One of the main issues of measuring intensivist performance is physician attribution. Each episode of care would involve multiple intensivists and other physicians. How should accountability be spread among all specialists? This issue is especially germane to the ICU population because a majority of patients have multiple conditions and may be treated by multiple physicians. Moreover, nearly three-quarters of the care by intensivists in the United States is delivered in what is considered an “open” or “low-intensity” ICU staffing model: An intensivist makes treatment recommendations but has no authority over patient care.12 Only in a small percentage of ICUs—mostly medical ICUs and ICUs in teaching hospitals—is critical care provided in a “high-intensity” or “closed” staffing pattern, in which treatment decisions are cohesively managed under the guidance of one intensivist.12,13
Therefore, intensivists in the open system more often treat episodes with multiple physicians and to the extent that efficiency varies among the physicians. Intensivists could be unfairly penalized or rewarded if the other physicians are more inefficient or more efficient. Also, multiple attributions could increase the number of episodes attributed (at least partially) to physicians, increasing the statistical precision of performance measures for them.
ICU LOS is a process measure that can be independent of quality and is easily manipulated. Encouraging earlier transfer out of the ICU could increase the risk of patient harm and increase readmission rate. On the other hand, in states that have access to LTACs, patients can be transferred to LTACs early in their course of treatment. Thus, without another measure, looking at ICU readmission, there may be pressure for clinicians to discharge ICU patients prematurely. There is potential, however, for adverse consequences that may harm patients and ultimately increase healthcare costs. Furthermore, ICU LOS should always account for ICU mortality and ICU readmission. The measures together balance concerns regarding transferring patients faster because, while the LOS measure may improve, the mortality measure is unlikely to improve and may even worsen.14,15
There is the potential that hospitals will be rewarded unfairly by transferring a large number of patients to LTACs and encouraging the overuse of post-acute care facilities, which would drive up overall costs. At the same time, the safety-net hospitals will be penalized because the uninsured have no other option for care. Thus, in states without LTACs, both safety-net and non-safety-net hospitals would have increased ICU LOS.
Another issue is coordination of care. In the United States, critical care and palliative care are mutually exclusive entities.16 After failing a prolonged treatment in the ICU, intensivists are often the first to discuss the goals of care with patients who have reached their end-of-life and their caregivers. Using ICU LOS as a process measure would discourage intensivists from providing time-consuming, yet important, end-of-life care for ICU patients, leading to more fragmentation of care. Having the potential penalty in mind, a goals-of-care conversation is often difficult; intensivists may find it easier simply to transfer the dying patient out of the ICU or into the LTACs.
Even though risk adjustment applies, using hospital mortality as a quality-outcome measure would not account for the impact of palliative care and the ability to transfer to LTACs. Mortality, in general, is higher in safety-net hospitals. Deaths from medical errors and deaths resulting from the decision not to pursue aggressive care are very different things. More than 90% of deaths are unrelated to unsafe care. Most other publicly available quality measures refer only to the in-patient mortality, creating an incentive to move patients to LTACs and other facilities when an end-of-life circumstance arises, an option that is not feasible in a safety-net hospital. Indeed, prior research shows that benchmarking-based in-hospital mortality simply delays death or shifts the site of death to an LTAC, without actually reducing overall mortality.15
Hospitals that serve economically disadvantaged populations, which presumably have less access to care in the community and lower levels of self-efficacy in navigating a complex, fragmented healthcare system, are going to be penalized the same as hospitals serving populations that do not struggle with these complexities. On the one hand, the safety-net hospitals cannot afford any reduction in resources. Generally speaking, states with LTACs would have lower readmission rates compared to states without LTACs. These measures reflect a process of care that is independent of quality and that can be misleading.