Faculty reimbursement for graduate medical education: who gives and who receives?
Explore the source record for details and available documents.
Critical Care↗
Biomedical subjects
C Bekes
Publications and source records attributed to C Bekes.
Prediction of survival of critically ill patients by admission comorbidity.
The objective of this study was to determine how well the Charlson index of comorbidity would predict mortality of critically ill patients; and how the predictive ability of the index would compare with that of the comorbidity component (Chronic Health Points) of the APACHE II system. This prospective cohort study included in its setting an intensive care unit (ICU) and intermediate ICU (IICU) in a teaching hospital. Patients included a previously assembled inception cohort of 201 patients consecutively admitted to either unit, followed until death or discharge from the hospital, excluding patients admitted after coronary artery bypass grafting, for planned dialysis, or transferred to the IICU from another intensive care unit. Main outcome measures were recorded as death in hospital versus survival at discharge. For each patient we had prospectively obtained all data necessary to predict the probability of in-hospital death using the APACHE II system, and to classify comorbidity using the Charlson index. The Charlson index had significant ability to discriminate between patients who would live and who would die (ROC curve area = 0.67, SE = 0.05). The Chronic Health Points component of APACHE II had no significant discriminating ability (ROC area = 0.57, SE = 0.05), although the full APACHE II system was an excellent predictor (area = 0.87, SE = 0.04). Logistic regression analyses suggested that the Charlson index could contribute significant (p = 0.03) prognostic information to that obtained from the components of APACHE II other than Chronic Health, i.e., acute physiological derangement, age, and reason for admission, but the Chronic Health Points component of APACHE II could not so contribute to the rest of APACHE II (p = 0.19). Our conclusion is that use of the detailed information about comorbidity captured by the Charlson index could improve prognostic predictions even for critically ill patients.
APACHE↗
Ego bias, reverse ego bias, and physicians' prognostic.
OBJECTIVE: To evaluate the effects of "ego bias" on physicians' prognostic judgments. Ego bias is defined as systematic overestimation of the prognosis of one's own patients compared with the expected outcome of a population of similar patients. DESIGN: A prospective study of an inception cohort of critically ill patients followed until death or discharge from the hospital. PATIENTS: Consecutive patients admitted to either an ICU or an intermediate ICU at a teaching hospital during January and February 1987, excluding patients admitted after coronary artery bypass grafting, for elective dialysis, or transferred to the intermediate ICU from another critical care unit. MAIN OUTCOME MEASURES AND COMPARISONS: House officers' and critical care attending physicians' assessments of the likelihood of inhospital survival for each patient, and their assessments of the overall survival rate of ICU and intermediate ICU patients were compared with each other and with actual survival rates. RESULTS: The attending physicians' predictions for individual patients were significantly lower than their judgments of the overall survival rate, 79.8% vs. 88.0%, p = .0067, suggesting the presence of a "reverse ego bias." The house officers' predictions for individual patients were significantly higher than their judgments of the overall survival rate, 73.5% vs. 68.9%, p = .018, suggesting the presence of ego bias. The magnitude and directions of these differences varied significantly among the attending physicians (F = 4.3, degrees of freedom = 3, p = .0062 by repeated-measures analysis of variance) and the house officers (F = 6.3, degrees of freedom = 5, p = .0001). CONCLUSIONS: The critical care attending physicians exhibited reverse ego bias that was mainly a function of their optimism about the overall survival rate for critically ill patients. The house officers exhibited ego bias that was mainly a function of their pessimism about the overall survival rate for critically ill patients.
Attitude of Health Personnel↗
Are two (inexperienced) heads better than one (experienced) head? Averaging house officers' prognostic judgments for critically ill patients.
Inexperienced physicians may make prognostic judgments and management decisions about acutely ill patients in the absence of supervision. We hypothesized that mathematically combining judgments of junior and senior house officers might yield aggregate judgments as good as those made by experienced critical care attending physicians. We obtained independent quantitative assessments of the likelihood of in-hospital survival for 269 sequential intensive care unit admissions from the patient's intern or resident and the critical care fellow and attending physician on duty within 24 hours of admission, and compared these judgements with mortality data. By logistic regression, the residents' and fellows' judgments added independent prognostic information to each other (likelihood ratio chi 2, 7.6; df = 1). The junior house officers' and fellows' assessments were significantly less reliable than the attending physicians' by calibration curves, and by Brier scores, 0.126 and 0.127 vs 0.119. All physicians had good discriminating ability (receiver operating characteristic areas [SE] were 0.83 [0.03], 0.85 [0.03], 0.86 [0.03], respectively). A simple average of the residents' and fellows' judgments was slightly but significantly more reliable by calibration curve and by Brier score, 0.117, and as discriminating (ROC area = 0.85, SE = 0.03) as the attending physicians' judgments. Nonmedical studies have shown that averaging independent judgments may compensate for people's tendency to make extreme estimates, and may take advantage of their complementary abilities. This first medical application of this technique suggests that this form of voting by secret ballot may prove useful for health care teams making other judgments and decisions.
Clinical Competence↗
The answer to "What are my chances, doctor?" depends on whom is asked: prognostic disagreement and inaccuracy for critically ill patients.
Physicians often must make prognostic judgments for critically ill patients, but we know little about how well they can perform this task. We prospectively measured disagreements among different physicians' quantitative prognostic judgments for 269 sequential admissions to an ICU, and evaluated the accuracy and discriminating ability of judgments made by different types of physicians. Many (44.7%) patients provoked one or more disagreements of at least 20 percentage points among the three possible pairings of physicians. Many patients whom one physician thought were certain to survive did not inspire such certainty in another of their doctors. The critical care attendings thought the changes of survival were less than or equal to 80% for 23, and between 81% and 95% for another 46 of 85 patients whom the patients' own attendings thought were certain to survive. There were some differences in the accuracy of the different physicians' estimates. All doctors showed excellent overall discriminating ability, but discriminated less well for postoperative patients. Lack of consensus about how to judge prognosis for critically ill patients may make it difficult to decide whom to admit to ICUs. These results underscore the need for valid predictive models to aid in decision-making for critically ill patients.
Adult↗
Reimbursement for intensive care services under diagnosis-related groups.
Current governmental policy, in an effort to reduce the federal deficit, has switched to a prospective payment system for hospital care of Medicare patients based on Diagnosis-Related Groups (DRGs). In New Jersey, all hospital care is reimbursed using a DRG system. This study examines the relationship between charges and reimbursement in a university hospital ICU under a DRG system for the care of patients who consume a large amount of the ICU resources. For patients who were classified Class IV under the Therapeutic Intervention Scoring System, with the possible exception of open heart patients, the charges for care delivered exceeded income received, with a net revenue of -$24,098 and an adjusted net revenue of -$5,057 for ICU Class IV patients (excluding open hearts). Thus, it appears that the care given to these patients may have resulted in a financial loss to the institution. If this were to continue, the financial impact might have a negative effect upon attempts to regionalize intensive care services.
Critical Care↗
Pulmonary edema complicating epiglottitis.
Explore the source record for details and available documents.
Epiglottitis↗
What difference do two days make? The inertia of physicians' sequential prognostic judgments for critically ill patients.
Medical authorities have asserted the importance of observing a patient's clinical course over time. Distinguished committees have suggested that changes over time in physicians' prognostic estimates should influence decisions to transfer patients out of intensive care units (ICUs). This study evaluated how the opportunity to observe patients over time affected physicians' prognostic estimates for a cohort of 269 critically ill patients sequentially admitted to a medical-surgical ICU in a teaching hospital. As soon as possible after admission and again 48 hours later, the authors obtained a quantitative estimate of the probability of survival through hospital discharge from each patient's house officer and primary attending physician, and the critical care attending physician on duty. They independently determined each patient's survival. From this population they analyzed 181 pairs of judgments made by the same house officers, 211 pairs by the same primary attendings, and 172 pairs by the same critical care attendings. The physicians' 48-hour estimates were little changed from their previous estimates for the same patients. The correlation coefficient for the house officers' paired estimates was 0.84 (p less than 0.0001); for the critical care attendings' estimates 0.84 (p less than 0.0001), and for the primary attendings' estimates, 0.90 (p less than 0.0001). Forty-eight hours did not substantially reduce the disagreements present between estimates made by different physicians for the same patient. No group of physicians substantially improved the reliability or the discriminating power of its later estimates. The physicians in the study could not take advantage of sequential clinical information over time. These results point out the need to teach physicians how to better integrate and process sequential clinical data.
Critical Care↗