The current findings suggest that small, but clinically meaningful differences may exist across institutions. Directing care preferentially to such institutions may be associated with improved outcomes on a community-wide basis. Nevertheless, important questions regarding the feasibility of such practices need to be explicitly explored. For example, which core ICU services should be provided by all hospitals? If some services are, in fact, regionalized, will ICU volumes be adequate in other hospitals to maintain clinicians’ skills in providing such services and to financially support these ICUs? Such questions may be best addressed by the establishment of community-based outcome initiatives that can track changes in patient outcomes and the costs of critical care over time.
In addition, differences in calibration of risk adjustment methods based on established national normative models or on locally derived models raise important questions regarding which yardstick is most appropriate to publicly compare institutional performance. For example, consumers may be most interested in local benchmarks that provide relative performance of facilities in a single region, given that for many services (particularly ICU care) it is not feasible to seek care elsewhere. Furthermore, because of changes in practice, national benchmarks that are not frequently updated may lose their clinical relevance. However, large, national corporations purchasing care in many health-care markets may believe a national reference point is not appropriate to compare outcomes across regions in which they operate. The use of national benchmarks may also highlight areas in which similar local practices lead to suboptimal outcomes, and for which local standards may not facilitate appropriate changes in care. buy ventolin inhaler
In summary, the current study suggests that physiologically based risk stratification methods can be successfully applied in nonresearch settings, are likely to be highly discriminatory, and can explain a substantial amount of the differences in observed ICU outcomes across institutions. The implementation of community-based initiatives that are based on such methods may provide important information about variations in patient outcomes and changes in practice patterns that occur over time. Such programs may also provide important insight into the impact of changes in the financing and organization of health care. The impact of current programs on health-care purchasing and on improving quality of care should be studied further.