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Abstract
OBJECTIVES To determine the total numbers of privileged and full-time equivalent intensivists in acute care hospitals with intensivists and compare the characteristics of hospitals with and without intensivists. DESIGN Retrospective analysis of the American Hospital Association Annual Survey Database (Fiscal Year 2015). SETTING Two-thousand eight-hundred fourteen acute care hospitals with ICU beds. PATIENTS None. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of the 2,814 acute care hospitals studied, 1,469 (52%) had intensivists and 1,345 (48%) had no intensivists. There were 28,808 privileged and 19,996 full-time equivalent intensivists in the 1,469 hospitals with intensivists. In these hospitals, the median (25-75th percentile) numbers of privileged and full-time equivalent intensivists were 11 (5-24) and 7 (2-17), respectively. Compared with hospitals without intensivists, hospitals with privileged intensivists were primarily located in metropolitan areas (91% vs 50%; p < 0.001) and at the aggregate level had nearly thrice the number of hospital beds (403,522 [75%] vs 137,146 [25%]), 3.6 times the number of ICU beds (74,222 [78%] vs 20,615 [22%]), and almost twice as many ICUs (3,383 [65%] vs 1,846 [35%]). At the hospital level, hospitals with privileged intensivists had significantly more hospital beds (median, 213 vs 68; p < 0.0001), ICU beds (median, 32 vs 8; p < 0.0001), a higher ratio of ICU to hospital beds (15.6% vs 12.6%; p < 0.0001), and a higher number of ICUs per hospital (2 vs 1; p < 0.0001) than hospitals without intensivists. CONCLUSIONS Analyzing the intensivist section of the American Hospital Association Annual Survey database is a novel approach to estimating the numbers of privileged and full-time equivalent intensivists in acute care hospitals with ICU beds in the United States. This methodology opens the door to an enhanced understanding of the current supply and distribution of intensivists as well as future research into the intensivist workforce.
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Breathett K, Liu WG, Allen LA, Daugherty SL, Blair IV, Jones J, Grunwald GK, Moss M, Kiser TH, Burnham E, Vandivier RW, Clark BJ, Lewis EF, Mazimba S, Battaglia C, Ho PM, Peterson PN. African Americans Are Less Likely to Receive Care by a Cardiologist During an Intensive Care Unit Admission for Heart Failure. JACC. HEART FAILURE 2018; 6:413-420. [PMID: 29724363 PMCID: PMC5940011 DOI: 10.1016/j.jchf.2018.02.015] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Accepted: 02/22/2018] [Indexed: 12/15/2022]
Abstract
OBJECTIVES This study sought to determine whether the likelihood of receiving primary intensive care unit (ICU) care by a cardiologist versus a noncardiologist was greater for Caucasians than for African Americans admitted to an ICU for heart failure (HF). The authors further evaluated whether primary ICU care by a cardiologist is associated with higher in-hospital survival, irrespective of race. BACKGROUND Increasing data demonstrate an association between better HF outcomes and care by a cardiologist. It is unclear if previously noted racial differences in cardiology care persist in an ICU setting. METHODS Using the Premier database, adult patients admitted to an ICU with a primary discharge diagnosis of HF from 2010 to 2014 were included. Hierarchical logistic regression models were used to determine the association between race and primary ICU care by a cardiologist, adjusting for patient and hospital variables. Cox regression with inverse probability weighting was used to assess the association between cardiology care and in-hospital mortality. RESULTS Among 104,835 patients (80.3% Caucasians, 19.7% African Americans), Caucasians had higher odds of care by a cardiologist than African Americans (adjusted odds ratio: 1.42; 95% confidence interval: 1.34 to 1.51). Compared with a noncardiologist, primary ICU care by a cardiologist was associated with higher in-hospital survival (adjusted hazard ratio: 1.20, 95% confidence interval: 1.11 to 1.28). The higher likelihood of survival did not differ by patient race (interaction p = 0.32). CONCLUSIONS Among patients admitted to an ICU for HF, African Americans were less likely than Caucasians to receive primary care by a cardiologist. Primary care by a cardiologist was associated with higher survival for both Caucasians and African Americans.
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Affiliation(s)
- Khadijah Breathett
- Division of Cardiovascular Medicine, Sarver Heart Center, University of Arizona, Tucson, Arizona.
| | - Wenhui G Liu
- Veteran Affairs Eastern Colorado Health Care System, Denver, Colorado
| | - Larry A Allen
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Stacie L Daugherty
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Irene V Blair
- Department of Psychology and Neuroscience, University of Colorado, Boulder, Colorado
| | | | - Gary K Grunwald
- Veteran Affairs Eastern Colorado Health Care System, Denver, Colorado; Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, Colorado Pulmonary Outcomes Research Group, University of Colorado, Aurora, Colorado
| | - Tyree H Kiser
- Division of Pulmonary Sciences and Critical Care Medicine, Colorado Pulmonary Outcomes Research Group, University of Colorado, Aurora, Colorado; Department of Clinical Pharmacy, University of Colorado, Aurora, Colorado
| | - Ellen Burnham
- Division of Pulmonary Sciences and Critical Care Medicine, Colorado Pulmonary Outcomes Research Group, University of Colorado, Aurora, Colorado
| | - R William Vandivier
- Division of Pulmonary Sciences and Critical Care Medicine, Colorado Pulmonary Outcomes Research Group, University of Colorado, Aurora, Colorado
| | - Brendan J Clark
- Division of Pulmonary Sciences and Critical Care Medicine, Colorado Pulmonary Outcomes Research Group, University of Colorado, Aurora, Colorado
| | - Eldrin F Lewis
- Division of Cardiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Sula Mazimba
- Division of Cardiology, University of Virginia Health System, Charlottesville, Virginia
| | - Catherine Battaglia
- Veteran Affairs Eastern Colorado Health Care System, Denver, Colorado; University of Colorado School of Public Health, Denver, Colorado
| | - P Michael Ho
- Veteran Affairs Eastern Colorado Health Care System, Denver, Colorado; Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado; Division of Pulmonary Sciences and Critical Care Medicine, Colorado Pulmonary Outcomes Research Group, University of Colorado, Aurora, Colorado
| | - Pamela N Peterson
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado; Division of Cardiology, Denver Health Medical Center, Denver, Colorado
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Tanios MA, Teres D, Park H, Beltran A, Sehgal A, Leo JD. The Impact of Implementing an Intensivist Model With Nighttime In-Hospital Nocturnist and Effect on ICU Outcomes. J Intensive Care Med 2018; 35:461-467. [PMID: 29458294 DOI: 10.1177/0885066618758246] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Various intensivist staffing models have been suggested, but the long-term sustainability and outcomes vary and may not be sustained. We examined the impact of implementing a high-intensity intensivist coverage model with a nighttime in-house nocturnist (non-intensivist) and its effect on intensive care unit (ICU) outcomes. METHODS We obtained historical control baseline data from 2007 to 2011 and compared the same data from 2011 to 2015. The Acute Physiological and Chronic Health Evaluation outcomes system was utilized to collect clinical, physiological, and outcome data on all adult patients in the medical ICU and to provide severity-adjusted outcome predictions. The model consists of a mandatory in-house daytime intensivist service that leads multidisciplinary rounds, and an in-house nighttime coverage is provided by nocturnist (nonintensivists) with current procedural skills in airways management, vascular access, and commitment to supervise house staff as needed. The intensivist continues to be available remotely at nighttime for house staff and consultation with the nocturnist. A backup intensivist is available for surge management. RESULTS First year yielded improved throughput (2428 patients/year to 2627 then 2724 at fifth year). Case mix stable at 53.7 versus 55.2. The ICU length of stay decreased from 4.7 days (predicted 4.25 days) to 3.8 days (4.15) in first year; second year: 3.63 days (4.29 days); third year: 3.24 days (4.37), fourth year: 3.34 days (4.45), and fifth year: 3.61 days (4.42). Intensive care unit <24 hours readmission remained at 1%; >24 hours increased from 4% to 6%. Low-risk monitoring admissions remained at an average 17% (benchmark 17.18%). Intensive care unit mortality improved with standardized mortality ration averaging at 0.84. Resident satisfaction surveys improved. CONCLUSIONS Implementing an intensivist service with nighttime nocturnist staffing in a high-intensity large teaching hospital is feasible and improved ICU outcomes in a sustained manner that persisted after the initial implementation phase. The model resulted in reduced and sustained observed-to-predicted length of ICU stay.
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Affiliation(s)
- Maged A Tanios
- Intensive Care Unit, Long Beach Memorial Hospital, Long Beach, CA, USA.,David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,Pulmonary Division, Long Beach Memorial Hospital, Long Beach, CA, USA
| | - Daniel Teres
- Department of Public Health and Community Medicine, Tufts School of Medicine, Boston, MA, USA
| | - Hyunsoon Park
- Intensive Care Unit, Long Beach Memorial Hospital, Long Beach, CA, USA
| | - Antonio Beltran
- Intensive Care Unit, Long Beach Memorial Hospital, Long Beach, CA, USA.,Pulmonary Division, Long Beach Memorial Hospital, Long Beach, CA, USA
| | - Arunpal Sehgal
- Intensive Care Unit, Long Beach Memorial Hospital, Long Beach, CA, USA.,Pulmonary Division, Long Beach Memorial Hospital, Long Beach, CA, USA
| | - James D Leo
- MemorialCare Health System, Fountain Valley, CA, USA
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Rubenfeld GD. Rebuttal From Dr Rubenfeld. Chest 2016; 149:629-30. [PMID: 26965970 DOI: 10.1016/j.chest.2015.11.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 11/06/2015] [Indexed: 10/22/2022] Open
Affiliation(s)
- Gordon D Rubenfeld
- Program in Trauma, Emergency and Critical Care, Interdepartmental Division of Critical Care Medicine, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada.
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