Association of intensive care unit patient-to-intensivist ratios with hospital mortality

Hayley B. Gershengorn, David A. Harrison, Allan Garland, M. Elizabeth Wilcox, Kathryn M. Rowan, Hannah Wunsch

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Abstract

IMPORTANCE The patient-to-intensivist ratio (PIR) across intensive care units (ICUs) is not standardized and the association of PIR with patient outcome is not well established. Understanding the impact of PIR on outcomes is necessary to optimize senior medical staffing and deliver high-quality care. OBJECTIVE To test the hypotheses that: (1) there is significant variation in the PIR across ICUs and (2) higher PIRs are associated with higher hospital mortality for ICU patients. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort analysis of patients (≥16 years) admitted to ICUs staffed by a single intensivist during daytime hours in the United Kingdom from 2010 to 2013. EXPOSURES Patient-to-intensivist ratios, which we defined for each patient as the number of patients cared for by the intensivist each day averaged over the patient's stay. MAIN OUTCOMES AND MEASURES Using standard summary statistics,we evaluated PIR variation across ICUs.We used multivariable, mixed-effect, logistic regression analysis to evaluate the association between PIR and hospital mortality at ultimate discharge from acute hospital (primary outcome) and at ICU discharge. FINDING Among 49 686 adults in 94 ICUs, median age was 66 (interquartile range [IQR], 52-76) years, and 45.1%were women. The ultimate hospital mortality was 25.7%. The median PIR for patients was 8.5 (IQR, 6.9-10.8; full range, 1.0-23.5), and varied substantially among individual ICUs. The association between PIR and ultimate hospital mortality was U-shaped; there was a reduction in the odds of mortality associated with an increasing PIR up to 7.5 after which the odds of mortality increased again significantly (average patient mortality for lowest PIR, 22%; PIR of 7.5, 15%; highest PIR, 19%; P = .003). A similar U-shaped association was seen for PIR and mortality in the ICU (nadir of mortality at a PIR of 7.8, P < .001). CONCLUSIONS AND RELEVANCE PIR varied across UK ICUs. The optimal PIR in this cohort of UK ICU patients was 7.5, with significantly increased ICU and hospital mortality above and below this ratio. The number of patients cared for by 1 intensivistmay impact patient outcomes.

Original languageEnglish (US)
Pages (from-to)388-396
Number of pages9
JournalJAMA Internal Medicine
Volume177
Issue number3
DOIs
StatePublished - Mar 1 2017

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Hospital Mortality
Intensive Care Units
Mortality

ASJC Scopus subject areas

  • Internal Medicine

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Gershengorn, H. B., Harrison, D. A., Garland, A., Wilcox, M. E., Rowan, K. M., & Wunsch, H. (2017). Association of intensive care unit patient-to-intensivist ratios with hospital mortality. JAMA Internal Medicine, 177(3), 388-396. https://doi.org/10.1001/jamainternmed.2016.8457

Association of intensive care unit patient-to-intensivist ratios with hospital mortality. / Gershengorn, Hayley B.; Harrison, David A.; Garland, Allan; Wilcox, M. Elizabeth; Rowan, Kathryn M.; Wunsch, Hannah.

In: JAMA Internal Medicine, Vol. 177, No. 3, 01.03.2017, p. 388-396.

Research output: Contribution to journalArticle

Gershengorn, HB, Harrison, DA, Garland, A, Wilcox, ME, Rowan, KM & Wunsch, H 2017, 'Association of intensive care unit patient-to-intensivist ratios with hospital mortality', JAMA Internal Medicine, vol. 177, no. 3, pp. 388-396. https://doi.org/10.1001/jamainternmed.2016.8457
Gershengorn, Hayley B. ; Harrison, David A. ; Garland, Allan ; Wilcox, M. Elizabeth ; Rowan, Kathryn M. ; Wunsch, Hannah. / Association of intensive care unit patient-to-intensivist ratios with hospital mortality. In: JAMA Internal Medicine. 2017 ; Vol. 177, No. 3. pp. 388-396.
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abstract = "IMPORTANCE The patient-to-intensivist ratio (PIR) across intensive care units (ICUs) is not standardized and the association of PIR with patient outcome is not well established. Understanding the impact of PIR on outcomes is necessary to optimize senior medical staffing and deliver high-quality care. OBJECTIVE To test the hypotheses that: (1) there is significant variation in the PIR across ICUs and (2) higher PIRs are associated with higher hospital mortality for ICU patients. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort analysis of patients (≥16 years) admitted to ICUs staffed by a single intensivist during daytime hours in the United Kingdom from 2010 to 2013. EXPOSURES Patient-to-intensivist ratios, which we defined for each patient as the number of patients cared for by the intensivist each day averaged over the patient's stay. MAIN OUTCOMES AND MEASURES Using standard summary statistics,we evaluated PIR variation across ICUs.We used multivariable, mixed-effect, logistic regression analysis to evaluate the association between PIR and hospital mortality at ultimate discharge from acute hospital (primary outcome) and at ICU discharge. FINDING Among 49 686 adults in 94 ICUs, median age was 66 (interquartile range [IQR], 52-76) years, and 45.1{\%}were women. The ultimate hospital mortality was 25.7{\%}. The median PIR for patients was 8.5 (IQR, 6.9-10.8; full range, 1.0-23.5), and varied substantially among individual ICUs. The association between PIR and ultimate hospital mortality was U-shaped; there was a reduction in the odds of mortality associated with an increasing PIR up to 7.5 after which the odds of mortality increased again significantly (average patient mortality for lowest PIR, 22{\%}; PIR of 7.5, 15{\%}; highest PIR, 19{\%}; P = .003). A similar U-shaped association was seen for PIR and mortality in the ICU (nadir of mortality at a PIR of 7.8, P < .001). CONCLUSIONS AND RELEVANCE PIR varied across UK ICUs. The optimal PIR in this cohort of UK ICU patients was 7.5, with significantly increased ICU and hospital mortality above and below this ratio. The number of patients cared for by 1 intensivistmay impact patient outcomes.",
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N2 - IMPORTANCE The patient-to-intensivist ratio (PIR) across intensive care units (ICUs) is not standardized and the association of PIR with patient outcome is not well established. Understanding the impact of PIR on outcomes is necessary to optimize senior medical staffing and deliver high-quality care. OBJECTIVE To test the hypotheses that: (1) there is significant variation in the PIR across ICUs and (2) higher PIRs are associated with higher hospital mortality for ICU patients. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort analysis of patients (≥16 years) admitted to ICUs staffed by a single intensivist during daytime hours in the United Kingdom from 2010 to 2013. EXPOSURES Patient-to-intensivist ratios, which we defined for each patient as the number of patients cared for by the intensivist each day averaged over the patient's stay. MAIN OUTCOMES AND MEASURES Using standard summary statistics,we evaluated PIR variation across ICUs.We used multivariable, mixed-effect, logistic regression analysis to evaluate the association between PIR and hospital mortality at ultimate discharge from acute hospital (primary outcome) and at ICU discharge. FINDING Among 49 686 adults in 94 ICUs, median age was 66 (interquartile range [IQR], 52-76) years, and 45.1%were women. The ultimate hospital mortality was 25.7%. The median PIR for patients was 8.5 (IQR, 6.9-10.8; full range, 1.0-23.5), and varied substantially among individual ICUs. The association between PIR and ultimate hospital mortality was U-shaped; there was a reduction in the odds of mortality associated with an increasing PIR up to 7.5 after which the odds of mortality increased again significantly (average patient mortality for lowest PIR, 22%; PIR of 7.5, 15%; highest PIR, 19%; P = .003). A similar U-shaped association was seen for PIR and mortality in the ICU (nadir of mortality at a PIR of 7.8, P < .001). CONCLUSIONS AND RELEVANCE PIR varied across UK ICUs. The optimal PIR in this cohort of UK ICU patients was 7.5, with significantly increased ICU and hospital mortality above and below this ratio. The number of patients cared for by 1 intensivistmay impact patient outcomes.

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