HHS Report Indicates Two-Thirds of ICU Patients Receive Suboptimal Care

A newly released report by the U.S. Department of Health and Human Services (HHS) indicates that two-thirds of patients needing critical care services may be receiving suboptimal care, because the current demand for critical care services has surpassed the supply of critical care specialists (intensivists) needed to provide optimal care. The report projects that this problem will be exacerbated by 2020 due to the aging population and the increased utilization of intensivists. In response to these findings, the nation's top critical care societies are working with Sen. Richard J. Durbin (D-IL), Assistant Minority Leader, to develop solutions to alleviate the current and future burden imposed by the critical care workforce shortage.

Recognizing that our country is facing a severe critical care workforce shortage is the first step in addressing this immense burden on the nation's health-care system, said American College of Chest Physicians president W. Michael Alberts, MD, MBA, FCCP. The time for comprehensive policy discussions on this issue is overdue. Congress and the appropriate Federal agencies must act now to avert this crisis.

In May 2006, the HHS Health Resources and Services Administration (HRSA) released to Congress its report titled, The Critical Care Workforce: A Study of the Supply and Demand for Critical Care Physicians, which estimates a 35 percent shortage of intensivists by 2020 as a result of the aging population and the growing demand for greater utilization of intensivists. The report reinforces findings that the involvement of intensivists improves outcomes for critically ill patients and suggests there is an imminent need to increase the intensivist supply. With an estimated 360,000 deaths occurring each year in intensive care units (ICU) not managed by intensivists, increasing the intensivist supply may help save up to 54,000 lives annually.

Research indicates that there is a direct correlation between patient outcomes and care provided or supervised by trained specialists, said Society of Critical Care Medicine president Charles G. Durbin, Jr., MD, FCCM. The lack of team members could have a tremendous impact on how critical care is delivered in the future.

The HRSA Report references findings from previous critical care workforce reports published by a collaboration of the nation's top critical care societies, including the American College of Chest Physicians (ACCP), American Thoracic Society (ATS), Society of Critical Care Medicine (SCCM), and the American Association of Critical-Care Nurses (AACN). The societies, collectively known as the Critical Care Workforce Partnership, previously reported that the demand for critical care services would increase rapidly due to the aging population, while the intensivist supply would not be able to care for a greater proportion of critically ill patients.

As outlined in the HRSA report, the critical care workforce shortage is unique in that it is due to the aging population, which has created an overwhelming demand for critical care services that will be intensified in the next two decades. In the United States, patients use approximately 18 million ICU days annually, and more than half of these days have been associated with care for patients older than 65 years. Between 2000 and 2020, the population under age 65 is expected to grow by 10 percent; the population age 65 and older is expected to grow by approximately 50 percent by 2020 and 100 percent by 2030. As a result, the growth and aging population alone will increase the demand for adult intensivist services by approximately 38 percent between 2000 and 2020. This assumes that the current utilization of intensivists to provide critical care services will remain the same.

Research indicates that intensivists provide the most optimal level of critical care, yet, only one third of all ICU patients are currently cared for by intensivists. Recent trends suggest that a growing proportion of critically ill patients are receiving intensivist services, so that current utilization and service delivery patterns underestimate the likely current and future demand. As outlined in the HRSA Report, if the current proportion of ICU patients whose care is directed by an intensivist were to increase to the more optimal level of two thirds, the demand for intensivists would likely increase by 63 percent. Between 2000 and 2020, increased intensivist utilization, combined with the aging population, would likely increase the demand for intensivists by129 percent above the current supply. Because intensivists are more likely to provide care in large hospitals, the shortage of intensivists is likely to be worse in areas or for populations that already have limited access to physicians.

The American Association of Critical-Care Nurses (AACN) is gravely concerned about the shortage of intensivists, said AACN past-president Kathleen M. McCauley, RN, PhD, FAAN, FAHA. A shortage of critical care specialists puts increasing pressure on critical care nurses who are already feeling the strain of our own workforce shortage and the challenges this presents in our mission to deliver excellent care to patients and their families.

The HRSA Report was developed at the request of the U.S. Senate and the Critical Care Workforce Partnership looks forward to working with Durbin, other members of Congress, and the Administration to develop solutions to the critical care workforce issues through legislative and regulatory changes. Among the solutions the Partnership recommends are increasing the efficiency of the current critical care workforce by developing incentives to better distribute critical care providers and supporting alternative delivery models, such as improving the current distribution of critical care resources; increasing the utilization of technology; and increasing the effective supply of critical care providers through cross-training.

To increase the supply of critical care professionals, the Partnership recommends expanding opportunities for U.S.-trained international medical graduates to practice in the United States and increasing medical and nursing school capacity to train critical care providers. The Partnership also suggests addressing the problem of patient demand by increasing support for critical care research in the elderly population and exploring alternative care pathways for elderly patients with high mortality conditions.

"The HRSA report is clear," says American Thoracic Society president Peter D. Wagner, MD. The number of patients who are critically ill is growing. The number of critical care specialists trained to treat these patients is not keeping pace. A shortage is not only imminent but upon us, and, unless steps are taken to address the shortage, patients with life-threatening diseases and others being cared for in ICUs will suffer."

The Critical Care Workforce Partnership represents four medical societies whose more than 100,000 members are integral to critical care delivery: the American College of Chest Physicians (ACCP), American Association of Critical-Care Nurses (AACN), American Thoracic Society (ATS), and the Society of Critical Care Medicine (SCCM).

Source: American College of Chest Physicians