Estimating ICU Benefit: A Randomized Study of Physicians

Objectives: The distinction between overuse and appropriate use of the ICU hinges on whether a patient would benefit from ICU care. We sought to test 1) whether physicians agree about which types of patients benefit from ICU care and 2) whether estimates of ICU benefit are influenced by factors unrelated to severity of illness. Design: Randomized study. Setting: Online vignettes. Subjects: U.S. critical care physicians. Interventions: Physicians were provided with eight vignettes of hypothetical patients. Each vignette had a single patient or hospital factor randomized across participants (four factors related and four unrelated to severity of illness). Measurements and Main Results: The primary outcome was the estimate of ICU benefit, assessed with a 4-point Likert-type scale. In total, 1,223 of 8,792 physicians volunteered to participate (14% recruitment rate). Physician agreement of ICU benefit was poor (mean intraclass correlation coefficient for each vignette: 0.06; range: 0–0.18). There were no vignettes in which more than two thirds of physicians agreed about the extent to which a patient would benefit from ICU care. Increasing severity of illness resulted in greater estimated benefit of ICU care. Among factors unrelated to severity of illness, physicians felt ICU care was more beneficial when told one ICU bed was available than if ICU bed availability was unmentioned. Physicians felt ICU care was less beneficial when family was present than when family presence was unmentioned. The patient’s age, but not race/ethnicity, also impacted estimates of ICU benefit. Conclusions: Estimates of ICU benefit are widely dissimilar and influenced by factors unrelated to severity of illness, potentially resulting in inconsistent allocation of ICU care. This does not necessarily represent the views of the U.S. Government or the Department of Veterans Affairs. Dr. Valley had full access to all of the data in the study and takes full responsibility for the integrity of the data and the accuracy of the data analysis; conceptualized and designed the study; acquired data; drafted the article; analyzed the statistical data; and obtained the fund. Drs. Valley, Admon, Zahuranec, Garland, Fagerlin, and Iwashyna analyzed and interpreted of data. Drs. Valley, Admon, Zahuranec, Garland, Fagerlin, and Iwashyna critically revised the article for important intellectual content. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (https://ift.tt/29S62lw). Supported, in part, by National Institutes of Health T32HL007749 and K23HL140165 (to Dr. Valley) and the Department of Veterans Affairs Health Services Research and Development grant 13–079 (to Dr. Iwashyna). The funding organizations had no role in the design and conduct of the study; in the collection, analysis, and interpretation of the data; or in the preparation, review, or approval of the article. Drs. Valley, Zahuranec, and Iwashyna received support for article research from the National Institutes of Health. Dr. Garland’s institution received funding from the Heart and Stroke Foundation of Canada, Research Manitoba, and the Canadian Institutes for Health Research. Drs. Fagerlin and Iwashyna disclosed government work. Dr. Admon disclosed that he does not have any potential conflicts of interest. For information regarding this article, E-mail: valleyt@umich.edu Copyright © by 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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