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Estimating ICU Benefit

A Randomized Study of Physicians

Valley, Thomas S., MD, MSc1–4; Admon, Andrew J., MD, MPH1; Zahuranec, Darin B., MD, MS2,3,5; Garland, Allan, MD, MA6; Fagerlin, Angela, PhD7,8; Iwashyna, Theodore J., MD, PhD1,2,4,9

doi: 10.1097/CCM.0000000000003473
Clinical Investigations

Objectives: The distinction between overuse and appropriate use of the ICU hinges on whether a patient would benefit from ICU care. We sought to test 1) whether physicians agree about which types of patients benefit from ICU care and 2) whether estimates of ICU benefit are influenced by factors unrelated to severity of illness.

Design: Randomized study.

Setting: Online vignettes.

Subjects: U.S. critical care physicians.

Interventions: Physicians were provided with eight vignettes of hypothetical patients. Each vignette had a single patient or hospital factor randomized across participants (four factors related and four unrelated to severity of illness).

Measurements and Main Results: The primary outcome was the estimate of ICU benefit, assessed with a 4-point Likert-type scale. In total, 1,223 of 8,792 physicians volunteered to participate (14% recruitment rate). Physician agreement of ICU benefit was poor (mean intraclass correlation coefficient for each vignette: 0.06; range: 0–0.18). There were no vignettes in which more than two thirds of physicians agreed about the extent to which a patient would benefit from ICU care. Increasing severity of illness resulted in greater estimated benefit of ICU care. Among factors unrelated to severity of illness, physicians felt ICU care was more beneficial when told one ICU bed was available than if ICU bed availability was unmentioned. Physicians felt ICU care was less beneficial when family was present than when family presence was unmentioned. The patient’s age, but not race/ethnicity, also impacted estimates of ICU benefit.

Conclusions: Estimates of ICU benefit are widely dissimilar and influenced by factors unrelated to severity of illness, potentially resulting in inconsistent allocation of ICU care.

1Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI.

2Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI.

3Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI.

4Michigan Center for Integrative Research in Critical Care, University of Michigan, Ann Arbor, MI.

5Department of Neurology, University of Michigan, Ann Arbor, MI.

6Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada.

7Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT.

8Veterans Affairs Salt Lake City Center for Informatics Decision Enhancement and Surveillance (IDEAS), Salt Lake City, UT.

9Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI.

*See also p. 133.

This does not necessarily represent the views of the U.S. Government or the Department of Veterans Affairs.

Dr. Valley had full access to all of the data in the study and takes full responsibility for the integrity of the data and the accuracy of the data analysis; conceptualized and designed the study; acquired data; drafted the article; analyzed the statistical data; and obtained the fund. Drs. Valley, Admon, Zahuranec, Garland, Fagerlin, and Iwashyna analyzed and interpreted of data. Drs. Valley, Admon, Zahuranec, Garland, Fagerlin, and Iwashyna critically revised the article for important intellectual content.

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Supported, in part, by National Institutes of Health T32HL007749 and K23HL140165 (to Dr. Valley) and the Department of Veterans Affairs Health Services Research and Development grant 13–079 (to Dr. Iwashyna). The funding organizations had no role in the design and conduct of the study; in the collection, analysis, and interpretation of the data; or in the preparation, review, or approval of the article.

Drs. Valley, Zahuranec, and Iwashyna received support for article research from the National Institutes of Health. Dr. Garland’s institution received funding from the Heart and Stroke Foundation of Canada, Research Manitoba, and the Canadian Institutes for Health Research. Drs. Fagerlin and Iwashyna disclosed government work. Dr. Admon disclosed that he does not have any potential conflicts of interest.

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