other stakeholders. We sought to elicit the perceived problems and solutions to the delivery of critical care services from a broad set of U.S. stakeholders.

Design: A consensus process involving purposive sampling of identified stakeholders, preconference Web-based survey, and 2-day conference.

Setting: Participants represented healthcare providers, accreditation and quality-oversight groups, federal sponsoring institutions, healthcare vendors, and institutional and individual payers.

Subjects: We identified 39 stakeholders for the field of critical care medicine. Thirty-six (92%) completed the preconference survey and 37 (95%) attended the conference.

Interventions: None.

Measurements and Main Results: Participants expressed moderate to strong agreement with the concerns identified by the critical care professionals and additionally expressed consternation that the critical care delivery system was fragmented, variable, and not patient-centered. Recommended solutions included regionalizing the adult critical care system into “tiers” defined by explicit triage criteria and professional competencies, achieved through voluntary hospital accreditation, supported through an expanded process of competency certification, and monitored through process and outcome surveillance; implementing mechanisms for improved communication across providers and settings and between providers and patients/families; and conducting market research and a public education campaign regarding critical care’s promises and limitations.

Conclusions: This consensus conference confirms that agreement on solutions to complex healthcare delivery problems can be achieved and that problem and solution frames expand with broader stakeholder participation. This process can be used as a model by other specialties to address priority setting in an era of shifting demographics and increasing resource constraints.

From the Center for Research on Health Care (AEB) and the CRISMA Laboratory (Clinical Research, Investigation, and Systems Modeling of Acute illness) (AEB, DCA), Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA; Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, WA (JMK, GDR); Division of Pulmonary, Allergy and Critical Care, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA (JMK); School of Nursing, University of Pennsylvania, Philadelphia, PA (KM); University of California-San Francisco School of Nursing, San Francisco, CA (DF); Harvard-MIT Division of Health Sciences & Technology, Division of Pediatric Critical Care, Baystate Medical Center, MA (JJF); Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN (RH); Methodist Hospital/Clarian Health Partners, Indianapolis, IN (JJ); Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (RGB); Department of Critical Care Medicine, Montefiore Medical Center and the Albert Einstein College of Medicine, New York, NY (DC); Sunnybrook and Women’s Health Sciences Center and Department of Medicine, University of Toronto, Toronto, Ontario, Canada (WS); Center for Health Equity Research and Promotion, Philadelphia VA Medical Center and The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA (DAA); and Henry Ford Health System, Detroit, MI (MK).

†Dr. Sibbald is deceased.

The PrOMIS Conference was organized with grant support from the American Association of Critical-Care Nurses, the American College of Chest Physicians, the American Thoracic Society, and the Society of Critical Care Medicine. The sponsoring organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.

Specific potential conflicts reported by the authors with regard to preparation of the manuscript are listed as follows. Dr. Chalfin has disclosed receiving consultancy fees from Analytica International. Dorrie Fontaine, RN, has disclosed receiving consultancy fees from Virginia Commonwealth School of Nursing and honoraria/speaking fees from Maine Nurses Association, Stanford Medical Center. The remaining authors have not disclosed any potential conflicts of interest. Full disclosure of all financial and intellectual conflicts by all participants in the conference is provided in the online appendix.

For information regarding this article, E-mail: angusdc@ccm.upmc.edu

© 2007 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins