The Effect of Multidisciplinary Rounds on Intensive Care Unit Mortality 6.3.09

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Author: Jeremy Kahn

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  • 1. The effect of multidisciplinary rounds on intensive care unit mortality Michelle M. Kim MSc, Amber E. Barnato MD MPH, Derek C. Angus MD MPH, Lee F. Fleisher MD and Jeremy M. Kahn MD MS Department of Health Care Management and Economics, Wharton School of Business; Departments of Medicine and Anesthesia and Critical Care, University of Pennsylvania School of Medicine; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, Departments of Medicine, Health Policy and Management, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
    • 107,324 medical patients in 112 hospitals
    • Hospitals grouped into 3 types by staffing pattern:
        • Low intensity physician staffing without multidisciplinary care
        • Low intensity physician staffing with multidisciplinary care
        • High intensity physician staffing with multidisciplinary care
    • Multidisciplinary care staffing was associated with lower 30-day odds of mortality (Table 2)
    • After stratifying by physician staffing models, hospitals staffed with multidisciplinary care teams were associated with lower 30-day odds of mortality
    Results
    • Professional societies and quality improvement organizations advocate an intensivist-led, multidisciplinary approach to critical care
    • Although many studies suggest the benefit of intensivist physicians staffing, few empiric data support a multidisciplinary approach
    Background
    • To determine the effects of daily multidisciplinary care rounds consisting of a physicians, nurses, respiratory therapists, clinical pharmacists, and other health care professionals on mortality in the intensive care unit
    Objectives
    • Daily rounds by a multidisciplinary care team are associated with lower mortality among general ICU patients
    • The survival benefit of intensivist physician staffing is in part explained by the presence of multidisciplinary care teams in high-intensity staffed ICUs
    Conclusions
    • Results only apply to non-surgical, non-cardiac, non-neurologic patients
    • Potential response bias due to incomplete survey response by 55 hospitals
    • Unable to observe patients in high-intensity staffing models without multidisciplinary teams
    Limitations Policy Implications
      • Routine multidisciplinary care rounds should
      • be implemented when staffing capabilities
      • allow
    Table 2. Association between organizational model and mortality   Variable Odds Ratio (95% CI) Model 1: Multidisciplinary care staffing alone No multidisciplinary care 1.00 Multidisciplinary care 0.84 (0.76-0.93) Model 2: Intensivist physician staffing alone Low intensity 1.00 High intensity 0.84 (0.75-0.94) Model 3: Interaction between intensivist physician staffing and multidisciplinary care Low intensity/ no multidisciplinary care 1.00 Low intensity/ multidisciplinary care 0.88 (0.79-0.97) High intensity/ multidisciplinary care 0.78   (0.68-0.89) Models were adjusted for age, gender, admission source, Elixhauser comorbidities, mechanical ventilation status, MediQual severity score, primary diagnosis, teaching status, ICU type, region, and annual volume. Total n = 107,324. Table 1. Hospital and Patient Characteristics Low intensity no MDC Low intensity MDC High intensity MDC Hospital characteristics N=54 N=36 N=22 Teaching 12 (22) 14 (39) 15(68) Number of beds 128 [77-208] 198 [83.5-311] 286 [144-645] Annual med ICU admissions 272 [147-402] 380 [196-705] 58 [304-1103] Medical ICU 2 (4) 4 (11) 9 (41) Combined ICU 52 (96) 32 (89) 13 (59) ICU beds 11 [6-16] 15 [9-29] 21 [16-48] Patient Characteristics N=39,549 N=34,348 N=33,427 Age (mean) 65.4 64.3 62.0 Female (%) 50.7 50.7 48.9 Black (%) 5.8 12.8 18.2 Mechanical Ventilation (%) 17.0 26.2 31.3 ICU length of stay, median [IQR] 2 [1-4] 2 [1-5] 2 [1-5] ICU = intensive care unit ; MDC= multidisciplinary care
    • Retrospective cohort study
    • Pennsylvania (PA) state discharge data linked to survey of PA hospitals about organization of ICU care for medical patients (n=162)
    • All patients admitted to PA ICUs from July 1, 2004 to June 30, 2006
    • Excluded:
      • Hospitals that did not respond to survey
      • Patients with non-medical diagnoses
    • Outcome: 30-day mortality
    • Effect of multidisciplinary care examined by itself and stratified by intensivist staffing model
    • Multivariate logistic regression to determine independent effect of staffing model
    Methods
  • 2. Table 1. Hospital,Intensive Care Unit, Patient Characteristics Low intensity/no multidisciplinary care Low intensity/ multidisciplinary care High intensity/ multidisciplinary care     (n=54) (n=36) (n=22) Hospital characterisitcs Teaching 12(22) 14 (39) 15(68) Number of beds 128 [77- 208] 198 [83.5-311] 286 [144-645] Annual med ICU admissions 272 [147- 402] 380 [196-705] 588 [304-1103] ICU characterisitcs ICU: Medical 2 (4) 4 (11) 9 (41) Combined 52(96) 32 (89) 13 (59) Number of beds 11 [6-16] 15 [9-29] 21 [16-48] Patient characteristics Age 65.4 ± 17.9 64.3 ± 18.6 62.0 ± 17.8 Female (%) 50.7 50.7 48.9 Black (%) 5.8 12.8 18.2 ICU = intensive care unit   Values are expressed as a frequency (percent), median [interquartile range], or {range}.
  • 3. Table 1. Hospital,Intensive Care Unit, Patient Characteristics Low intensity/no multidisciplinary care Low intensity/ multidisciplinary care High intensity/ multidisciplinary care   (n=54) (n=36) (n=22) Hospital characterisitcs Teaching 12 (22) 14 (39) 15(68) Number of beds 128 [77-208] 198 [83.5-311] 286 [144-645] Annual med ICU admissions 272 [147-402] 380 [196-705] 588 [304-1103] ICU characterisitcs Medical ICU 2 (4) 4 (11) 9 (41) Combined Icu 52 (96) 32 (89) 13 (59) Number of beds 11 [6-16] 15 [9-29] 21 [16-48] Patient characteristics Age 65.4 ± 17.9 64.3 ± 18.6 62.0 ± 17.8 Female (%) 50.7 50.7 48.9 Black (%) 5.8 12.8 18.2 ICU = intensive care unit   Values are expressed as a frequency (percent), median [interquartile range], or {range}.
  • 4. Table 1. Hospital,Intensive Care Unit, Patient Characteristics Low intensity/no multidisciplinary Low intensity/ multidisciplinary High intensity/ multidisciplinary   (n=54) (n=36) (n=22) Hospital characterisitcs Teaching 12 (22) 14 (39) 15(68) Number of beds 128 [77-208] 198 [83.5-311] 286 [144-645] Annual med ICU admissions 272 [147-402] 380 [196-705] 588 [304-1103] ICU characterisitcs Medical ICU 2 (4) 4 (11) 9 (41) Combined Icu 52 (96) 32 (89) 13 (59) Number of beds 11 [6-16] 15 [9-29] 21 [16-48] Patient characteristics Age 65.4 ± 17.9 64.3 ± 18.6 62.0 ± 17.8 Female (%) 50.7 50.7 48.9 Black (%) 5.8 12.8 18.2 ICU = intensive care unit   Values are expressed as a frequency (percent), median [interquartile range], or {range}
  • 5. Table 2. Association between organizational models and 30-day mortality a   Variable Odds Ratio (95% CI)   Model 1: Multidisciplinary care staffing alone No multidisciplinary care 1.00 Multidisciplinary care 0.84 (0.76-0.93) Model 2: Intensivist physician staffing alone Low intensity 1.00 High intensity 0.84 (0.75-0.94) Model 3: Interaction between intensivist physician staffing and multidisciplinary care teams Low intensity/ no Multidisciplinary care 1.00   Low intensity/ multidisciplinary care 0.88 (0.79-0.97) High intensity/ multidisciplinary care 0.78   (0.68-0.89)   a Models were adjusted for age, gender, admission source, Elixhauser comorbidities, mechanical ventilation status, MediQual severity score, primary diagnosis, teaching status, ICU type, region, and annual volume. Total n = 107,324. Table 1. Association between intensivist physician staffing and 30-day mortality for all patients a Model 1: Multidisciplinary care staffing alone Model 2: Intensivist physician staffing alone Model 3: Interaction between intensivist physician staffing and multidisciplinary care teams Variable Odds Ratio (95% CI) Variable Odds Ratio (95% CI) Variable Odds Ratio (95% CI) No multidisciplinary care 1.00 Low intensity 1.00 Low intensity/no multidisciplinary care 1.00 Multidisciplinary care 0.84 High intensity 0.84 Low intensity/ multidisciplinary care 0.88 (0.76-0.93) (0.75-0.94) (0.79-0.97) High intensity/ multidisciplinary care 0.78 (0.68-0.89)             a Models were adjusted for age, gender, admission source, Elixhauser comorbidities, mechanical ventilation status, MediQual severity score, primary diagnosis, teaching status, ICU type, region, and annual volume. Total n = 107,324.
  • 6. Table 1. Association between intensivist physician staffing and 30-day mortality for all patients a   Model 1: Multidisciplinary care staffing alone Model 2: Intensivist physician staffing alone Model 3: Interaction between intensivist physician staffing and multidisciplinary care teams Variable Odds Ratio (95% CI)   Variable Odds Ratio (95% CI)   Variable Odds Ratio (95% CI) No multidisciplinary care 1.00 Low intensity/no multidisciplinary care 1.00 Multidisciplinary care 0.84 Low intensity/ multidisciplinary care 0.88 (0.76-0.93) 1.00 Low intensity (0.79-0.97) 0.84 High intensity High intensity/ multidisciplinary care 0.78 (0.68-0.89)                 a Models were adjusted for age, gender, admission source, Elixhauser comorbidities, mechanical ventilation status, MediQual severity score, primary diagnosis, teaching status, ICU type, region, and annual volume. Total n = 107,324.
  • 7. Table 1. Association between intensivist physician staffing and 30-day mortality for all patients a Model 1: Multidisciplinary care staffing alone Model 2: Intensivist physician staffing alone Model 3: Interaction between intensivist physician staffing and multidisciplinary care teams Variable Odds Ratio (95% CI) Variable Odds Ratio (95% CI) Variable Odds Ratio (95% CI) No multidisciplinary care 1.00 Low intensity 1.00 Low intensity/no multidisciplinary care 1.00 Multidisciplinary care 0.84 High intensity 0.84 Low intensity/ multidisciplinary care 0.88 (0.76-0.93) (0.75-0.94) (0.79-0.97) High intensity/ multidisciplinary care 0.78 (0.68-0.89)             a Models were adjusted for age, gender, admission source, Elixhauser comorbidities, mechanical ventilation status, MediQual severity score, primary diagnosis, teaching status, ICU type, region, and annual volume. Total n = 107,324.
  • 8. Table 1. Association between intensivist physician staffing and 30-day mortality for all patients a Model 1: Multidisciplinary care staffing alone Model 2: Intensivist physician staffing alone Model 3: Interaction between intensivist physician staffing and multidisciplinary care teams Variable Odds Ratio (95% CI) Variable Odds Ratio (95% CI) Variable Odds Ratio (95% CI) No multidisciplinary care 1.00 Low intensity 1.00 Low intensity/no multidisciplinary care 1.00 Multidisciplinary care 0.84 High intensity 0.84 Low intensity/ multidisciplinary care 0.88 (0.76-0.93) (0.75-0.94) (0.79-0.97) High intensity/ multidisciplinary care 0.78 (0.68-0.89)             a Models were adjusted for age, gender, admission source, Elixhauser comorbidities, mechanical ventilation status, MediQual severity score, primary diagnosis, teaching status, ICU type, region, and annual volume. Total n = 107,324.
  • 9. Table 1. Association between intensivist physician staffing and 30-day mortality for all patients a Model 1: Multidisciplinary care staffing alone Model 2: Intensivist physician staffing alone Model 3: Interaction between intensivist physician staffing and multidisciplinary care teams Variable Odds Ratio (95% CI) Variable Odds Ratio (95% CI) Variable Odds Ratio (95% CI) No multidisciplinary care 1.00 Low intensity 1.00 Low intensity/no multidisciplinary care 1.00 Multidisciplinary care 0.84 High intensity 0.84 Low intensity/ multidisciplinary care 0.88 (0.76-0.93) (0.75-0.94) (0.79-0.97) High intensity/ Multidisciplinary care 0.78 (0.68-0.89)             a Models were adjusted for age, gender, admission source, Elixhauser comorbidities, mechanical ventilation status, MediQual severity score, primary diagnosis, teaching status, ICU type, region, and annual volume. Total n = 107,324.
  • 10. Table 1. Association between intensivist physician staffing and 30-day mortality for all patients a   Model 1: Multidisciplinary care staffing alone Model 2: Intensivist physician staffing alone Model 3: Interaction between intensivist physician staffing and multidisciplinary care teams Variable Odds Ratio (95% CI) Variable Odds Ratio (95% CI) Variable Odds Ratio (95% CI) No multidisciplinary care 1.00 Low intensity 1.00 Low intensity/no multidisciplinary care 1.00 Multidisciplinary care 0.84 High intensity 0.84 Low intensity/ multidisciplinary care 0.88 (0.76-0.93) (0.75-0.94) (0.79-0.97) High intensity/ multidisciplinary care 0.78 (0.68-0.89)             a Models were adjusted for age, gender, admission source, Elixhauser comorbidities, mechanical ventilation status, MediQual severity score, primary diagnosis, teaching status, ICU type, region, and annual volume. Total n = 107,324.
  • 11. Table 3. Association between intensivist physician staffing and 30-day mortality for all patients*   Model 1: Multidisciplinary care staffing alone Model 2: Intensivist physician staffing alone Model 3: Interaction between intensivist physician staffing and multidisciplinary care teams Variable Odds Ratio (95% CI)   Variable Odds Ratio (95% CI)   Variable Odds Ratio (95% CI) No multidisciplinary care 1.00 Low intensity 1.00 Low intensity/no multidisciplinary care 1.00 Multidisciplinary care 0.84 High intensity 0.83 Low intensity/ multidisciplinary care 0.88 (0.76-0.93) (0.74-0.93) (0.80-0.97) High intensity/ multidisciplinary care 0.77 (0.68-0.88)                 *Models were adjusted for age, gender, admission source, Elixhauser comorbidities, mechanical ventilation status, MediQual severity score, primary diagnosis, teaching status, ICU type, region, and annual volume. Total n = 86,286.
  • 12. Table 3. Association between intensivist physician staffing and 30-day mortality for all patients*   Model 1: Multidisciplinary care staffing alone Model 2: Intensivist physician staffing alone Model 3: Interaction between intensivist physician staffing and multidisciplinary care teams Variable Odds Ratio (95% CI)   Variable Odds Ratio (95% CI)   Variable Odds Ratio (95% CI) No multidisciplinary care 1.00 Low intensity 1.00 Low intensity/no multidisciplinary care 1.00 Multidisciplinary care 0.84 High intensity 0.83 Low intensity/ multidisciplinary care 0.88 (0.76-0.93) (0.74-0.93) (0.80-0.97) High intensity/ multidisciplinary care 0.77 (0.68-0.88)                 *Models were adjusted for age, gender, admission source, Elixhauser comorbidities, mechanical ventilation status, MediQual severity score, primary diagnosis, teaching status, ICU type, region, and annual volume. Total n = 86,286.
  • 13. Table 3. Association between intensivist physician staffing and 30-day mortality for all patients*   Model 1: Multidisciplinary care staffing alone Model 2: Intensivist physician staffing alone Model 3: Interaction between intensivist physician staffing and multidisciplinary care teams Variable Odds Ratio (95% CI)   Variable Odds Ratio (95% CI)   Variable Odds Ratio (95% CI) No multidisciplinary care 1.00 Low intensity 1.00 Low intensity/no multidisciplinary care 1.00 Multidisciplinary care 0.84 High intensity 0.83 Low intensity/ multidisciplinary care 0.88 (0.76-0.93) (0.74-0.93) (0.80-0.97) High intensity/ multidisciplinary care 0.77 (0.68-0.88)                 *Models were adjusted for age, gender, admission source, Elixhauser comorbidities, mechanical ventilation status, MediQual severity score, primary diagnosis, teaching status, ICU type, region, and annual volume. Total n = 86,286.