Physician staffing patterns and clinical outcomes in critically ill patients - A systematic review
Physician staffing patterns and clinical outcomes in critically ill patients - A systematic review
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DOI：
10.1001/jama.288.17.2151
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发表时间：
2002-11-06
影响因子：
120.7
通讯作者：
Young, TL
中科院分区：
文献类型：
--
作者：
Pronovost, PJ;Angus, DC;Young, TL
背景重症监护病房（ICU）医生配置差异很大，其与患者预后的关系尚不清楚。目的评价ICU医生配置与患者预后的关系。数据来源（1965年1月1日至2001年9月30日），用于以下医学主题词（MeSH）术语：重症监护病房、ICU、卫生资源/利用、住院、医务人员医院组织和管理、人员配备和调度、住院时间和LOS。我们还使用了以下文本词：人员配备、重症监护、危重、护理和专家。为了识别观察性研究，我们增加了MeSH术语病例对照研究和回顾性研究。虽然我们检索了非英语引文，但我们仅审查了英语文章。我们还搜索了EMBASE，HealthStar（卫生服务、技术、管理和研究）和HSRPROJ（正在进行的卫生服务研究项目）通过互联网感恩医学和科克伦图书馆和手工检索重症监护国家科学会议的摘要会议记录（1994年1月1日至2001年12月31日）。研究选择我们选择了重症成人或儿童的随机和观察对照试验。研究调查了ICU主治医生的人员配置策略以及医院和ICU死亡率和住院时间（LOS）的结局。研究由2名评审员选择和评论。我们回顾了2590篇摘要，并确定了26项相关的观察性研究（其中1项包括2项比较），导致27项替代人员配置策略的比较。20项研究集中在一个单一的ICU.Data Synthesis我们分组ICU医生的工作人员分为低强度（没有重症监护或选择性重症监护咨询）或高强度（强制性重症监护咨询或封闭的ICU [所有护理由重症监护]）组。17项研究中有16项（94%）高强度人员配备与较低的住院死亡率相关，住院死亡率的相对风险汇总估计值为0.71（95%置信区间[CI]，0.62-0.82）。15项研究中有14项（93%）高强度人员配备与ICU死亡率降低相关，ICU死亡率的相对风险汇总估计值为0.61（95%CI，0.50-0.75）。高强度的人员配备减少了13项研究中的10项，减少了18项研究中的14项，而没有病例组合adjustment.Conclusions高强度的人员配备减少了4项研究中的2项，减少了2项研究中的医院LOS，并在两项研究中调整了病例组合。没有研究发现在病例组合调整后，高强度人员配备会增加LOS。
Context Intensive care unit (ICU) physician staffing varies widely, and its association with patient outcomes remains unclear.Objective To evaluate the association between ICU physician staffing and patient outcomes.Data Sources We searched MEDLINE (January 1, 1965, through September 30, 2001) for the following medical subject heading (MeSH) terms: intensive care units, ICU, health resources/utilization, hospitalization, medical staff hospital organization and administration, personnel staffing and scheduling, length of stay, and LOS. We also used the following text words: staffing, intensivist, critical, care, and specialist. To identify observational studies, we added the MeSH terms case-control study and retrospective study. Although we searched for non-English-language citations, we reviewed only English-language articles. We also searched EMBASE, HealthStar (Health Services, Technology, Administration, and Research), and HSRPROJ (Health Services Research Projects in Progress) via Internet Grateful Med and The Cochrane Library and hand searched abstract proceedings from intensive care national scientific meetings (January 1, 1994, through December 31, 2001).Study Selection We selected randomized and observational controlled trials of critically ill adults or children. Studies examined ICU attending physician staffing strategies and the outcomes of hospital and ICU mortality and length of stay (LOS). Studies were selected and critiqued by 2 reviewers. We reviewed 2590 abstracts and identified 26 relevant observational studies (of which 1 included 2 comparisons), resulting in 27 comparisons of alternative staffing strategies. Twenty studies focused on a single ICU.Data Synthesis We grouped ICU physician staffing into low-intensity (no intensivist or elective intensivist consultation) or high-intensity (mandatory intensivist consultation or closed ICU [all care directed by intensivist]) groups. High-intensity staffing was associated with lower hospital mortality in 16 of 17 studies (94%) and with a pooled estimate of the relative risk for hospital mortality of 0.71 (95% confidence interval [CI], 0.62-0.82). High-intensity staffing was associated with a lower ICU mortality in 14 of 15 studies (93%) and with a pooled estimate of the relative risk for ICU mortality of 0.61 (95 % CI, 0.50-0.75). High-intensity staffing reduced hospital LOS in 10 of 13 studies and reduced ICU LOS in 14 of 18 studies without case-mix adjustment.Conclusions High-intensity staffing was associated with reduced hospital LOS in 2 of 4 studies and ICU LOS in both studies that adjusted for case mix. No study found increased LOS with high-intensity staffing after case-mix adjustment.