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The Critical Care Workforce: A Study of the Supply and
Demand for Critical Care Physicians
Chapter
1: Workforce Issues in Critical Care
Specialty
History
This
report considers intensivists to be physicians certified
in critical care who primarily deliver care to patients
in an intensive care unit. Most hospitals in the United
States have maintained at least one ICU since the late 1960’s,
although the use of ICUs has continued to grow as hospital
patients have become more severely ill and as technology
has increased the level of care available to the most critically
ill patients. [17]
Critical care is one of the newest specialties to be certified
under the American Board of Medical Specialties, with the
first examination for internal medicine (IM) specialists
in critical care held in 1987. [18]
We note that our study focuses on the adequacy of intensivist
supply to provide adult critical care. Population projections
suggest a large increase in demand for such services due
to an aging population.
Only
seven percent of internists with board certification in
critical care have been trained in critical care as their
only subspecialty; Angus and colleagues found that the majority
of those providing intensivist services trained in combined
pulmonary and critical care programs. [19]
In addition to their critical care training, intensivists
have completed training in internal medicine, anesthesia,
general surgery, pediatrics, or obstetrics and gynecology.
Intensivists care for critically ill patients alongside
nurses, respiratory therapists, pharmacists, and physician
assistants.
Pulmonologists
are certified in pulmonary medicine and are trained in the
care of patients with a variety of lung and respiratory
disorders. These disorders include a number of common diseases
such as asthma, chronic obstructive pulmonary disease and
emphysema. Pulmonologists complete a residency in internal
medicine and a fellowship in pulmonary medicine either by
itself or in conjunction with training in critical care.
Growth
of Pulmonology and Critical Care Medicine
Pulmonary
medicine originally evolved as a specialty as physicians
developed increasing interest in patients with tuberculosis.
As antimicrobial therapy developed, and broader knowledge
was acquired, pulmonologists expanded their expertise to
a wide variety of illnesses affecting the respiratory system.
Internists
became more interested in the care of critically ill ICU
patients with pulmonologists pioneering the critical care
field because of their expertise in the respiratory disorders
of mechanically ventilated patients. Critical care has
continued to be a significant part of the scope of practice
of pulmonologists throughout its development as a distinct
specialty.
Mechanical
ventilation was first used primarily for patients in the
operating room, but became increasingly utilized in the
care of patients with respiratory failure associated with
a variety of illnesses. Surgical specialists, including
those practicing obstetrics and gynecology, were frequently
involved in the care of critically ill patients who were
mechanically ventilated in both surgical and recovery rooms.
ICUs became more prevalent in the 1950’s as the number of
ventilated patients grew and were grouped together for increased
efficiency of care. [20]
Anesthesiologists were the first physicians to take a leading
role in caring for ICU patients because of their experience
in the operating and recovery rooms.
Previous
analysis of the critical care workforce has examined pulmonologists
and critical care specialists within internal medicine as
one heterogeneous group that may fulfill similar functions.
However, physician certification and discipline of primary
training may help to identify those physicians who deliver
a significant volume of critical care services because they
are associated with practice characteristics.
Internists
trained exclusively in pulmonary medicine spend about 23
percent of patient care hours in the ICU, whereas those
trained exclusively in critical care (without pulmonary
training) spend more than 46 percent of patient care hours
in the ICU. [21]
Surgeons and anesthesiologists account for a smaller proportion
of practicing intensivists, about 10 percent, and are most
likely to be involved in the care of post-operative patients.
Training Requirements
While
many pulmonologists are also certified as intensivists,
separate training requirements exist for both certifications.
- Critical
Care Medicine fellowships are generally 2 years, with
at least 1 year of direct clinical care. The other year
may be spent in research or related activities.
- Pulmonary
Disease fellowships are also at least 2 years in duration.
Pulmonologists must acquire clinical proficiency in many
of the same areas as those certified in critical care.
They also learn how to supervise pulmonary function tests
and perform a number of other procedures specific to the
respiratory system (e.g., bronchoscopy and pleural biopsy).
However, the frequency and duration of caring for critically
ill inpatients may be less than that for critical care
fellowships.
- Combined
pulmonary and critical care fellowships require that physicians
meet the proficiency requirements of both specialty certifications.
Fellowships must be at least 3 years in duration, with
two of these years spent in primarily clinical activity.
The
close relationship between the practice of pulmonary care
and that of critical care medicine is reflected in fellowship
training. This relationship may be because leaders in pulmonary
medicine believe that “their survival and growth is vitally
linked with critical care medicine.” [22]
In recognition of this fact, many training programs in pulmonary
medicine appended “critical care” to their name during the
1980's.
Because
ICU patients are the most severely ill inpatients, they
have mortality rates estimated to be between 12 and 17 percent.
[23] Almost 500,000
people die in ICUs every year; 360,000 of these patients
are not managed by intensivists. [24]
Intensive care units have become an increasingly important
part of U.S. inpatient care as less severely ill patients
are cared for in the outpatient setting and inpatients are,
on average, sicker than patients admitted a decade ago.
ICUs are expected to become even more important as the elderly
increase in number and account for a greater proportion
of ICU admissions
The Growing
Elderly Population
The
COMPACCS study examined the supply of intensivists and pulmonologists
that provide services to adults in the U.S., as well as
the expected demand for those services between 1997 and
2030. In their analysis, more than half of all ICU days
were found to be associated with care for patients older
than 65 years of age. Some of the sickest patients—those
with respiratory insufficiency, multiple organ failure,
and sepsis—were most likely to be cared for by intensivists
in the critical care setting.
The
most significant factor influencing the growth in demand
for critical care services projected by the study is the
aging of the population. Americans over the age of 65 consume
the majority of ICU services and this group will grow both
in total number and as a proportion of the population.
If age-specific, per capita utilization of critical care
services remains constant, COMPACCS estimated that in the
absence of an increase in intensivist supply by 2020 there
could be a 20 percent deficit in supply of intensivists.
Intensivist
Staffing and Quality of Care
Patient
outcomes and the quality of care in the ICU are related
to who delivers that care and how care is organized. The
organization of the ICU follows three general models: [25]
- Open
ICU—an open ICU is one in which patients are admitted
by an attending physician of record (such as a general
internist, surgeon, or family practitioner) with intensivists
available for consultation. All decisions are ultimately
guided by the attending of record, even those that involve
the intensivist.
- Intensivist
co-management—an open ICU, as above, in which patients
receive mandatory consultation from an intensivist.
While the patient is in the ICU, the primary attending
of record is a “co-attending” physician that collaborates
with the intensivist in the management of the critically
ill patient.
- Closed
ICU—an ICU in which admitted patients are transferred
to the care of an intensivist (or team of intensivists)
assigned to the ICU on a full-time basis. In closed units,
patients are admitted to the ICU only after the intensivist
approves their admission.
A growing
body of literature describes the economic and quality of
care benefits of “closed” ICU staffing models. [26],
[27] Despite this,
intensivists currently treat only 37 percent of ICU patients.
[28] Dedicated
intensivists staff an even smaller proportion of ICUs.
However, more hospitals appear to be moving towards intensivist-managed
care of ICU patients in response to the evidence base as
well as payer pressures.
Young
and Birkmeyer estimated that 360,000 deaths occur every
year in ICUs which are not managed by intensivists, and
that intensivist staffing might save 54,000 lives annually.
[29] However,
as a recent review of the evidence for the Agency for Healthcare
Research and Quality (AHRQ) suggested, “this analysis may
underestimate the importance of intensivist-managed ICUs.
In addition to mortality, other quality of care outcome
measures that might be improved by intensivists include
rates of ICU complications, inappropriate ICU utilization,
patient suffering, appropriate end-of-life palliative care,
and futile care.” [30]
The
business community has recently responded to concerns over
quality of care by creating the Leapfrog Group. Leapfrog
attempts to leverage the purchasing power of Fortune 500
companies whose annual spending on health care exceeds $45
billion. The consortium has chosen to promote three patient
safety practices: the use of computerized physician order
entry, the oversight of critical care physicians in the
care of ICU patients (inpatient physician staffing or IPS),
and the use of evidence-based hospital referral systems.
The growing evidence base supporting intensivist management
of critically ill patients, reinforced by major support
from the Leapfrog Group, has led to increasing demand for
critical care physicians in recent years.
Based
upon Leapfrog estimates, the proportion of hospitals requiring
that an intensivist is involved in the care of critically
ill patients has more than doubled in the last 5 years.
While previous estimates were that only 10 percent of ICUs
met IPS standards, Leapfrog Regional Roll-Out reports indicate
that 22 percent of 605 study hospitals meet standards at
the present time. This estimate indicates a significant
movement towards greater utilization of intensivist services.
The change in ICU organization has been dramatic; many hospitals
which publicly resisted the Leapfrog IPS recommendation
have subsequently moved to intensivist-managed ICUs. [31]
Pronovost
and colleagues have estimated that over $5 billion and 53,000
lives could be saved annually if ICU physician staffing
changes were implemented in non-rural U.S. hospitals. [32]
These estimates are consistent with earlier studies examining
the impact of ICU staffing changes on patient mortality.
[33] The combined
appeal of improved quality along with the potential for
significant cost savings makes the movement towards closed
ICU staffing likely to continue, thereby increasing demand
for intensivist services in the foreseeable future. However,
as the same AHRQ review noted, increasing demand for specialists
in critical care medicine is likely to go unmet until a
greater number of physicians are trained in this specialty.
The
COMPACCS analysis also projected that the anticipated shortage
of intensivists becomes much more severe if a greater proportion
of critical care is delivered by intensivists—as is likely
to occur given current trends. The study suggests that
if intensivists were to care for two-thirds of the ICU patients
in the U.S., available supply would meet only half of the
current demand. As is described in subsequent sections,
our analysis supports the findings that demand for intensivists
will continue to be greater than available supply in the
next three decades.
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