Physician-Level Variation in Outcomes of Mechanically Ventilated Patients.

Link to article at PubMed

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Physician-Level Variation in Outcomes of Mechanically Ventilated Patients.

Ann Am Thorac Soc. 2017 Dec 28;:

Authors: Kerlin MP, Epstein A, Kahn JM, Iwashyna TJ, Asch DA, Harhay MO, Ratcliffe SJ, Halpern SD

RATIONALE: Physicians are increasingly being held accountable for patient outcomes. Yet their specific contribution to the outcomes remains uncertain.
OBJECTIVE: 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 & Medicaid Services and the American Medical Association from 2008 and 2009. We identified intensivists by training background, board certification, and claims for serviced provided to patients admitted to an intensive care unit (ICU). We assigned patients to intensivists for outcome attribution based on submitted claims for critical care and inpatient services. We estimated the physician-specific adjusted odds ratios 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. 30-day mortality was 43% and median hospital length of stay was 11 days (IQR 6 to 18). The physician adjusted odds ratio varied from 0.72 to 1.64 (median 0.99 and IQR 0.92 to 1.09). 48% of physicians were outliers, with an adjusted odds ratio significantly different from 1. However, among intensivists, physician experience was not associated with 30-day mortality (duration OR 1.00 per additional year, 95% CI 1.00 to 1.01; volume OR 1.00 per additional patient, 95% CI 1.00 to 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.

PMID: 29283699 [PubMed - as supplied by publisher]

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