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In this issue, Levy and colleagues (10) explore the effects of ICU physician staffing models on mortality in Project IMPACT, a consortium of ICUs that receive benchmarking data in an effort to improve their care. Their findings not only refute the claim that intensivist-staffed ICUs improve outcomes but raise the possibility that intensivists are actually harmful. It is a complex study made more so by combining 2 separate research questions: one on the effect of intensivist care in choice ICUs and the other on intensivist care in no-choice ICUs.
Most of the patients in this cohort received care in choice ICUs, where someone, presumably a physician, decided whether to involve an intensivist. The investigators found that elective management by an intensivist in choice ICUs was associated with increased mortality. Elective management by an intensivist in a choice ICU should not be confused with intensivist staffing. The choice ICUs would all be classified as low-intensity staffed ICUs because intensivist involvement with a patient's care was discretionary. The effect of intensivists in low-intensity–staffed ICUs has not been studied extensively, but Levy and colleagues are not the first to raise concerns about this model of care. Treggiari and colleagues (11) demonstrated that elective consultation by a pulmonologist in open ICUs was associated with no benefit in patients with acute lung injury. These authors attributed the lack of association to indication bias, arguing that physicians would be more likely to seek help in cases that they judged to have worse prognosis. Because physicians' predictions of outcome contribute to prognoses generated by mathematical models, indication bias is difficult to eliminate from observational studies with regression models (12). Estimates of prognosis probably affect the decision to involve an intensivist, making the analysis of the choice ICUs susceptible to the same bias. Despite these limitations, these 2 studies certainly raise concerns that elective intensivist consultation
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