Physician-Level Variation in Outcomes of Mechanically Ventilated Patients.

Kerlin MP, Epstein A, Kahn JM, Iwashyna TJ, Asch DA, Harhay MO, Ratcliffe SJ, Halpern SD. Physician-Level Variation in Outcomes of Mechanically Ventilated Patients. Annals of the American Thoracic Society. 2018 Mar 1; 15(3):371-379.

Related HSR&D Project(s)

• IIR 13-079 – REcovery after in hoSpital Cardiac arrest: late outcomes and Utilization_ResCU

Dimensions for VA is a web-based tool available to VA staff that enables detailed searches of published research and research projects.

If you have VA-Intranet access, click here for more information vaww.hsrd.research.va.gov/dimensions/

VA staff not currently on the VA network can access Dimensions by registering for an account using their VA email address.    Search Dimensions for VA for this citation
* Don't have VA-internal network access or a VA email address? Try searching the free-to-the-public version of Dimensions

Search for Abstract from PubMed

---

Abstract:

RATIONALE: Physicians are increasingly being held accountable for patient outcomes, yet their specific contribution to the outcomes remains uncertain. OBJECTIVES: To determine variation in outcomes of mechanically ventilated patients among intensivists, as well as associations between intensivist experience and patient outcomes. METHODS: We performed a retrospective cohort study of mechanically ventilated Medicare fee-for-service patients in acute care hospitals in Pennsylvania using administrative, clinical, and physician data from Centers for Medicare and Medicaid Services and the American Medical Association from 2008 and 2009. We identified intensivists by training background, board certification, and claims for services provided to patients admitted to an intensive care unit. We assigned patients to intensivists for outcome attribution based on submitted claims for critical care and in-patient services. We estimated the physician-specific adjusted odds ratios (ORs) for 30-day mortality using a hierarchical model with a random effect for physician, adjusted for patient and hospital characteristics. We tested for independent association of physician experience with patient outcomes using mixed-effects regression for the primary outcome of 30-day mortality. We defined physician experience in two ways: years since training completion ("duration") and annual number of mechanically ventilated patients ("volume"). RESULTS: We assigned 345 physicians to 11,268 patients. The 30-day mortality was 43% and median hospital length of stay was 11 days (interquartile range? = 6-18). The physician adjusted OR varied from 0.72 to 1.64 (median? = 0.99; interquartile range? = 0.92-1.09). A total of 48% of physicians was outliers, with an adjusted OR significantly different from 1. However, among intensivists, physician experience was not associated with 30-day mortality (duration OR? = 1.00 per additional year; 95% confidence interval? = 1.00-1.01; volume OR? = 1.00 per additional patient; 95% confidence interval? = 1.00-1.00). CONCLUSIONS: Intensivists independently contribute to outcomes of Medicare patients who undergo mechanical ventilation, as evidenced by the variation in risk-adjusted mortality across intensivists. However, physician experience does not underlie this relationship between intensivists, suggesting the need to identify modifiable physician factors to improve outcomes.