The New Intensivists

The Hospitalist. 2008 October;2008(10):

October 1, 2008|The Hospitalist

As critical care workforce shortages continue, and as Medicare enrollment swells—a number slated to increase an estimated 50% by 2030—hospitalists are increasingly filling in the gaps in their institutions’ intensive care units.1-2 In SHM’s 2005-06 survey, “The Authoritative Source on the State of the Hospital Medicine Movement,” for example, 75% of participants reported caring for patients in the ICU.3

The Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS) has predicted a 22-35% The Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS) has predicted a 22-25% shortfall of needed critical care physicians (also called “intensivists”) by 2030. Are hospitalists a viable option to fill the void created by the shortage of intensivists? What is the practice scope of hospitalists in the ICU? Which models work for effective co-management of ICUs and can hospitalists help to deliver round-the-clock coverage in the ICU that the Leapfrog Group safety standards have stipulated should be provided by intensivists?4 According to academic and community-based hospitalists and intensivists, much depends on local demographics and each hospital’s ICU model.

Two Models

Michael A. Gropper, MD, PhD, believes hospitalists are well suited to help manage patients in the critical care unit. At the University of California, San Francisco (UCSF), where Gropper is a professor, vice chair of the Department of Anesthesia and Perioperative Care, and the Medical Center’s director of critical care medicine, the ICU uses a co-management system.

Intensivists and Patient Mortality: Another Look

A study from Levy, et al. that was published in the June 3 issue of the Annals of Internal Medicine showed patients managed by critical care physicians had a higher risk of mortality than those not managed by intensivists.1 These results surprised many in the critical care and hospital medicine communities:

Intensivist Dr. Gropper: “It may be that the statistical model used was comparing two different types of hospitals—not just ICUs, and thus it may have compared ‘apples to oranges.’ However, I like to have an open mind and shouldn’t just dismiss the idea [that ICUs run by intensivists can be harmful]. Essentially every other study, including the major meta-analysis by Pronovost et al., has shown that intensivists help—so I don’t think we should jump on this bandwagon too fast!”2

Hospitalist Dr. Sharpe: “Maybe only patients with a certain degree of illness need an intensivist. If they’re not that ill, a hospitalist may actually be better trained to figure out how intensive the care should be. Overall, this study should not, however, change staffing. I think the smartest studies going ahead will look at a breakdown by degree of illness and length of ICU stay.”

Hospitalist Dr. Bossard: “I do severity-adjusted data review, and I know that the way our software adjusts for severity may not allow us to compare like to like. My perspective is that intensivists do a good job, and we’re not convinced that the study adequately compensated for severity adjustment.”

Hospitalist Dr. Axon: “This is one of those studies we’re going to talk a lot about because it’s counter to all the research that has come before. It parallels what has happened in hospital medicine, where early studies showed improvements or efficiencies in length of stay and cost per case over non-hospitalists, and later studies have not. The working definition of critical care management differs from hospital to hospital, so you may not be making direct comparisons.”

References:

Levy MM, Rapoport J, Lemeshow S, et al. Association between critical care physician management and patient mortality in the intensive care unit. Ann Intern Med 2008;148(11):801-809.
Pronovost PJ, Angus DC, Dorman T, et al. Physician staffing patterns and clinical outcomes in critically ill patients: A systematic review. JAMA 2002;288:2151-2162.