Marya D. Zilberberg, MD; Andrew F. Shorr, MD, MPH
Potential Financial Conflicts of Interest: None disclosed.
Zilberberg MD, Shorr AF. What Conclusions Should Be Drawn between Critical Care Physician Management and Patient Mortality in the Intensive Care Unit?. Ann Intern Med. 2008;149:771-772. doi: 10.7326/0003-4819-149-10-200811180-00022
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Published: Ann Intern Med. 2008;149(10):771-772.
TO THE EDITOR:
In their study, Levy and colleagues (1) have reported that, on the basis of the data from Project IMPACT, patients managed by intensivists have a higher risk for hospital death than those managed by a non–critical care specialist. Although the authors tried earnestly to remove some of the confounding and heterogeneity by applying adjustments for propensity scores and other variables, they have rightfully acknowledged the possibility of residual confounding. However, other limitations, some acknowledged and others not, impair our interpretation of the results.
First, the high number of excluded cases due to missing data predisposes the study to a selection bias. Second, the authors were unable to ascertain which individual patients were cared for by an intensivist, but rather were forced to divide patients into groups based on the likelihood of being cared for by an intensivist. This classification was quite imprecise, resulting in more than 50% of patients in each group being lumped into the 5% to 95% group, an admittedly vast range of probabilities, predisposing the study to an ecological fallacy. Third, the authors did not stratify their results by do-not-resuscitate status, a factor likely to produce effect heterogeneity. This is an important consideration, because intensivists may be more attentive to end-of-life care practices than non–critical care physicians. Fourth, the end point of hospital mortality was not adjusted for exposure time (that is, length of stay), and thus leaves open the possibility that this outcome was influenced by differing discharge practices between the groups of physicians (2).
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