Though more extensive testing needs to be done, initial reports indicate that patients in intensive care units have lower mortality rates when visited by a team of hospital staff versus a single person. The findings are early, sure, but the stats are a promising look into what could happen if hospitals were to staff more to fulfill these needs.

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Team Approaches to Hospital Care May Improve Outcomes

February 23, 2010 — Daily rounds by a multidisciplinary team of physicians, nurses, and other healthcare professionals are associated with lower mortality among patients in the intensive care unit (ICU), according to a report in the February 22 issue of the Archives of Internal Medicine. A second report finds that surgical patients are increasingly being managed jointly by a surgeon and a hospitalist or other clinician.

"Critically ill patients are medically complex and may benefit from a multidisciplinary approach to care," write Michelle M. Kim, MSc, from the University of Pennsylvania, Philadelphia, and colleagues in the first report. "A multidisciplinary approach acknowledges the complexities of modern critical care and the important role of communication between health care providers in delivering comprehensive care."

There has been little research on multidisciplinary care and outcomes, and there are few data to justify widespread adoption of this approach. Moreover, the few existing studies have been done at single centers and are therefore limited.

The aim of this study was to determine the independent effect of multidisciplinary care teams on the mortality of critically ill patients.

The researchers analyzed data from 107,324 patients admitted to 112 acute care hospitals in Pennsylvania between 2004 and 2006. They found that multidisciplinary care was associated with a 16% reduction in the risk for death (odds ratio [OR], 0.84; 95% confidence interval [CI], 0.76 - 0.93; P = .001).

The lowest odds of death were in ICUs that had both high-intensity physician staffing and multidisciplinary care teams (OR, 0.78; 95% CI, 0.68 - 0.89; P < .001), followed by ICUs with low-intensity physician staffing and multidisciplinary teams (OR, 0.88; 95% CI, 0.79 - 0.97; P = .01), compared with hospitals with low-intensity physician staffing but no multidisciplinary care teams.

A limitation of the study is that the data were derived from nonsurgical, noncardiac patients only and may not be generalizable to other ICU patients.

The authors write that their study provides empirical evidence to support a multidisciplinary model of critical care. "Our study shows that hospitals without the ability to implement high-intensity physician staffing can still achieve significant mortality reductions by implementing a multidisciplinary, team-based approach."

Findings Important for Critical Care Specialty

In an accompanying commentary, J. Perren Cobb, MD, from Massachusetts General Hospital, Boston, writes that the findings are important for both patients and the specialty of critical care.

Ms. Kim and colleagues' report "adds to the growing body of literature demonstrating that outcomes are best for critically ill and injured patients who are cared for in ICUs by an intensivist-led team that provides multidisciplinary care."

Only 20% of the ICUs in this study provided high-intensity staffing combined with multidisciplinary care. Although these data are limited to Pennsylvania, the situation is probably similar across the United States, Dr. Cobb writes. "If so, then the majority of critically ill or injured patients in the United States still do not have access to the ICU care model that is associated with the lowest risk of death, thereby likely resulting in deaths that could otherwise be prevented."

Dr. Cobb adds that care for patients in ICUs with low-intensity staffing and with no multidisciplinary team care could be improved if the essential features of high-quality teams can be exported.

"As an important first step, Kim and colleagues suggest that simply creating multidisciplinary care teams in ICUs that do not have high-intensity physician staffing might significantly improve outcomes, an especially important hypothesis to test given the reality of the supply-and-demand imbalance," Dr. Cobb concludes.

Joint Management of Surgical Patients

In another report, Gulshan Sharma, MD, MPH, from the University of Texas Medical Branch, Galveston, and colleagues found a rapid rise in the percentage of hospitalized surgical patients who were comanaged by a medicine physician.

"Comanagement of surgical patients by medicine physicians (generalist physicians or internal medicine subspecialists) has been shown to improve efficiency and to reduce adverse outcomes," the authors write.

In this study, they sought to examine the extent to which comanagement is used during hospitalizations for common surgical procedures in the United States.

Dr. Sharma and his team studied 694,806 Medicare fee-for-service beneficiaries who were hospitalized for surgery between 1996 and 2006 and calculated the proportion of these patients who were comanaged with a general physician or internal medicine subspecialist, along with their surgeon, during their hospital stay.

Comanagement was defined by the physicians submitting a claim for evaluation and management services on at least 70% of the days that patients were hospitalized.

Between 1996 and 2006, 35.2% of patients were comanaged by a medicine physician (23.7% by a generalist physician, 14% by an internal medicine subspecialist, and 2.5% by both). The percentage of patients who were comanaged was relatively unchanged from 1996 to 2000, and then increased sharply by 11.4% per year between 2001 and 2006.

Older patients, those with more comorbidities, and those receiving care at midsized (200 - 499 beds) nonteaching or for-profit hospitals were more likely to be comanaged.

The growth in comanagement was the result of increased comanagement by hospitalist physicians, the authors write.

They note that their study has several limitations, including examining comanagement in a fee-for-service Medicare population only; looking at 15 surgical procedures, which account for just 39.1% of all operations performed in this population; and the arbitrary definition of comanagement, which was based on a nonsurgeon physician submitting claims on at least 70% of hospital days. A further limitation is that they did not assess outcomes "and therefore cannot comment on any benefits of comanagement," they write.

"In summary, comanagement of surgical patients by medicine physicians is increasing," they conclude. "To meet this need, training in internal medicine should include medical management of surgical patients."

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