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Patient Characteristics and ICU Organizational Factors That Influence Frequency of Pulmonary Artery Catheterization
John Rapoport, PhD;
Daniel Teres, MD;
Jay Steingrub, MD;
Thomas Higgins, MD;
William McGee, MD;
Stanley Lemeshow, PhD
JAMA. 2000;283:2559-2567.
Context Hemodynamic monitoring of patients with a pulmonary artery catheter is controversial because there are few data confirming its effectiveness, and patient and intensive care unit (ICU) organizational factors associated with its use are unknown.
Objective To determine pulmonary artery catheter use in relationship to type of ICU organization and staffing, and patient characteristics, including severity of illness and insurance coverage.
Design, Setting, and Patients Retrospective database study of 10,217 nonoperative patients who received treatment at 34 medical, mixed medical and surgical, and surgical ICUs at 27 hospitals during 1998 (patients were enrolled in Project IMPACT).
Main Outcome Measures Pulmonary artery catheter use based on severity of illness measured by the Simplified Acute Physiology Score, resuscitation status at ICU admission, and ICU organizational variables, including type, size, and model.
Results A pulmonary artery catheter was used for 831 patients (8.1%) in the ICU. In multivariate analysis adjusted for severity of illness, age, diagnosis, and do-not-resuscitate status, full-time ICU physician staffing was associated with a two-thirds reduction in the probability of catheter use (odds ratio [OR], 0.36; 95% confidence interval [CI], 0.28-0.45). Higher catheter use was associated with white race (OR, 1.38; 95% CI, 1.10-1.72) and private insurance coverage (OR, 1.33; 95% CI, 1.10-1.60). Admission to a surgical ICU was associated with a 2-fold increase in probability of catheter use (OR, 2.17; 95% CI, 1.70-2.76) compared with either medical or mixed medical and surgical ICUs.
Conclusion Organizational characteristics of ICUs, insurance reimbursement, and race, as well as clinical variables, are associated with variation in practice patterns regarding pulmonary artery catheter use. Understanding such influences, combined with studies measuring clinical and economic outcomes, can contribute to the development of policies for the rational use of pulmonary artery catheters.
Author Affiliations: Department of Economics, Mount Holyoke College, South Hadley, Mass (Dr Rapoport); Center for Health Services Research (Dr Teres), Departments of Medicine and Surgery (Drs Teres, Steingrub, Higgins, and McGee) and Anesthesia (Dr Higgins), Baystate Medical Center, Springfield, Mass; Tufts University School of Medicine, Boston, Mass (Drs Teres, Steingrub, Higgins, and McGee); and the Biostatistics Program, Ohio State University, Columbus (Dr Lemeshow).
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