The “ PrOMIS ” of things to come *

S ociety has high expectations of modern medicine, and critical care is no exception to this rule. However, aging populations (1), workforce shortages (2, 3), and rising costs (4) of intensive care are creating a demand for urgent structural change of intensive care services by healthcare administration to maintain quality of care. This requires a thorough system examination using the two most important tools in healthcare research: outcome evaluation and performance assessment. Currently, mortality is used as almost the sole outcome measure of intensive care unit (ICU) treatment. If critical care professionals wish to maintain an adequate level of service, performance should also be controlled. In their well-written opinion survey published in this issue of Critical Care Medicine, Dr. Barnato and colleagues (5) address exactly these issues in the realm of critical care organization, all of which may have a profound impact on the future prioritization and quality of care in U.S. critical services. This study, conducted during the PrOMIS conference by a highly competent group of researchers, used consensus processes to define the pertinent problems and reached several interesting conclusions. Dr. Barnato and colleagues (5) recommend standardization of critical care performance by drawing practice management guidelines for all aspects of critical care delivery (staffing, training, and work) with centralized supervision of compliance with these recommendations. Other than sporadic papers examining the rate of compliance with specific work recommendations (6, 7), this aspect of critical care management has rarely been addressed. The authors also suggest expansion of outcome evaluation to include the rate of complications, inappropriate care, and preventable deaths as well as post-ICU quality of life. This assessment should be accompanied by incentive-based, performance-related reimbursement. National market research of the public perception of critical care, possibly followed by public education (i.e., basic knowledge and realistic expectations of critical care services), is a novelty in critical care. Little is known regarding public awareness and understanding of this discipline (8, 9). Proper conduct of direct to consumer address regarding medical services has been shown to change public demand (e.g., in cardiology) (10). Thus, the possible impact of public demand on policy decision makers in favor of critical care services remains unknown and probably underexploited. Tiering of the adult critical system based on local needs, capabilities, and professional competencies is a welcome but not entirely new idea. It concurs with the 2003 American College of Critical Care Medicine expert opinion guidelines statement recommending categorization of ICUs into three levels in order to match ICU services to regional needs of the population, individual hospitals’ resources, academic status, and available staff (11). To the best of our knowledge, little has been done to implement these guidelines since their publication 4 yrs ago, probably reflecting the difficulties in materializing theories to deeds in this field. Another interesting, albeit highly controversial, consensus solution suggested by the authors is the training of noncritical care physicians in critical care to relieve manpower shortages evolving in this discipline. In fact, Haupt et al. (11) already suggested a similar solution for specific ICUs. This suggestion would be unacceptable had it not been based on the broad agreement that given the present difficulties with recruitment to the specialty of critical care and professional retention, creating more training slots for critical care professionals is unrealistic. Currently, only 37% of all ICU patients in the United States are cared by “intensivists,” and these remain concentrated particularly in large and academic hospitals (12). In light of this reality, professional “stand-offishness” may not be beneficial for any party, and difficult as it may be to accept, moderation and willingness to compromise most likely will allow critical care professionals to remain in a position to modify any suggested solution to this problem. Despite its merits, the article by Dr. Barnato and colleagues (5) suffers from problems similar to those of critical care system research today. In their zeal to effect a change, the authors have reached conclusions (outcomes), overlooking the no less major issue of the methods used in selecting the participants of this conference (structure and process). To provide their recommendations with greater substance than those of previous publications (13), the authors set inclusion of “nonphysician stakeholders” as a major objective of the PrOMIS group in order to incorporate their opinions/concerns. This objective was not achieved since only 30% of the 39 conference participants represented this group. Not surprisingly, conference conclusions largely overlapped with concerns expressed by critical care professionals in previous gatherings. Had the sample size allowed, it might be also have been interesting to observe the results of the preand postconference opinion survey stratified into participant groups in order to see whether the different stakeholders had different views regarding the important issues in critical care and whether they changed as a result of the conference. The evolving crisis in U.S. critical care services has been acknowledged in several publications (12–14). Considering both current and predicted problems, the authors of these papers have put forward important recommendations. However, these have never been implemented. Such recommendations become moot when squab*See also p. 1003.