Monday June 9, 2008
Evidence based medicine: Is it like changing wind

Commentary on new article published in Ann Intern Med 1

In the recent years medicine has focused on evidence based care. Critical care medicine has also seen the influx of lot of studies pointing in the same directions, ranging from activated protein C in severe sepsis and it’s down fall, to tight glycemic sugar control in sepsis and it’s down fall, to the yo-yo swinging data on use of steroids in sepsis. Only one thing was holding steadfast in this time of ever changing and contradictory data on different issues over time, we clearly saw one thing holding strong was that Intensivist model with 24/7 coverage in ICU saves life. Even the Leapfrog data from April 2008 favors the role of intensivist in improving survival and decreasing mortality by 40% in ICU and 30% decrease in hospital mortality, but lets check the data out which got published in Annals of Internal Medicine on the basis of Project IMPACT data ( a national database of ICU patients) 1. The project IMPACT database is a large administrative database originally developed by Society of Critical Care Medicine in 1996).

Design: Retrospective analysis of a large, prospectively collected database of critically ill patients in 123 ICUs in 100 US hospitals.

Patients: IMPACT project data base from 2000 to 2004 included 142,392 patients admitted to 123 ICUs. Of those 101,832 met criteria and qualified for analysis.

Measurements: Difference in hospital mortality between patients cared for entirely critical care physicians, and patients cared for entirely by non-critical care physicians.

An expanded Simplified Acute Physiology Score (SAPS) was used to adjust for severity of illness, and propensity score was used to adjust for difference in the probability of selective referral to critical care physicians.

Results: After adjustment for severity of illness and propensity score, hospital mortality rates were higher for patients who received care by Critical Care Management than for those who did not. Patient taken care by intensivist were sicker. They also end up in getting more procedures.


Limitations of the study:

1. Project Impact measures only ICU and hospital mortality. No information was collected after they left the hospital.
2. Process of identifying and management of patients has limitations.
3. Data elements for analysis are limited to those available in IMPACT database. Presence or absence of protocols, order sets, the length of experience of nursing staff, nurse patient ratio, how many group of critical care physicians, hand off procedures not known.
4. Percentage of patients managed by full time intensivist cannot be identified in IMPACT database, therefore cannot assess the benefit of full time, onsite management by ICU physicians.
   

our editors' Conclusion: Further well designed prospective study should be undertaken.

Reference: click to get abstract

Levy MM, Rapoport J, Lemeshow S, Chalfin DB, Phillips G, Danis M. Association between critical care physician management and patient mortality in the intensive care unit.

Ann Intern Med 2008; 148:801-809