AP-HP, Cochin Academic Hospital, Surgical ICU, F-75014 Paris, France.
Ann Intensive Care. 2014 Feb 1;4(1):2. doi: 10.1186/2110-5820-4-2.
Observational studies on mechanical ventilation (MV) show practice variations across ICUs. We sought to determine, with a case-vignette study, the heterogeneity of processes of care in ICUs focusing on mechanical ventilation procedures, and whether organizational patterns or physician characteristics influence practice variations.
We conducted a cross-sectional multicenter study using the case-vignette methodology. Descriptive analyses were calculated for each organizational pattern and respondent characteristics. An Index of Qualitative Variation (IQV, from 0, no heterogeneity, to a maximum of 1) was calculated.
Forty ICUs from France (N = 33) and Switzerland (N = 7) participated; 396 physicians answered our case-vignettes. There was major heterogeneity of management processes related to MV within and across centers (mean IQV per center 0.51, SD 0.09). We observed the lowest variability (mean IQV per question < 0.4) for questions related to intubation procedure, ventilation of acute respiratory distress syndrome and the use of the semirecumbent position. We observed a high variability (mean IQV per question > 0.6) for questions related to management of endotracheal tube or suctioning, management of sedation and analgesia, and respect of autonomy. Heterogeneity was independent of respondent characteristics and of the presence of written procedures. There was a correlation between the processes associated with the highest variability (mean IQV per question > 0.6) and the annual volume of ICU admission (r = 0.32 (0.01 to 0.58)) and MV (r = 0.38 (0.07 to 0.63)). Within ICUs there was a large heterogeneity regarding knowledge of a local written procedure.
Large clinical practice variations were found among ICUs. High volume centers were more likely to have heterogeneous practices. The presence of a local written procedure or respondent characteristics did not influence practice variation.
观察性研究表明，机械通气（MV）在 ICU 之间存在实践差异。我们试图通过病例情节研究来确定 ICU 中关注机械通气程序的护理过程的异质性，以及组织模式或医生特征是否会影响实践差异。
我们使用病例情节方法进行了一项横断面多中心研究。对每个组织模式和受访者特征进行描述性分析。计算了定性变异指数（IQV，从 0 表示无差异，最大为 1）。
法国（N=33）和瑞士（N=7）的 40 个 ICU 参与了研究；396 名医生回答了我们的病例情节。MV 管理过程在中心内和中心之间存在很大的异质性（中心每例的平均 IQV 为 0.51，SD 为 0.09）。我们观察到与插管程序、急性呼吸窘迫综合征的通气和半卧位使用相关的问题（每问题的平均 IQV<0.4）的变异性最低。我们观察到与气管内导管或抽吸、镇静和镇痛管理以及自主权尊重相关的问题（每问题的平均 IQV>0.6）的变异性很高。异质性与受访者特征和书面程序的存在无关。与变异性最高的（每问题的平均 IQV>0.6）相关的过程之间存在相关性，包括 ICU 入院量（r=0.32（0.01 至 0.58））和 MV（r=0.38（0.07 至 0.63））。在 ICU 内部，对于当地书面程序的了解存在很大的异质性。
在 ICU 之间发现了很大的临床实践差异。高容量中心的实践差异更大。当地书面程序的存在或受访者特征并未影响实践差异。
