Insiders' Insights

Regionalizing care for critically ill patients is a concept that will likely gain momentum in the upcoming months driven in part by work force shortages, demand for services and rising costs. Proponents say patient outcomes will be improved if care is restricted to a few dedicated treatment centers. But detractors are concerned that access to care will be negatively impacted—especially for patients in smaller communities.

D. Rohan Jeyarajah, MD
Director of surgical oncology
Methodist Dallas Medical Center
Dallas

The pros to regionalization of care for critically ill patients would be improved outcomes in centers that deal with complex illnesses on a more frequent basis due to the clustering of resources and expertise. The cons are the impact to patients and their families. Some patients would rather stay with a physician they know in an area close to their family. We need to be careful about dictating to our patients where they need to get care. Two forces are pushing this idea: healthcare payers and physicians. For instance, centers that do more complex procedures generally have earlier discharges, which benefit the payer and hospital. Physicians out in the community are not always willing or able to take care of critically ill patients because of resource utilization. The concept will gain momentum and complex diseases will probably be transferred centered around organ-based referrals. For example, regionalization of pancreatitis may occur, but not pneumonia.

John E. Heffner, MD
Garnjobst Chair, Department of Medicine
Providence Portland Medical Center
Portland, OR

We face a major shortage of critical-care physicians and nurses. We will need to focus our available expertise to the most critically ill patients, which will require regionalization of ICU care. Patients with lower-severity illnesses can be managed within tertiary referral units or ICUs in smaller hospitals, but patients with more severe illnesses benefit from intensivist services. Such models of care exist, such as trauma services and organ transplantation. The major benefit resides in improved patient outcomes—matching the right care in a timely and appropriate manner. The major drawback is adequate payment for critical-care services. The existing reimbursement system does not support regionalization, wherein some centers will receive the most resource-intense patients. The idea of regionalization of critical care will receive greater attention as work force shortages worsen and demand for services accelerates.

—Carrie Vaughan