title: Perceived barriers to the regionalization of adult critical care in the United States: a qualitative preliminary study.
abstract: BACKGROUND
  Regionalization of adult critical care services may improve outcomes for critically ill patients. We sought to develop a framework for understanding clinician attitudes toward regionalization and potential barriers to developing a tiered, regionalized system of care in the United States.
  
  
  METHODS
  We performed a qualitative study using semi-structured interviews of critical care stakeholders in the United States, including physicians, nurses and hospital administrators. Stakeholders were identified from a stratified-random sample of United States general medical and surgical hospitals. Key barriers and potential solutions were identified by performing content analysis of the interview transcriptions.
  
  
  RESULTS
  We interviewed 30 stakeholders from 24 different hospitals, representing a broad range of hospital locations and sizes. Key barriers to regionalization included personal and economic strain on families, loss of autonomy on the part of referring physicians and hospitals, loss of revenue on the part of referring physicians and hospitals, the potential to worsen outcomes at small hospitals by limiting services, and the potential to overwhelm large hospitals. Improving communication between destination and source hospitals, provider education, instituting voluntary objective criteria to become a designated referral center, and mechanisms to feed back patients and revenue to source hospitals were identified as potential solutions to some of these barriers.
  
  
  CONCLUSIONS
  Regionalization efforts will be met with significant conceptual and structural barriers. These data provide a foundation for future research and can be used to inform policy decisions regarding the design and implementation of a regionalized system of critical care.
authors.affiliation: Division of Pulmonary, Allergy & Critical Care, University of Pennsylvania School of Medicine, 3400 Spruce Street, Philadelphia, PA 19104, USA. jmkahn@mail.med.upenn.edu
authors.forename: Jeremy M
authors.initials: JM
authors.lastname: Kahn
authors.forename: Rebecca J
authors.initials: RJ
authors.lastname: Asch
authors.forename: Theodore J
authors.initials: TJ
authors.lastname: Iwashyna
authors.forename: Gordon D
authors.initials: GD
authors.lastname: Rubenfeld
authors.forename: Derek C
authors.initials: DC
authors.lastname: Angus
authors.forename: David A
authors.initials: DA
authors.lastname: Asch
mesh_terms: D000288:Administrative Personnel; D000328:Adult; D001291:Attitude of Health Personnel; D003422:Critical Care; D003695:Delivery of Health Care / Q000458:organization & administration*; D006801:Humans; D007362:Intensive Care Units; D007407:Interviews as Topic; D012017:Referral and Consultation; D012040:Regional Health Planning; D014481:United States