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The Effect of ICU Physician Staffing and Hospital Volume on Outcomes After Hepatic Resection

Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD

Peter J. Pronovost, MD, PhD

Departments of Surgery, Anesthesiology/Critical Care Medicine, Health Policy and Management, Johns Hopkins University School of Medicine, Hygiene and Public Health, Baltimore, MD

Pamela A. Lipsett, MD

Departments of Surgery, Anesthesiology/Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, Plipsett{at}jhmi.edu

Outcomes following complex surgical procedures vary between medical centers. High-volume providers demonstrate superior outcomes to low-volume centers. We hypothesize that differences in intensive care unit (ICU) physician staffing are associated with outcomes following hepatic resection. Data on ICU staffing was obtained from a questionnaire and linked to clinical and economic data from the Health Services Cost Review Commission (HSCRC) for all adult patients who had hepatectomy (n = 569) in the state of Maryland from 1994 to 1998. Multivariate regression with hierarchical modeling was used to determine the association between in-hospital mortality, length of stay, postoperative complications, and health care costs with daily rounds by an ICU physician after adjusting for patient and hospital characteristics. The crude in-hospital mortality rate was 1.5% in hospitals that have daily rounds by an ICU physician versus 7.8% in hospitals that did not (p = 0.001). In a multivariate analysis, adjusting for case mix and hospital and surgeon volume, lack of daily rounds by an ICU physician was associated with a fourfold increased in-hospital mortality [odds ratio (OR) 3.8; 95% confidence interval (CI) 1.4-10.2]. In addition, reintubation (OR 16.2; 95% CI 3.8-67.0), pulmonary insufficiency (OR 8.0; 95% CI 1.8-35.0), pneumonia (OR 3.7; 95% CI 1.2-11.3), and acute renal failure (OR 9.3; 95% CI 1.2-74) were more frequent without daily rounds by an ICU physician. Low-volume hospitals had a 21% (95% CI 2-44%; p = 0.03) increased length of stay and a 22% increased total hospital cost (95% CI 1-48%; p = 0.04) compared with high-volume hospitals. Both daily rounds by an ICU physician and high hospital volume are associated with improved outcomes after hepatic resection. Patients undergoing high-risk surgery should seek referral to centers with both daily rounds by an ICU physician and extensive experience with the operation.

Journal of Intensive Care Medicine, Vol. 17, No. 1, 41-47 (2002)
DOI: 10.1177/088506660201700104


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				J. B. Dimick, J. A. Cowan Jr, J. A. Knol, and G. R. Upchurch Jr Hepatic Resection in the United States: Indications, Outcomes, and Hospital Procedural Volumes From a Nationally Representative Database Arch Surg, February 1, 2003; 138(2): 185 - 191. [Abstract] [Full Text] [PDF]

				J. B. Dimick, P. J. Pronovost, J. A. Cowan Jr, and P. A. Lipsett Postoperative Complication Rates After Hepatic Resection in Maryland Hospitals Arch Surg, January 1, 2003; 138(1): 41 - 46. [Abstract] [Full Text] [PDF]