title: Variations in Case-Mix-Adjusted Duration of Mechanical Ventilation Among ICUs.
abstract: OBJECTIVE
  To develop a model that predicts the duration of mechanical ventilation and then to use this model to compare observed versus expected duration of mechanical ventilation across ICUs.
  
  
  METHODS
  Retrospective cohort analysis.
  
  
  METHODS
  Eighty-six eligible ICUs at 48 U.S. hospitals.
  
  
  METHODS
  ICU patients receiving mechanical ventilation on day 1 (n = 56,336) admitted from January 2013 to September 2014.
  
  
  METHODS
  None.
  
  
  RESULTS
  We developed and validated a multivariable logistic regression model for predicting duration of mechanical ventilation using ICU day 1 patient characteristics. Mean observed minus expected duration of mechanical ventilation was then obtained across patients and for each ICU. The accuracy of the model was assessed using R. We defined better performing units as ICUs that had an observed minus expected duration of mechanical ventilation less than -0.5 days and a p value of less than 0.01; and poorer performing units as ICUs with an observed minus expected duration of mechanical ventilation greater than +0.5 days and a p value of less than 0.01. The factors accounting for the majority of the model's explanatory power were diagnosis (71%) and physiologic abnormalities (24%). For individual patients, the difference between observed and mean predicted duration of mechanical ventilation was 3.3 hours (95% CI, 2.8-3.9) with R equal to 21.6%. The mean observed minus expected duration of mechanical ventilation across ICUs was 3.8 hours (95% CI, 2.1-5.5), with R equal to 69.9%. Among the 86 ICUs, 66 (76.7%) had an observed mean mechanical ventilation duration that was within 0.5 days of predicted. Five ICUs had significantly (p < 0.01) poorer performance (observed minus expected duration of mechanical ventilation, > 0.5 d) and 14 ICUs significantly (p < 0.01) better performance (observed minus expected duration of mechanical ventilation, < -0.5 d).
  
  
  CONCLUSIONS
  Comparison of observed and case-mix-adjusted predicted duration of mechanical ventilation can accurately assess and compare duration of mechanical ventilation across ICUs, but cannot accurately predict an individual patient's mechanical ventilation duration. There are substantial differences in duration of mechanical ventilation across ICU and their association with unit practices and processes of care warrants examination.
authors.affiliation: 1Prescient Healthcare Consulting, Charlottesville, VA. 2Cerner Corporation, Vienna, VA. 3Department of Biostatistics, Kansas University Medical Center, Kansas City, MO. 4Division of Critical Care Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY. 5Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Departments of Anesthesia and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada. 6Department of Anesthesiology and Critical Care Medicine, George Washington University Hospital, Washington, DC.
authors.forename: Andrew A
authors.initials: AA
authors.lastname: Kramer
authors.forename: Hayley B
authors.initials: HB
authors.lastname: Gershengorn
authors.forename: Hannah
authors.initials: H
authors.lastname: Wunsch
authors.forename: Jack E
authors.initials: JE
authors.lastname: Zimmerman
mesh_terms: D004194:Disease; D005260:Female; D005544:Forecasting / Q000379:methods; D006801:Humans; D007362:Intensive Care Units / Q000592:standards / Q000706:statistics & numerical data*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D010829:Physiological Phenomena; D012121:Respiration, Artificial / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D020379:Risk Adjustment; D013997:Time Factors