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Original Research: Critical Care |

Prehospital Management of Evolving Critical Illness by the Primary Care ProviderPrimary Care Provider Management of Acute Illness FREE TO VIEW

Kerri A. Ellis, DNP; Alireza Hosseinnezhad, MD; Ashfaq Ullah, MD; Yuka-Marie Vinagre, MD, PhD; Stephen P. Baker, MScPH; Craig M. Lilly, MD, FCCP
Author and Funding Information

From the Graduate School of Nursing and the Department of Medicine (Dr Ellis), UMass Memorial Medical Center; Department of Medicine (Drs Hosseinnezhad and Ullah), and Department of Critical Care Medicine (Dr Vinagre), St. Vincent Hospital; and the Departments of Information Services and Cell Biology (Mr Baker), Graduate School of Biomedical Sciences, and Departments of Medicine Anesthesiology, and Surgery (Dr Lilly), Clinical and Population Health Research Program Graduate School of Biomedical Sciences, University of Massachusetts Medical School, Worcester, MA.

Correspondence to: Craig M. Lilly, MD, FCCP, UMass Memorial Medical Center, 281 Lincoln St, Worcester, MA 01605; e-mail: craig.lilly@umassmed.edu


Funding/Support: The authors have reported to CHEST that no funding was received for this study.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2013;144(4):1216-1221. doi:10.1378/chest.12-2906
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Published online

Background:  The factors that limit primary care providers (PCPs) from intervening for adults with evolving, acute, severe illness are less understood than the increasing frequency of management by acute care providers.

Methods:  Rates of prehospital patient management by a PCP and of communication with acute care teams were measured in a multicenter, cross-sectional, descriptive study conducted in all four of the adult medical ICUs of the three hospitals in central Massachusetts that provide tertiary care. Rates were measured for 390 critical care encounters, using a validated instrument to abstract the medical record and conduct telephone interviews.

Results:  PCPs implemented prehospital management for eight episodes of acute illness among 300 encounters. Infrequent prehospital management by PCPs was attributed to their lack of awareness of the patient’s evolving acute illness. Only 21% of PCPs were aware of the acute illness before their patient was admitted to an ICU, and 33% were not aware that their patient was in an ICU. Rates of PCP involvement were not appreciably different among provider groups or by patient age, sex, insurance status, hospital, ICU, or ICU staffing model.

Conclusions:  We identified lack of PCP awareness of patients’ acute illness and high rates of PCP referral to acute care providers as the most frequent barriers to prehospital management of evolving acute illness. These findings suggest that implementing processes that encourage early patient-PCP communication and increase rates of prehospital management of infections and acute exacerbations of chronic diseases could reduce use of acute care services.

Figures in this Article

Informal conversations with adult, critically ill patients and their families about their strategies for managing evolving acute illness suggested that there are barriers that limit patients from leveraging the expertise of their primary care providers (PCPs). Patients preferred the timely response of the emergency medical system to contacting outpatient offices, in part due to processes that delayed access to their PCP. Patients also believed that the urgent treatments that they needed were not readily or routinely available through the office of their PCP. These observations are consistent with a those of a growing number of studies that detail who manages acute illness in our current health-care environment. According to a US study of 354 million episodes of acute illness, PCPs managed care for 42% of acute care episodes, ED providers managed 28%, specialty providers managed 20%, and urgent-care providers managed 7%.1 The high level of uninsured patients who had acute care episodes managed by ED physicians has been interpreted as evidence for a lack of access to PCPs. More detailed information regarding when, where, and how acutely ill patients engage the health-care system is key to advancing our understanding of how to best provide early intervention for infections and acute exacerbations of chronic illness.

We sought to understand how often PCPs were involved in the prehospital management of adults with evolving acute illnesses. To make estimates that were less dependent on local and known complicating factors, we selected a population that included patients from many PCP practices, included patients from more than one nonfederal health-care system, and selected a population with a diverse, well-balanced mix of public and private payers.2 A survey was used to measure rates of prehospital management and identify the barriers that prevented PCPs from implementing treatments for patients with evolving acute illness.

Study Design

This was a multicenter study evaluating PCP prehospital management for patients with evolving acute illness. This study was conducted between July 19, 2011, and May 14, 2012, at all four adult, medical, tertiary hospital ICUs of the three hospitals in central Massachusetts that provide tertiary care. Three of the four ICUs used a closed staffing model and one ICU used an open model. The study was designed to identify institutions and processes that resulted in higher rates of PCP prehospital management. After accounting for a 10% rate of incomplete or unavailable records, a sample size of 300 episodes of care was calculated to have an 80% probability of detecting a 20% difference in the rates of prehospital management among the participating ICUs using the χ2 test at an α level of 0.05. The University of Massachusetts Medical School Committee for the Protection of Human Subjects in Research (approval number 00004009) and the institutional review boards at each participating site approved the study. Informed consent was obtained from each PCP at the start of a telephone interview.

A six-item questionnaire was developed by an interdisciplinary focus group using a modified Delphi method and was refined after review by a focus group of seven PCPs who had used the instrument to measure communication regarding one or more of the patients admitted to an adult medical ICU. The instrument was validated by comparing the responses of the PCPs regarding their interactions with the patients to reports from the patient or their representative.

Cases were acquired using a cluster sampling approach in which screening was conducted on randomly selected days. On these days, all patients in an ICU were screened using electronic tools and efforts were made to contact the PCP of every qualifying case. Telephone interviews were conducted by study staff, trained by established methods,3 who contacted PCPs identified by the patient, family, or in the electronic medical record. Cases were eligible for enrollment when identified within 96 h of patient ICU admission and if they had an identifiable PCP who responded to one of three daily contact attempts made during office hours. If the PCP was not readily available for an immediate telephone conversation, the study staff left a message with return contact information to call back at a convenient time, made a follow-up call later the same day, and, when necessary, on the two following working days.

After confirming the patient’s identity using two identifiers and that a PCP-patient relationship existed, the PCP was contacted, verbal consent for the interview was obtained, and a standardized scripted interview was conducted. It included the following six items:

  • 1. Were you aware that the patient is in the hospital? (Yes/No)

  • 2. Who let you know about the illness or hospitalization? (Six levels of response)

  • 3. Did the patient contact your service about the present illness before coming to the hospital? (Yes/No)

  • 4. Was any prehospital intervention recommended by you? (Five levels of positive response/No) If yes, describe.

  • 5. Have you seen the patient in clinic in the last 6 months? (Yes/No)

  • 6. Was this telephone call useful to you? (Yes/No)

Responses were recorded on data-gathering forms, transferred into an electronic database, and confirmed as correctly transcribed by a second member of the study staff.

Categorical variables were compared by χ2 analysis with appropriate degrees of freedom when numbers of observations in each cell were adequate or by the Fisher-Freeman-Halton Test. Significance was prospectively set at the 0.05 level. Statistical analyses were performed with SPSS version 19 (IBM Corp).4

A PCP-patient relationship, defined as at least one patient encounter with their PCP, was identified for 363 encounters (93%) (Fig 1). Complete interview data were obtained from 235 PCPs for 300 of 363 encounters. One subject had two separate ICU encounters during a single hospital stay. We were unable to contact 63 PCPs (17%): 32 PCPs (8.8%) were out of office without a readily available covering clinician, and 31 (8.5%) were unable to complete the interview and did not return calls (Fig 1). The age and sex of the patients and information about their PCPs are presented in Table 1. The characteristics of the 91 patients who were excluded on the basis of not having a PCP who could be identified or contacted were similar to those of included cases. Excluded cases were slightly younger, more likely to be men, and to have an alcohol-related rather than a chronic disease-related diagnosis like congestive heart failure or COPD. The instrument had favorable reliability and accuracy characteristics, as PCP responses were fully concordant with the report or patients or proxies for all 46 instances in which this information was available.

Figure Jump LinkFigure 1. Enrollment of primary care providers.Grahic Jump Location
Table Graphic Jump Location
Table 1 —Patient and PCP Demographics

DO = doctor of osteopathy; MD = medical doctor; NP = nurse practitioner; PA = physician assistant; PCP = primary care provider; SIQR = semi-interquartile range.

a 

Except where otherwise indicated.

Among patients with a PCP who was available by telephone, prehospital management was prescribed for eight of 300 episodes of acute illness (3%). The most frequent barrier to prehospital management was lack of communication with the PCP. We found that the patient or their representative contacted their PCP before 51 of 300 acute care encounters (17%). Lack of communication between the patient and the PCP was identified as a barrier for 65% of encounters (249 of 382) that did not involve PCP management. We also identified other barriers, including direct patient referral to an acute care system by their PCP for 11% of encounters (43 of 382), a PCP who was out of their office without a readily available covering clinician for 8% of encounters (32 of 382), and a PCP who was in their office but not available in 8% of encounters (31 of 382). The least frequently identified barrier was the lack of a PCP-patient relationship (7%, 27 of 382 encounters). Documentation of PCP involvement during an ICU admission was infrequent. Among 300 episodes of acute illness, there were 17 instances (5.7%) of documented PCP involvement. A verbal contribution to the plan of care was made by the PCP for six episodes (2%) and a recommendation for management was recorded into the medical record for 11 (3.7%).

Fifty-one PCPs (17%) had direct communication with the patient or caregiver about the present illness prior to the patient’s episode of acute care. PCPs initiated prehospital management for eight of 51 patients (16%) and referred the patient to an acute care service without an intervention for 43 of 51 episodes (84%) (Table 2). The PCP was aware that the patient was critically ill before arrival in the ICU for 63 of 300 encounters (21%) and 4% of critically ill adults had their PCP contacted while they were in an ED. The PCP was aware of the patient’s ICU admission by the time of the telephone interview for 197 of 300 encounters (66%).

Table Graphic Jump Location
Table 2 —PCP Prehospital Interventions

See Table 1 legend for expansion of abbreviation.

a 

No. of interventions among 300 encounters.

PCP notification of their patient’s hospital admission was primarily by an automated method that included an electronically generated letter, a fax, or e-mail. Unidirectional communication methods were used for 87 of 300 of encounters (29%). Notification of the acute illness was communicated to the PCP by the patient, or the patient’s family or friend, or by another member of the PCP’s practice group for 47 encounters (16%) (Table 1). Direct communication was used for 80 of 300 encounters (26%). There were no statistically significant differences in the rates or methods of communication among health-care systems, by ICU, according to the type of ICU staffing model, or by payor. Similar to our findings of institutional characteristics, we did not detect differences in rates or methods of communication by provider group; by patient characteristics, including age, sex, primary admission diagnosis; or by who notified the PCP about the present illness.

The main finding of this study is that 3% of 300 episodes of evolving acute illness involved prehospital management that was directed by the patent’s PCP or service. The fraction of episodes managed by the PCP was also low when referrals to an acute care provider were considered as being managed by the PCP (51 of 300 episodes [17%]) (Table 2).

To understand why the rates of prehospital management were low, we identified the barriers that prevented PCP intervention. The most frequent barrier to prehospital management was that the PCP was not aware of the acute illness. This was due, in part, to a reactive approach to event detection that depended on patients or their caregivers contacting the PCP. A lack of awareness accounted for 83% of encounters (249 of 300) in which a PCP could have been involved and for 65% of all encounters (249 of 382). Other barriers to PCP prehospital management were identified less frequently. These included direct patient referral by the PCP to the acute care system, which should be considered appropriate management for patients with rapidly progressive or severe physiologic abnormalities; a PCP who was out of their office without a readily available covering provider; and a PCP who was in their office but not available. The least frequent category was that of patients who lacked a relationship with a PCP. Even among the 17% of patients who contacted their PCP, the majority did not receive prehospital management. Of these patients, 84% were directed to access the acute care system in a manner that did not involve the PCP communicating or collaborating with an acute care provider. Information about the existence of relationships and communication with PCPs who were included in this report allowed more specific interpretations of the causes behind acute care use and challenged the notion that the dominant determinant of use is access to a relationship with a PCP.

The finding that a PCP-patient relationship was not the major barrier to prehospital management of acutely ill adults is consistent with a report from the National Health Interview Survey on ED use.2 The National Health Interview Survey identified process barriers to acute care interventions by PCPs. These barriers included the patient’s inability to get through to a PCP team member or to get a timely appointment, and the patient’s perception that the wait time in the physician’s office was too long, that PCP office hours were too limited, or that transportation was not available.2 Infrequent management of evolving acute illness by PCPs is consistent with reports of high rates of PCP referral of patients with acute symptoms to an ED for management.1,57 Rising rates of acute care referral have been ascribed to PCPs’ limited ability to provide urgent treatments for acute illness in the office setting and time restrictions due to office hours. Taken together with our findings of low rates of prehospital management of acute illness, these studies suggest that there are systemic process factors that promote the use of acute care services and discourage the use of primary care services by those with unscheduled health-care needs.

In addition to noting low levels of prehospital management, we also detected suboptimal rates and forms of communication among acute care providers and PCPs both before and during a hospital stay. Among 300 episodes of severe acute illness, we found that only 197 patients (66%) who had a relationship with a PCP included a communication event. The most frequent form of communication was unidirectional electronic notification that occurred after the patient was in the ICU. Electronic notification is thought to be a suboptimal because it lacks the exchange of information benefits of dialogue.8 The timing, scope, and form of this type of unidirectional communication make it impossible for PCPs to influence early management decisions and limit their ability to contribute to inhospital care. We found evidence of interactive communication for 80 of 300 episodes of care (27%): 63 communication events were initiated by acute care providers, and 17 were initiated by a PCP. These low rates of bidirectional communication are similar to the rate of 23% reported by others for PCPs and hospitalists9 and the rate of 35% reported for communication of ICU physicians and general practitioners.10 These low rates of prehospital management and communication diverge from patient expectations that their personal physician communicates background medical and treatment preference information to an acute care or specialist provider.11

Technological advances in information and communication systems make new approaches to prehospital management practical and achievable. Patient recognition of evolving disease, access to urgent treatments, and monitoring of patient responses can be leveraged by longitudinal and acute care providers to accomplish the aims of early intervention and prevention of emergent-services use. Innovative health-care systems are developing solutions that integrate technological and human resources,12 including urgent care centers that support monitored populations13 and employing specialty nurses who use home monitoring devices to support high-risk patients in paradigms that involve close communication with PCPs and that leverage the expertise of specialists.14 These elements can be coordinated into dedicated call centers that leverage information collected by PCPs, information from home- or facility-based monitoring systems, and point-of-care laboratory testing to enable a proactive approach that makes treatments for acute illnesses more available.

This observational study has several important limitations, including the potential for influence by local practice or institutional factors. To determine whether the study population of critically ill adults from central Massachusetts was similar to the corresponding US population, we compared it to reports that included the characteristics we collected. We found that the study patients had age and sex distributions similar to those reported for a large US study of critically ill adults15 and that the rates of readmission of patients in our study were similar to those reported for Medicare beneficiaries.16 We did not find clinically significant variation in the rates of prehospital management or communication among providers that was attributable to the part of the central Massachusetts community in which the patient resided; the PCP or group; the ICU, hospital, or health-care system that cared for the patient; or the payor that supported their encounter. The consistency of low rates of prehospital management and communication among providers across these strata suggests that the findings are not due to easily identifiable local factors and may reflect more general or structural aspects of systems that deliver care to patients with acute severe illness. Despite this internal consistency and the fact that the findings are consistent with those from national utilization studies, there may be factors that are present in other settings that limit generalization of our findings. The high rates of access to PCPs that we observed for the central Massachusetts population may underestimate the importance of access in populations where PCPs are less available. In addition, the rates of PCP prehospital management for specialty ICUs, like trauma, neurosciences, and cardiovascular ICUs, may be different than those we measured for ICUs that care for medical-service patients. The design of our study prevented us from measuring how frequently needed services were available in the office of the PCP. However, the high rate of referral to other sites suggests that needed services are often not available at the offices of PCPs. The selection of patients who became severely ill may have resulted in an underestimation of the rates of PCP prehospital management of acute illness because successful management is expected to prevent admission to an ICU.

We identified low rates of prehospital management, as low as 3% to 17%, by PCPs of patients with evolving life-threatening illnesses as a common and potentially modifiable factor that could contribute to adult ICU use. The disproportionate costs of adult critical care17,18 suggest that primary prevention strategies that engage patients with their longitudinal care providers19 in new paradigms of early recognition and prehospital management could reduce wasteful use and should be investigated.

Author contributions: Drs Ellis and Lilly had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Dr Ellis: contributed to study concept and design; data acquisition, analysis, and interpretation; and writing and revision of the manuscript and served as principal author.

Dr Hosseinnezhad: contributed to study concept and design, data acquisition, and revision of the manuscript.

Dr Ullah: contributed to data acquisition and revision of the manuscript.

Dr Vinagre: contributed to data analysis and interpretation and revision of the manuscript.

Mr Baker: contributed to data analysis and interpretation and revision of the manuscript.

Dr Lilly: contributed to study concept and design; data acquisition, analysis, and interpretation; and writing and revision of the manuscript.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Other contributions: The authors acknowledge St. Vincent Hospital and UMass Memorial Medical Center for their generous support of this study that was conducted without extramural support. The authors are indebted to Robert A. Klugman, MD, of the UMass Memorial Medical primary care group for his thoughtful review of the manuscript.

Pitts SR, Carrier ER, Rich EC, Kellermann AL. Where Americans get acute care: increasingly, it’s not at their doctor’s office. Health Aff (Millwood). 2010;29(9):1620-1629. [CrossRef] [PubMed]
 
Cheung PT, Wiler JL, Lowe RA, Ginde AA. National study of barriers to timely primary care and emergency department utilization among Medicaid beneficiaries. Ann Emerg Med. 2012;60(1):4-10. [CrossRef] [PubMed]
 
Noy D. Setting up targeted research interviews: a primer for students and new interviewers. Qual Rep. 2009;14(3):454-465.
 
IBM Corp. SPSS 19.0 Command Syntax Reference. Chicago, IL: IBM Corp; 2010.
 
Berenson RA, Rich EC. US approaches to physician payment: the deconstruction of primary care. J Gen Intern Med. 2010;25(6):613-618. [CrossRef] [PubMed]
 
McCusker J, Karp I, Cardin S, Durand P, Morin J. Determinants of emergency department visits by older adults: a systematic review. Acad Emerg Med. 2003;10(12):1362-1370. [CrossRef] [PubMed]
 
Ionescu-Ittu R, McCusker J, Ciampi A, et al. Continuity of primary care and emergency department utilization among elderly people. CMAJ. 2007;177(11):1362-1368. [CrossRef] [PubMed]
 
Lee RG, Garvin T. Moving from information transfer to information exchange in health and health care. Soc Sci Med. 2003;56(3):449-464. [CrossRef] [PubMed]
 
Bell CM, Schnipper JL, Auerbach AD, et al. Association of communication between hospital-based physicians and primary care providers with patient outcomes. J Gen Intern Med. 2009;24(3):381-386. [CrossRef] [PubMed]
 
Etesse B, Jaber S, Mura T, et al; AzuRéa Group. How the relationships between general practitioners and intensivists can be improved: the general practitioners’ point of view. Crit Care. 2010;14(3):R112. [CrossRef] [PubMed]
 
Arora VM, Prochaska ML, Farnan JM, et al. Problems after discharge and understanding of communication with their primary care physicians among hospitalized seniors: a mixed methods study. J Hosp Med. 2010;5(7):385-391. [CrossRef] [PubMed]
 
Shields M. From clinical integration to accountable care. Ann Health Law. 2011;20(2):151-164. [PubMed]
 
Merritt B, Naamon E, Morris SA. The influence of an Urgent Care Center on the frequency of ED visits in an urban hospital setting. Am J Emerg Med. 2000;18(2):123-125. [CrossRef] [PubMed]
 
Naylor M, Keating SA. Transitional care. Am J Nurs. 2008;108(9 Suppl):58-63. [CrossRef] [PubMed]
 
Lilly CM, Zuckerman IH, Badawi O, Riker RR. Benchmark data from more than 240,000 adults that reflect the current practice of critical care in the United States. Chest. 2011;140(5):1232-1242. [CrossRef] [PubMed]
 
Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-1428. [CrossRef] [PubMed]
 
Alsarraf AA, Fowler R. Health, economic evaluation, and critical care. J Crit Care. 2005;20(2):194-197. [CrossRef] [PubMed]
 
Milbrandt EB, Kersten A, Rahim MT, et al. Growth of intensive care unit resource use and its estimated cost in Medicare. Crit Care Med. 2008;36(9):2504-2510. [CrossRef] [PubMed]
 
Johnson TK, Borgos S. Evolve and integrate: a new imperative for ambulatory care. Healthc Financ Manage. 2012;66(4):68-73. [PubMed]
 

Figures

Figure Jump LinkFigure 1. Enrollment of primary care providers.Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1 —Patient and PCP Demographics

DO = doctor of osteopathy; MD = medical doctor; NP = nurse practitioner; PA = physician assistant; PCP = primary care provider; SIQR = semi-interquartile range.

a 

Except where otherwise indicated.

Table Graphic Jump Location
Table 2 —PCP Prehospital Interventions

See Table 1 legend for expansion of abbreviation.

a 

No. of interventions among 300 encounters.

References

Pitts SR, Carrier ER, Rich EC, Kellermann AL. Where Americans get acute care: increasingly, it’s not at their doctor’s office. Health Aff (Millwood). 2010;29(9):1620-1629. [CrossRef] [PubMed]
 
Cheung PT, Wiler JL, Lowe RA, Ginde AA. National study of barriers to timely primary care and emergency department utilization among Medicaid beneficiaries. Ann Emerg Med. 2012;60(1):4-10. [CrossRef] [PubMed]
 
Noy D. Setting up targeted research interviews: a primer for students and new interviewers. Qual Rep. 2009;14(3):454-465.
 
IBM Corp. SPSS 19.0 Command Syntax Reference. Chicago, IL: IBM Corp; 2010.
 
Berenson RA, Rich EC. US approaches to physician payment: the deconstruction of primary care. J Gen Intern Med. 2010;25(6):613-618. [CrossRef] [PubMed]
 
McCusker J, Karp I, Cardin S, Durand P, Morin J. Determinants of emergency department visits by older adults: a systematic review. Acad Emerg Med. 2003;10(12):1362-1370. [CrossRef] [PubMed]
 
Ionescu-Ittu R, McCusker J, Ciampi A, et al. Continuity of primary care and emergency department utilization among elderly people. CMAJ. 2007;177(11):1362-1368. [CrossRef] [PubMed]
 
Lee RG, Garvin T. Moving from information transfer to information exchange in health and health care. Soc Sci Med. 2003;56(3):449-464. [CrossRef] [PubMed]
 
Bell CM, Schnipper JL, Auerbach AD, et al. Association of communication between hospital-based physicians and primary care providers with patient outcomes. J Gen Intern Med. 2009;24(3):381-386. [CrossRef] [PubMed]
 
Etesse B, Jaber S, Mura T, et al; AzuRéa Group. How the relationships between general practitioners and intensivists can be improved: the general practitioners’ point of view. Crit Care. 2010;14(3):R112. [CrossRef] [PubMed]
 
Arora VM, Prochaska ML, Farnan JM, et al. Problems after discharge and understanding of communication with their primary care physicians among hospitalized seniors: a mixed methods study. J Hosp Med. 2010;5(7):385-391. [CrossRef] [PubMed]
 
Shields M. From clinical integration to accountable care. Ann Health Law. 2011;20(2):151-164. [PubMed]
 
Merritt B, Naamon E, Morris SA. The influence of an Urgent Care Center on the frequency of ED visits in an urban hospital setting. Am J Emerg Med. 2000;18(2):123-125. [CrossRef] [PubMed]
 
Naylor M, Keating SA. Transitional care. Am J Nurs. 2008;108(9 Suppl):58-63. [CrossRef] [PubMed]
 
Lilly CM, Zuckerman IH, Badawi O, Riker RR. Benchmark data from more than 240,000 adults that reflect the current practice of critical care in the United States. Chest. 2011;140(5):1232-1242. [CrossRef] [PubMed]
 
Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-1428. [CrossRef] [PubMed]
 
Alsarraf AA, Fowler R. Health, economic evaluation, and critical care. J Crit Care. 2005;20(2):194-197. [CrossRef] [PubMed]
 
Milbrandt EB, Kersten A, Rahim MT, et al. Growth of intensive care unit resource use and its estimated cost in Medicare. Crit Care Med. 2008;36(9):2504-2510. [CrossRef] [PubMed]
 
Johnson TK, Borgos S. Evolve and integrate: a new imperative for ambulatory care. Healthc Financ Manage. 2012;66(4):68-73. [PubMed]
 
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