title: Perceptions of the appropriateness of care in California adult intensive care units.
abstract: BACKGROUND
  Increased demand for expensive intensive care unit (ICU) services may contribute to rising health-care costs. A focus on appropriate use may offer a clinically meaningful way of finding the balance. We aimed to determine the extent and characteristics of perceived inappropriate treatment among ICU doctors and nurses, defined as an imbalance between the amount or intensity of treatments being provided and the patient's expected prognosis or wishes.
  
  
  METHODS
  This was a cross-sectional study of doctors and nurses providing care to patients in 56 adult ICUs in California between May and August 2013. In total, 1,363 doctors and nurses completed an anonymous electronic survey.
  
  
  RESULTS
  Thirty-eight percent of 1,169 respondents (95% confidence interval (CI) 35% to 41%, 51.1% of physicians and 35.8% of nurses) identified at least one patient as receiving inappropriate treatment. Respondents most commonly reported that the amount of treatment provided was disproportionate to the patient's expected prognosis or wishes-325 out of 429 (76%, 95% CI 72% to 80%)--and that treatment was 'too much' in 93% of cases. Factors associated with perceived inappropriateness of treatment were the belief that death in their ICU is seen as a failure (odds ratio (OR) 5.75, 95% CI 2.28 to 14.53, P = 0.000), profession (doctors more than nurses) (OR 2.50, 95% CI 1.58 to 3.97, P = 0.000), lack of collaboration between doctors and nurses (OR 1.84, 95% CI 1.21 to 2.80, P = 0.004), intent to leave their job (OR 1.73, 95% CI 1.18 to 2.55, P = 0.005), and the perceived responsibility to control health-care costs (OR 1.57, 95% CI 1.05 to 2.33, P = 0.026). Providers supported formal communication training (90%, 95% CI 88% to 92%) and mandatory family meetings (89%, 95% CI 87% to 91%) as potential solutions to reduce the provision of inappropriate treatment.
  
  
  CONCLUSIONS
  Doctors and nurses working in California ICUs frequently perceive treatment to be inappropriate. They also identified measures that could reduce the provision of inappropriate treatment.
authors.affiliation: Commonwealth Fund 2012-13 Harkness Fellow, Kaiser Permanente Oakland, 1 Kaiser Plaza, Oakland, 94612, CA, USA. matthew.anstey@health.wa.gov.au.|Sir Charles Gairdner Hospital, Level 4 G Block, Hospital Avenue, Nedlands, 6009, WA, Australia. matthew.anstey@health.wa.gov.au.
authors.forename: Matthew H
authors.initials: MH
authors.lastname: Anstey
authors.affiliation: Center for Effectiveness & Safety Research, 100 S. Los Robles, 3rd Floor, Pasadena, CA, 91101, USA. john.l.adams@kp.org.
authors.forename: John L
authors.initials: JL
authors.lastname: Adams
authors.affiliation: Center for Effectiveness & Safety Research, 100 S. Los Robles, 3rd Floor, Pasadena, CA, 91101, USA. elizabeth.a.mcglynn@kp.org.
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: McGlynn
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D002055:Burnout, Professional; D002140:California; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D007362:Intensive Care Units / Q000592:standards*; D008297:Male; D011795:Surveys and Questionnaires; D013727:Terminal Care / Q000191:economics; D019564:Unnecessary Procedures / Q000191:economics* / Q000523:psychology; D000078329:Workforce