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Meeta Prasad Kerlin, MD, MSCE; Scott D. Halpern, MD, PhD
Author and Funding Information

From the Pulmonary, Allergy, and Critical Care Division, Department of Medicine (Drs Kerlin and Halpern), Center for Clinical Epidemiology and Biostatistics (Drs Kerlin and Halpern), and Department of Medical Ethics and Health Policy (Dr Halpern), Perelman School of Medicine, University of Pennsylvania; and Leonard Davis Institute of Health Economics (Drs Kerlin and Halpern), P30 Roybal Center on Behavioral Economics and Health (Dr Halpern), and Fostering Improvement in End-of-Life Decision Science (FIELDS) Program (Dr Halpern), University of Pennsylvania.

CORRESPONDENCE TO: Meeta Prasad Kerlin, MD, MSCE, Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, 3600 Spruce St, W Gates Bldg, Rm 05011, Philadelphia, PA 19104; e-mail: prasadm@uphs.upenn.edu


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.

FUNDING/SUPPORT: This project was supported in part by a grant from the National Heart, Lung, and Blood Institute [K08HL116771 to Dr Kerlin] and a grant from the Agency for Healthcare Research and Quality [K08HS018406 to Dr Halpern].

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


Chest. 2015;148(2):e67-e68. doi:10.1378/chest.15-1097
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To the Editor:

We appreciate the comments of Drs Sriratanaviriyakul and Albertson and Dr Rho and colleagues in response to our study of nighttime intensivist staffing.1 We agree wholeheartedly with Drs Sriratanaviriyakul and Albertson that mortality has significant limitations as an outcome in this and all studies of ICUs, as we discussed briefly in our recent article.1 Further, as we note in our review of critical care randomized trials, mortality is widely accepted as the primary outcome in research on critically ill patients, but it has a number of methodologic and conceptual limitations.2,3 Indeed, our study may be the first to systematically address this limitation by directly examining patterns of limitations on life support. However, we acknowledge that this effort was exploratory in nature and does not address all the weaknesses of mortality as a critical care outcome measure. We agree that further work is needed to more fully unpack mortality as an outcome and to identify other relevant outcomes in ICU research.

We also agree with Dr Rho and colleagues about the importance of understanding the impact of nighttime intensivist staffing on education, as we have noted previously in CHEST.4 However, as we described in that more thorough treatment of this important issue, we do not believe the educational outcomes to be studied are yet apparent. The majority of ICUs in this country, and indeed the world, are not staffed by medical trainees; thus, the key educational issue is the ultimate preparedness of future ICU staff physicians to function independently. However, the studies of educational outcomes thus far have focused primarily on perceptions of education and autonomy, which may or may not actually correlate with competency. Therefore, as nighttime staffing patterns in ICUs continue to evolve, with implications on our future workforce, we too hope that this area of research will continue to be pursued.

Acknowledgments

Role of sponsors: The funding agencies played no role in the development of the research or the manuscript. The Cerner Corporation, which owns IMPACT, made no contributions to the study beyond providing the data.

Kerlin MP, Harhay MO, Kahn JM, Halpern SD. Nighttime intensivist staffing, mortality, and limits on life support: a retrospective cohort study. Chest. 2015;147(4):951-958. [CrossRef] [PubMed]
 
Holloway RG, Quill TE. Mortality as a measure of quality: implications for palliative and end-of-life care. JAMA. 2007;298(7):802-804. [CrossRef] [PubMed]
 
Harhay MO, Wagner J, Ratcliffe SJ, et al. Outcomes and statistical power in adult critical care randomized trials. Am J Respir Crit Care Med. 2014;189(12):1469-1478. [CrossRef] [PubMed]
 
Kerlin MP, Halpern SD. Twenty-four-hour intensivist staffing in teaching hospitals: tensions between safety today and safety tomorrow. Chest. 2012;141(5):1315-1320. [CrossRef] [PubMed]
 

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References

Kerlin MP, Harhay MO, Kahn JM, Halpern SD. Nighttime intensivist staffing, mortality, and limits on life support: a retrospective cohort study. Chest. 2015;147(4):951-958. [CrossRef] [PubMed]
 
Holloway RG, Quill TE. Mortality as a measure of quality: implications for palliative and end-of-life care. JAMA. 2007;298(7):802-804. [CrossRef] [PubMed]
 
Harhay MO, Wagner J, Ratcliffe SJ, et al. Outcomes and statistical power in adult critical care randomized trials. Am J Respir Crit Care Med. 2014;189(12):1469-1478. [CrossRef] [PubMed]
 
Kerlin MP, Halpern SD. Twenty-four-hour intensivist staffing in teaching hospitals: tensions between safety today and safety tomorrow. Chest. 2012;141(5):1315-1320. [CrossRef] [PubMed]
 
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