Q J Med 2003; 96: 583-591
© 2003 Association of Physicians
Variation in intubation decisions for patients with chronic obstructive pulmonary disease in one critical care network
From the 1Health Services Research Unit, London School of Hygiene and Tropical Medicine, London, 2Department of Primary Care. University of Birmingham, 3Department of Critical Care, University Hospital Birmingham, and 4Department of Critical Care, City Hospital, Birmingham, UK
Received 9 April 2003 and in revised form 21 May 2003
Background: Anecdotal evidence suggests variation in intubation decisions for chronic obstructive pulmonary disease (COPD) patients with respiratory failure, but little is known about the extent of or reasons for this variability.
Aim: To describe clinician decision-making for patients with exacerbations of COPD considered for intubation.
Design: Telephone simulation study.
Methods: Consultants responsible for COPD admissions in the Heart of England Critical Care network were asked to decide whether or not to admit three patients with COPD to ICU on the basis of information conveyed over the telephone. Consultants were also asked to predict patients survival in ICU hospital and at 180 days on the assumption that the patient did receive ICU care.
Results: Of the 120 consultants, 98 (82%) took part; 89% would admit patient 1, 64% patient 2, and 40% patient 3. The prediction of survival if ICU admission had occurred differed significantly between admitters and non-admitters. Mean predicted post-ICU hospital survival for patient 1 was 46% (95%CI 43–49) for admitters, and 13% (95%CI 6–19) for non-admitters (p < 0.001). The respective figures for patient 2 were 38% (95%CI 34–42) vs. 12% (95%CI 8–15) (p < 0.001), and for patient 3, 28% (95%CI 24–33) vs. 13% (95%CI 10–16) (p < 0.001). For a housebound COPD patient in their mid 70s, the mean (SD) threshold of predicted hospital survival below which consultants would recommend not admitting to ICU was 22% (13.2%).
Conclusions: Consultants differed markedly in their admitting decisions about identical patients. Objective outcome prediction models might improve equity in ICU bed use for patients with COPD.
Address correspondence to Dr M.J. Wildman, Health Services Research Unit, Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT. e-mail: Martin.Wildman{at}lshtm.ac.uk
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