Kerl in 2017

ANNALSATS Articles in Press. Published on 28-December-2017 as 10.1513/AnnalsATS.
201711-867OC
Page 1 of 37
Physician-Level Variation in Outcomes of Mechanically Ventilated Patients

Meeta Prasad Kerlin, MD MSCE 1,2, Andrew Epstein, PhD3,4, Jeremy M. Kahn, MD MS5, Theodore
J. Iwashyna, MD, PhD6,7, David A. Asch, MD MBA3,5, Michael O. Harhay, PhD2,8, Sarah J. Ratcliffe,
PhD2,8, Scott D. Halpern, MD PhD1,2,8
1
Pulmonary, Allergy and Critical Care Division, Department of Medicine, Perelman School of
Medicine at the University of Pennsylvania
2
Palliative and Advanced Illness Research (PAIR) Center, Department of Medicine, Perelman
School of Medicine at the University of Pennsylvania
3
General Internal Medicine, Department of Medicine, Perelman School of Medicine at the
University of Pennsylvania
4
Philadelphia Veterans Administration Medical Center
5
Department of Critical Care Medicine, University of Pittsburgh School of Medicine
6
Pulmonary & Critical Care Division, Department of Internal Medicine, University of Michigan
7
VA Center for Clinical Management Research, VA Ann Arbor Health System
8
Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the
University of Pennsylvania
Corresponding Author:
Meeta Prasad Kerlin, MD MSCE
Pulmonary, Allergy, and Critical Care Division
Perelman School of Medicine at the University of Pennsylvania
3600 Spruce Street, Gibson 05011
Philadelphia, Pennsylvania 19104
Office 215-614-0627
Email prasadm@uphs.upenn.edu
Author Contributions: MPK and SDH were involved in all parts of the study. MPK was involved
in data analysis and the primary writing of the manuscript. All authors were involved in
designing the study and revising the manuscript.
Funding: National Heart, Lung, and Blood Institute (K08 HL116771, MPK)
Running Head: Intensivist experience and patient outcomes
Key Words: intensive care; critical care outcomes; respiration, artificial; physician
Subject Category: 4.6 ICU Management/Outcome
Word Count: 3442
This article has an online data supplement, which is accessible from this issue's table of content
online at www.atsjournals.org
Copyright © 2017 by the American Thoracic Society

ANNALSATS Articles in Press. Published on 28-December-2017 as 10.1513/AnnalsATS.201711-867OC
Page 2 of 37
Abstract
Rationale: Physicians are increasingly being held accountable for patient outcomes. Yet their
specific contribution to the outcomes remains uncertain.
Objective: To determine variation in outcomes of mechanically ventilated patients among
intensivists, as well as associations between intensivist experience and patient outcomes.
Methods: We performed a retrospective cohort study of mechanically ventilated Medicare fee-
for-service patients in acute care hospitals in Pennsylvania, using administrative, clinical, and
physician data from Centers for Medicare & Medicaid Services and the American Medical
Association from 2008 and 2009. We identified intensivists by training background, board
certification, and claims for serviced provided to patients admitted to an intensive care unit
(ICU). We assigned patients to intensivists for outcome attribution based on submitted claims
for critical care and inpatient services. We estimated the physician-specific adjusted odds ratios
for 30-day mortality using a hierarchical model with a random effect for physician, adjusted for
patient and hospital characteristics. We tested for independent association of physician
experience with patient outcomes using mixed effects regression for the primary outcome of
30-day mortality. We defined physician experience in two ways: years since training
completion (“duration”) and annual number of mechanically ventilated patients (“volume”).
Results: We assigned 345 physicians to 11,268 patients. 30-day mortality was 43% and median
hospital length of stay was 11 days (IQR 6 to 18). The physician adjusted odds ratio varied from
0.72 to 1.64 (median 0.99 and IQR 0.92 to 1.09). 48% of physicians were outliers, with an
adjusted odds ratio significantly different from 1. However, among intensivists, physician

Page 3 of 37
experience was not associated with 30-day mortality (duration OR 1.00 per additional year, 95%
CI 1.00 to 1.01; volume OR 1.00 per additional patient, 95% CI 1.00 to 1.00).
Conclusions: Intensivists independently contribute to outcomes of Medicare patients who
undergo mechanical ventilation, as evidenced by the variation in risk-adjusted mortality across
intensivists. However, physician experience does not underlie this relationship between
intensivists, suggesting the need to identify modifiable physician factors to improve outcomes.
Abstract Word Count: 323

Page 4 of 37
By some estimates, more than 750,000 patient admissions to acute-care hospitals in the United
States each year include mechanical ventilation.1,2 In-hospital mortality for such patients nears
40%.1,3 Several landmark clinical trials have provided evidence-based treatments to reduce
mortality in mechanically ventilated admissions.4-7 However, uptake of the evidence has been
slow and uneven,8-12 and admission outcomes have not appreciably changed over time and
remain highly variable.13,14
Physicians seem natural targets to improve quality of care and adherence to evidence-
based medicine. They are primarily responsible for clinical decision-making, and some studies
suggest that different physician characteristics can explain some of the variability in patient
outcomes.15-17 Therefore, better understanding the role of physicians in outcome of
mechanically ventilated patients may inform strategies to improve their care.
One specific physician attribute that may be associated with outcomes is experience in
caring for mechanically ventilated patients. Indeed, evidence in many fields supports an
experience-outcome relationship: hospitalists achieve better outcomes for medical inpatients
than non-hospitalists;18,19 obstetricians with more years of experience have fewer maternal
complications;20 institutions that care for more patients requiring certain services, including
mechanical ventilation, achieve better outcomes than lower-volume hospitals;14,18,21-30 and
critical care physicians may achieve better outcomes than non-critical care physicians for ICU
patients overall.31,32 On the other hand, one study demonstrated that specialized ICUs perform
no better than general ICUs;33 another study found that physicians with greater experience
achieve worse outcomes for patients with ischemic stroke;34 and yet another demonstrated

Page 5 of 37
that initial skill of obstetricians explains more of the variation in physician performance than
experience itself.35
We aimed to define the relationship between critical care experts (“intensivists”) and
the outcomes of mechanically ventilated patients. To do so, we sought to quantify the variation
in patient outcomes attributable to the physician as well as test the hypothesis that greater
physician experience would be associated with improved patient outcomes.
Methods
We performed a retrospective cohort study of patients undergoing mechanical ventilation in an
intensive care unit in an acute care hospital in the Commonwealth of Pennsylvania between
2008 and 2009. We selected this population because hospital discharge data collected by the
Pennsylvania Health Care Cost Containment Council (PHC4) during these years included a
measure of risk of in-hospital mortality based on a multivariable prediction model using patient
clinical and physiological data, thereby enabling risk adjustment superior to what would
typically be possible using administrative data.30 2009 was the most recent year when
complete mortality-risk data were collected. The study was approved by the Institutional
Review Board of the University of Pennsylvania.
Data Sources
We used data from several sources. First, we obtained administrative data from the Centers for
Medicare and Medicaid Services (CMS), including the Medicare Provider and Analysis Review

Page 6 of 37
(MedPAR) Files, Beneficiary Summary Files, and the Carrier Files from 2008 and 2009 to obtain
patient-level hospital admission data, 30-day mortality, and final action fee-for-service claims
submitted by individual physicians. Second, we obtained Inpatient Discharge Data from PHC4
for the same hospital admissions, which included a predicted probability of in-hospital death for
a sample of patients with select inpatient diagnoses based on the MediQual Atlas, which uses
physiologic variables collected at the time of hospital admission.36 Third, we obtained physician
data from the American Medical Association (AMA) Physician Masterfile, including current and
historical data regarding physicians’ education, training, and professional certification. Fourth,
we obtained historical data on hospitals’ affiliations with medical training programs from the
Accreditation Council for Graduate Medical Education (ACGME) website.37 The Online Data
Supplement provides further details of the data sources.
Study Population
We included all hospital admissions from January 1, 2008 through December 1, 2009 that
included an intensive care unit (ICU) stay according to the CMS revenue center code38 of
Medicare fee-for-service beneficiaries aged 18 years or older. We identified patients who
underwent invasive mechanical ventilation according to the presence of International
Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedure codes for
mechanical ventilation (96.7x).39 For patients who underwent inter-hospital transfers (defined
as admission to a hospital within one calendar day of another hospital discharge for the same
beneficiary), we combined the hospital admissions and considered the first hospital admission
that included an ICU stay to be the start of the entire hospitalization.40 We excluded admissions

Page 7 of 37
with a length-of-stay of less than one calendar day (i.e., admitted and discharged on the same
date), because these admissions would be unlikely to be affected by an individual physician.
Physician Assignment Strategy
To assign admissions to intensivist physicians, we first defined the physicians eligible for
assignment as those physicians who had either (1) critical care board certification (through
internal medicine, surgery, or anesthesia) in 2008 or 2009, and inpatient claims for at least 9
ICU admissions in 2008 (the 25th percentile of volume of Medicare FFS ICU admissions among
physicians with critical care board certification); or (2) inpatient claims for at least 48 ICU
admissions in 2008 (the median volume of Medicare FFS ICU admissions among physicians with
critical care board certification). In the absence of a gold-standard definition of an “intensivist,”
we chose this definition to capture the population of physicians who are most likely to care for
ICU patients. Next, we assigned an intensivist to an admission in based on Current Procedural
Terminology (CPT) codes for inpatient initial and subsequent care (99221, 99222, 99223, 99231,
99232, 99233) and critical care services (99291, 99292). We assigned a physician if a single
intensivist submitted at least 50% of all claims for critical care services submitted by all
intensivists. Some admissions had no claims for critical care services by eligible intensivists. For
these admissions, we assigned a physician if a single intensivist submitted at least 50% of all
claims for any type of inpatient services submitted by any intensivist. Admissions unassigned in
either of these steps were excluded.

Page 8 of 37
Study Variables
The primary exposure variable was intensivist experience, defined in two ways: duration of
practice and incident volume during the study period. Duration of practice equaled the number
of years between the year of the services provided by a physician and the completion of
terminal residency or fellowship training. Incident volume equaled the total number of
mechanically ventilated admissions for whom the physician submitted any type of inpatient
service claim in 2008. We also defined a third exposure variable as four categories of
experience, combining binary definitions (high or low, based on median values) of duration and
volume. The primary outcome was mortality within 30 days of hospital admission. Secondary
outcomes were hospital length-of-stay and hospital discharge destination.
We identified potential confounders among patient, hospital, and physician variables a
priori, as further detailed in the Online Data Supplement. We classified admissions as medical
or surgical according to the Medicare Severity-Diagnosis Related Group (MS-DRG). Because we
found that the MediQual Atlas predicted mortality score was missing for approximately 11% of
the study population, we adjusted for severity of illness in primary analyses using the
components of the Acute Organ Failure Score, a risk adjustment methodology for ICU
admissions using administrative data.41 We obtained physician specialty background from the
AMA database. When missing (i.e., no record of residency training or board certification), we
performed web searches for publicly available board certification data. We defined hospital
volume of mechanically ventilated patients as the number of Medicare FFS beneficiaries who
were admitted and underwent mechanical ventilation in 2008.

Page 9 of 37
Statistical Analysis
We restricted all analyses to intensivist physicians and hospitals with at least 10 assigned
patients, for stability of multivariable regression models. To explore the overall contribution of
intensivists to patients’ 30-day mortality, we first estimated physicians’ adjusted odds ratios in
order to visually inspect physician variability in outcomes. To do so, we fit multivariable logistic
regression models including all patient and hospital variables and a random effect term for
physicians, as further detailed in the Online Data Supplement. The resultant adjusted odds
ratios are derived from the empirical Bayes estimates of the physician effect and reflect the
odds ratio for 30-day mortality attributable to the physician. We classified physicians as outliers
if the 95% credible intervals of the adjusted odds ratio did not include 1. We then estimated the
median odds ratio and its 95% credible interval as a measure of among-physician variance.42
The median odds ratio is the median value of the set of odds ratios that could be obtained by
comparing otherwise identical patients (according to the values of all covariates included in the
model) assigned to two different, randomly chosen physicians. In other words, it is the median
odds ratio between the patient assigned to the physician with a higher risk-adjusted mortality
rate compared to the one assigned to the physician with lower risk-adjusted mortality. Because
it is mathematically comparable to odds ratios for patient or hospital characteristics, its use
enables direct comparisons of the contributions of physician assignment and other factors, such
as patient characteristics, to outcomes. Last, we estimated the intracluster correlation, which
compares within- and between-physician variance, as a final way to examine physician-
attributable contributions to patients’ 30-day mortality.

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For primary analyses of 30-day mortality, we estimated a series of mixed effects logistic
regression models, as detailed further in the Online Data Supplement. The fully adjusted
models included all patient, physician, and hospital variables, and a random effect for physician
to account for clustering. We selected this modeling strategy for two main reasons: because it
would permit us to account for two levels of clustering if necessary, the physician and the
hospital; and because it would allow for cluster-level variables, including the exposures of
interest, to be included in the models. As detailed in the Online Data Supplement, the addition
of a random effect for hospital was deemed unnecessary. One model included only the
duration experience variable; another model included the volume experience variable; a third
model included the categorical variable for experience that combined duration and volume
definitions; and a fourth model included both experience variables plus a multiplicative
interaction term. We also pre-specified tests for effect modification by (1) medical versus
surgical status and (2) hospital volume, and accordingly built models including multiplicative
interaction terms of each experience variable with these factors. We then estimated Cox
proportional hazards models for each definition of physician experience to study the secondary
outcome of hospital length of stay, with censoring on death and using shared-frailty models to
incorporate a random effect for physician.43 Last, we estimated mixed effects logistic regression
models to study the secondary outcome of likelihood of discharge to home among survivors.
We performed five pre-specified sensitivity analyses. First, we restricted the definition
of intensivist to only those with critical care board certification during 2008 or 2009. Second,
we restricted analyses to admissions where 100% of claims for critical care services were
submitted by a single intensivist. Third, we included all physicians and hospitals with less than

Page 11 of 37
10 patient assignments. Fourth, we repeated the analyses using the MediQual predicted
mortality instead of the Acute Organ Failure Score for severity of illness risk adjustment. Fifth,
we repeated the analyses modeling the exposure variables using restricted cubic splines with
knots according to percentiles as recommended by Harrell.44
We considered a two-sided p-value of 0.05 as the threshold for statistical significance in
all analyses. All analyses were performed using Stata® 14.2 (StataCorp LLC, College Station,
Texas).
Role of the Funding Source
The funders had no role in the design and conduct of the study; collection, management,
analysis, and interpretation of the data; and preparation, review, or approval of the manuscript;
and in the decision to submit the paper for publication.
Results
Among 23,545 admissions of mechanically ventilated, fee-for-service Medicare patients to
Pennsylvania hospitals during the study period, we assigned 345 intensivists to 11,268 of these
patients (48%) in 104 hospitals (Figure 1). Table 1 summarizes admission characteristics and
outcomes. Admissions that were and were not able to be assigned to intensivists according to
the primary strategy were similar (Table E1).
The median number of patients assigned to a physician was 25 (IQR 16 to 40), and to a
hospital was 75 (IQR 21 to 155). Table 2 details hospital and physician characteristics. Most

Page 12 of 37
hospitals were in metropolitan locations and were not primary sites for critical care training
programs. The median age of physicians was 46 (IQR 40 to 53), and a majority of physicians had
a background in internal medicine. Median duration of experience was 11 years (IQR 4 to 19),
and median volume of admissions of mechanically ventilated patients in 2008 was 36 (IQR 23 to
57). Among 329 intensivists who had data available for both duration and volume of
experience, there was no correlation between the two experience definitions (Spearman’s rho
0.06, p=0.21; Figure E1).
Figure 2 illustrates variability in physician adjusted odds ratio, accounting for patient
and hospital characteristics. The median physician adjusted odds ratio was 0.99 (IQR 0.92 to
1.09). 166 physicians (48%) were classified as outliers, in that they had adjusted odds ratios
with 95% credible intervals that did not include 1. The median value of the odds ratios
comparing otherwise identical patients assigned to different physicians was 1.26 (95% credible
interval 1.19-1.35). Given a baseline 30-day mortality risk of 43%, this odds ratio translates into
a mortality risk of 49%, or a median absolute risk difference of 6%. The intracluster correlation,
a measure of the variance in outcomes explained by the physician, was 0.018 (95% CI 0.010-
0.030).
In all mixed effects logistic regression models with a random effect for physician, there
was no statistically significant association of intensivist experience with 30-day mortality (Table
3 and Table E2). In models with four categories of experience combining binary definitions of
duration and volume, there was similarly no association of any category of experience with 30-
day mortality. There was also no statistically significant interaction between experience and
either medical versus surgical status or hospital volume, or between duration and volume of

Page 13 of 37
experience (Table E3). Results were nearly identical in all pre-specified sensitivity analyses
(Table E4).
Intensivist experience was also not associated with hospital length of stay (HR 1.00, 95%
CI 1.00 to 1.01 for duration of experience; and HR 1.00, 95% CI 1.00 to 1.00 for volume of
experience). And among patients who survived to discharge, there was also no association of
intensivist experience with the odds of being discharged to home (OR 0.99; 95% CI 0.99 to 1.00
for duration of experience; and OR 0.99; 95% CI 0.99 to 1.00 for volume of experience).
Discussion
This study of over 11,000 patients undergoing mechanical ventilation within 104 hospitals
provides evidence that 30-day mortality varies widely by physicians, suggesting that physicians
indeed contribute to their patients’ outcomes. However, despite the acuity and complexity of
this population, physician experience in managing mechanically ventilated patients is not
associated with patient mortality. This finding appears to be robust, as it did not differ across
several definitions of experience, across predefined patient subgroups, across hospitals with
variable institutional experience and volume of mechanically ventilated patients, or in any of
several sensitivity analyses, including one where a single physician was responsible for all
critical care services. Furthermore, physician experience was not associated with differences in
hospital length of stay or likelihood of being discharged to home.
Our study has several strengths. It is the first to our knowledge to evaluate the specific
role of physicians in outcomes of mechanically ventilated patients, a population at high risk of

Page 14 of 37
morbidity and mortality. Furthermore, it includes a large number of organizationally diverse
practice settings, increasing the generalizability of the results. In conjunction, it uses advanced
statistical methods to account for potential confounding. However, it also has several notable
limitations. First, although we selected outcomes that are objective, frequently used, and
highly unlikely to be inaccurate given their close ties to reimbursement, other study variables
may have been misclassified. Second, as with any observational study, there are risks of bias
related to unmeasured confounding. However, in the face of such confounding it would be
unusual to observe effects so precisely null, and particularly unusual to find null effects across
different methods of risk adjustment. Third, the mixed effects modeling strategy by design
accounts for low numbers of observations within clusters, adjusting estimates of smaller
clusters towards a null value. While this is desirable in many uses of random effects, such as
performance assessment, this strategy may minimize the effect of volume,45 one of our two
exposure definitions. However, there was no correlation between duration and volume
experience, so we would not expect this issue to affect the analyses using the duration of
experience as the exposure definition. Fourth, the population was limited to Medicare fee-for-
service beneficiaries. Whether volume of this patient population correlates with overall volume
of mechanically ventilated patients is unknown, and if poor, would bias the results towards the
null. Furthermore, our results may not generalize to other populations of mechanically
ventilated patients. Fifth, it is possible that our definitions of experience poorly capture the
actual underlying construct. However, the observation of similarly null findings using two
different measures of experience as well as a third, combined measure, limits this concern.
Last, the study period was approximately 8 years ago, and delivery of care to mechanically

Page 15 of 37
ventilated patients has possibly changed over time. We chose the study population during this
specific period due to the availability of a risk adjustment variable that was superior to
administrative risk adjustment alone, and we felt that a relationship between physician
experience and outcomes should not change from one practice era to another; however, it is
possible that organizational factors (such as intensivist staffing models or interprofessional
rounding) that may have changed over time could influence our results.
We had hypothesized that physician experience would be associated with these patient
outcomes because institutional volume is related to outcomes for mechanically ventilated
patients,14,30 and physician experience is related to outcomes of patients with other
conditions.25,34,46-51 There are several potential explanations for our failure to find similar
associations. One possibility is that physician experience truly plays no role how physicians care
for mechanically ventilated patients along dimensions that affect outcomes. Such a conclusion
is plausible in the settings of ICUs, where interprofessional teams of clinicians and other
organizational factors may effectively compensate for or buffer against the contributions from
individual physicians.32,52-58 Alternatively, the null findings could be attributable to the innate
challenges of attributing outcomes of complex patients to individual physicians. Many patients
who undergo mechanical ventilation have complex medical issues and are co-managed by
several different physicians from different specialties, such that assigning responsibility to a
single physician for outcomes may be unrealistic.
A third potential explanation is that our strategy for physician assignment may have led
to misclassification of the exposure. We found little precedent for attributing outcomes of
mechanically ventilated patients, and a claims-based strategy may simply be inadequate to

Page 16 of 37
identify the most responsible physician. One previous study of ICU patients with pneumonia
that used claims to assign physicians for outcome attribution did find that increasing physician
experience was associated with decreased patient mortality.59 However, the strategy for
physician assignment was not described in this study, and the data reflect patients and
physicians in Taiwan, where physician staffing and care delivery may differ substantially from
Pennsylvania hospitals. We did find associations between certain physician characteristics (such
as location of medical school graduation) and patient outcomes similar to those previously
reported,15 suggesting that our strategy for physician assignment was appropriate.
Furthermore, our results were preserved in multiple sensitivity analyses, including one
restricted to patients for whom all intensivist critical care claims were by a single intensivist,
providing further support for these findings.
Although physician experience did not to contribute to patient outcomes, we
nonetheless observed considerable variability in patient outcomes depending on their assigned
physician. The median odd ratio of 1.26 is greater than the odds ratios of patient characteristics
with well-accepted associations with mortality, such as gender (1.16 for males). Our study
cannot elucidate whether this variability is attributable to differences in skill managing
mechanical ventilation or other physiologic or clinical elements that are not related to
experience, differences in propensities to engage in goals of care conversations and set limits
on life support, or other factors. However, whereas many patient characteristics are fixed,
physician characteristics may be modified or overcome by organizational interventions.
Therefore, a deeper understanding of which physician characteristics explain this variability
may reveal novel targets for future interventions to improve patient outcomes overall.

Page 17 of 37
In summary, we find that the outcomes of mechanically ventilated patients vary
according to which physician cares for them, but this variability is not explained by the number
of years physicians have been in practice or by their prior experience managing mechanically
ventilated patients. These findings suggest that further study is needed to better understand,
and therefore address, physician-level variability in patient outcomes.

Page 18 of 37
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Page 22 of 37
Figure 1: Selection of study population
*Eligible visits included Medicare FFS patients admitted between 1/1/2008 and 12/1/2009 to
an ICU within an acute care hospital in PA who underwent mechanical ventilation, aged 18
years or older, and discharged by the end of the calendar year 2009.

Page 23 of 37
Figure 2: Distribution of adjusted odds ratios among physicians with patient assignments.*
*The red line indicates an adjusted odds ratio of 1.
All models were mixed effects logit models with a random effect for physician assigned.
Covariates included were participant characteristics (age, race, gender, medical versus surgical
diagnosis, acute organ failure score categories, Elixhauser comorbidities, admission source,
weekend vs. weekday admission) and hospital characteristics (urbanicity, type of affiliation with
critical care training program, hospital volume of mechanically ventilated patients, and
percentage of patients within a hospital with claims by an intensivist).

Page 24 of 37
Table 1: Participant characteristics and outcomes

Characteristics (n=11,268)
Age, median (IQR) 76 (66-83)
Male gender, No. (%) 5,601 (50%)
Chronic comorbidities*, No. (%)
Congestive heart failure 1,447 (13%)
Chronic pulmonary disease 1,130 (10%)
Neurological disorders 1,090 (10%)
Hypertension 952 (8%)
Renal failure 833 (7%)
Diabetes 680 (6%)
Liver disease 232 (2%)
Admission source, No. (%)
Emergency department 7,343 (65%)
Direct admission 2,873 (26%)
Outside hospital transfer 1046 (9%)
Unknown 6 (<1%)
Surgical MS-DRG, No. (%) 4,140 (37%)
Weekend admission, No. (%) 3,022 (27%)
30-day mortality, No. (%) 4,840 (43%)
Discharged to home 2,184 (19%)
Hospital length of stay†, median 11 (6-18)
(IQR)
Abbreviations: MS-DRG, Medicare Severity-Diagnosis Related Group; IQR, interquartile range
*As classified according to Elixhauser, only if coded as present on admission

†Total number of calendar days in the hospital (e.g., admission and discharge on the same day
would be one calendar day)

Page 25 of 37
Table 2: Physician and hospital characteristics in 2008

Physician characteristics n=345
Age, median (IQR)* 46 (40-53)
Years since med school graduation, median 19 (12-26)
(IQR)
Years since completion of terminal training 11 (4-19)
program, median (IQR) †
Graduation from non-US med school, No. (%) 93 (27%)
Board certified in any CC specialty, No. (%) 289 (84%)
Specialty background~
Internal medicine 303 (88%)
Surgery 40 (12%)
Anesthesia 15 (4%)
Emergency Medicine 3 (1%)
Family practice 3 (1%)
Volume of ICU patients for whom any 101 (67-156)
inpatient claims were filed in 2008, median
(IQR) **
Volume of MV patients for whom any 36 (23-57)
inpatient claims were filed in 2008, median
(IQR)**
Hospital characteristics n=104
Urbanicity, No. (%)
Metropolitan location 92 (88%)
Non-metropolitan but urban location 12 (12%)
Affiliation with CC program, No. (%)
CC training program 13 (13%)
Other training programs 44 (42%)
No training programs 47 (45%)
Volume of Medicare FFS patients admitted to 352 (192-472)
an ICU in 2008, median (IQR)^
Volume of mechanically ventilated Medicare 64 (36-120)
FFS patients in 2008, median (IQR)^
Percentage of patients with any claims by an 77% (58%-
intensivist, median (IQR)^ 84%)

Page 26 of 37
Abbreviations: IQR, interquartile range; US, United States; CC, critical care; FFS, fee-for-service
*Data available for 341 physicians

†
Data available for 339 physicians
~22 (6%) physicians have more than one specialty background; no specialty data was available
for 3 (1%) physicians.
** 335 physicians have claims for patients in 2008.
^Includes both assigned and unassigned Medicare FFS patients admitted in 2008

Page 27 of 37
Table 3: Variables associated with 30-day mortality among mechanically ventilated Medicare patients
Level Variable Definition of physician experience
Years since completion of training Volume of MV patients in 2008
n=11,119 patients n=11,152 patients
Assigned to 339 physicians Assigned to 335 physicians
OR 95% CI p-value OR 95% CI p-value
Physician Experience 1.00 1.00-1.01 0.11 1.00 1.00-1.00 0.82
IM specialty background 1.09 0.90-1.32 0.38 1.09 0.90-1.32 0.39
Foreign med school 0.92 0.81-1.04 0.17 0.88 0.78-0.99 0.03
Patient Age
>74 Reference Reference
65-74 0.61 0.55-0.67 <0.01 0.60 0.55-0.66 <0.01
55-64 0.44 0.38-0.51 <0.01 0.44 0.38-0.51 <0.01
45-54 0.35 0.29-0.43 <0.01 0.35 0.29-0.43 <0.01
<45 0.24 0.18-0.31 <0.01 0.24 0.18-0.31 <0.01
Female gender 0.86 0.79-0.93 <0.01 0.86 0.80-0.94 <0.01
Medical diagnosis 2.80 2.56-3.07 <0.01 2.81 2.57-3.08 <0.01
Hospital Metropolitan location 0.92 0.68-1.26 0.62 0.93 0.69-1.23 0.60
CC program affiliation
None Reference Reference
Some training program 0.99 0.85-1.16 0.85 1.01 0.87-1.18 0.89
Primary CC program 1.10 0.90-1.33 0.90 1.13 0.92-1.38 0.24
Abbreviations: MV, mechanically ventilated; IM, internal medicine; CC, critical care; OR, odds ratio; CI, confidence interval.

Page 28 of 37
All models were mixed effects logit models with a random effect for physician assigned. Other covariates included but not shown
were white vs. non-white race, acute organ failure score categories, Elixhauser comorbidities, admission source, weekend vs.
weekday admission, hospital volume of mechanically ventilated patients, and percentage of patients within a hospital with claims by
an intensivist.

Page 29 of 37
Online Data Supplement
Physician-Level Variation in Outcomes of Mechanically Ventilated Patients

Meeta Prasad Kerlin, MD MSCE, Andrew Epstein, PhD, Jeremy M. Kahn, MD MS, Theodore J. Iwashyna, MD,
PhD, David A. Asch, MD MBA, Michael O. Harhay, PhD, Sarah J. Ratcliffe, PhD, Scott D. Halpern, MD PhD
SECTION PAGE
Supplemental methods 2
Table E1 4
Figure E1 5
Table E2 6
Table E3 8
Table E4 9

Page 30 of 37
SUPPLEMENTAL METHODS
Data sources
PHC4 is an independent state agency responsible for addressing the problem of escalating health costs, ensuring the quality of health
care, and increasing access to health care of all citizens regardless of ability to pay. As such, it collects clinical and administrative data
for benchmarking and research purposes, and has, for a limited set of diagnoses, included the MediQual Atlas Admission Severity for
mortality prediction, a validated score for risk adjustment which results in a substantial improvement over administrative data alone in
studies of critical illness outcomes. While PHC4 has provided data for this study, PHC4 specifically disclaims responsibility for any
analyses, interpretations, or conclusions.
The CMS MedPAR file contains detailed patient-level administrative data for hospital discharges. The CMS Beneficiary Summary
Files included death dates for all beneficiaries, to allow for calculation of 30-day mortality. The CMS Carrier File includes detailed
claims data, such as date-stamped line items identifying the services provided by individual physicians and the diagnosis codes linked
to those services. Physicians are identified in the Carrier File by National Provider Identification (NPI) number. Patients are identified
in CMS data by a unique beneficiary ID. For this project, the CMS data processor and distributor provided a crosswalk between the
beneficiary ID and social security number to PHC4, so that PHC4 data also included the CMS beneficiary ID to allow linkage of the
datasets.
The AMA Physician Masterfile includes physician demographic and training data, including the specialty training program(s), year(s)
of graduation, and specialty certification. The AMA also maintains historical residency and certification databases. These data were
linked to CMS data via physician NPI number.
Study variables
We identified potential confounders among patient, hospital, and physician variables a priori. In addition to the Acute Organ Failure
Score (which includes administrative variables for the presence of acute organ failure at the time of hospital admission and Elixhauser
comorbidities, as described the main manuscript) patient variables included age, race (white versus non-white), gender, location prior
to hospital admission (weekend vs. weekday admission. Hospital variables were number of hospital beds (fewer than 100 beds, 100-
300 beds, or more than 300 beds), affiliation with medical training programs (categorized as no affiliation, affiliation with medical
training programs but not critical care programs, or affiliated with critical care programs), annual volume of mechanically ventilated
patients (defined as the number of Medicare FFS beneficiaries who were admitted and underwent mechanical ventilation in 2008),
whether the hospital was located in a metropolitan area, and the percentage of ICU admissions within a hospital that included claims
by an eligible physician (as a measure of intensity of critical care service delivery). Physician variables included country of medical
school (United States vs. other) and specialty background (internal medicine vs. other). Physicians for whom country of medical
school was missing were assumed to have graduated from non-US schools. Physicians for whom no specialty background was
available from the AMA database or the ABIM certification website were assumed to be non-internal medicine.
We visually inspected lowess plots of each continuous variable with the logit of 30-day mortality to determine the functional form for
modeling. Because the relationships appeared non-linear for hospital volume of mechanically ventilated patients and hospital
percentage of ICU admissions with claims for critical care service, we modeled those using a restricted cubic spline. All other
continuous variables were modeled assuming a linear relationship.
Statistical analysis
After assigning physicians to admissions, we estimated the physician-specific adjusted odds ratios (AORs) and 95% credible intervals
for the outcome of 30-day mortality to visually inspect physician variability in outcome. The AORs were derived from a mixed effects
logistic regression model that included a random effect for the physician, as well as patient characteristics (age, gender, medical versus
surgical diagnosis, race, presence of acute organ failure at the time of hospital admission, Elixhauser comorbidities, source of
admission to the hospital, and weekend versus weekday admission) and hospital characteristics (metropolitan location, number of
hospital beds, affiliation with medical training programs, hospital volume, and frequency of critical care claims for ICU patients) for
risk adjustment. We fit the model on the complete analytic dataset of 11,268 visits. The model provides an empirical Bayes estimate of
the physician random effect which, when exponentiated, is the AOR for each physician. In other words, it is odds ratio for the
outcome attributable to the physician, after adjustment for all the other covariates in the model. We calculated the 95% credible
intervals for the AORs from the standard errors of the physician random effects that are similarly empirically derived. We classified
physicians as outliers if the 95% credible intervals of the adjusted odds ratio did not include 1. These same mixed effects
logistic regression models were the basis for calculation of the median odds ratio and the intracluster correlation of physicians.
For all analyses of the association of physician experience with 30-day mortality, we determined a priori that we would use mixed
effects models. We selected this modeling strategy for two main reasons. First, it would permit us to account for two levels of
clustering if necessary, the physician and the hospital. Second, it would allow for cluster-level variables to be included in the models.
In analyses where the cluster variable is modeled as a fixed effect, perfect collinearity would result in the drop-out of cluster-level
variables, such as the exposures of interest (physician experience) and other physician characteristics.
2

Page 31 of 37
In order to determine whether clustering at both the physician and the hospital levels were needed, we first built a simple mixed
effects logistic regression model of physician experience with 30-day mortality using a restricted population of only those admissions
assigned to physicians that only practiced within a single hospital in order to include nested random effects for physicians within
hospital. Because the variance for the random effect was exceedingly small and the intracluster correlation was identical at both levels,
we proceeded with a single random effect for the physician for all subsequent analyses. We then sequentially built three models, first
adding all patient variables, then adding all hospital variables, and then adding all other physician variables. We additionally built
separate models including multiplicative interaction terms between the experience variables and (1) medical versus surgical status and
(2) hospital volume, based on a priori hypotheses.

Page 32 of 37
Table E1: Assigned and unassigned admissions are similar.
Assigned Unassigned p-value

(n=11,268) (n=9651)
Age, median (IQR) 76 (66-83) 76 (66-83) 0.62‡
Male gender, No. (%) 5,601 (50%) 4,674 (48%) 0.07
Chronic comorbidities*, No. (%)
Congestive heart failure 1,447 (13%) 1,282 (13%) 0.34
Hypertension 952 (8%) 999 (10%) <0.01
Chronic pulmonary disease 1,130 (10%) 1,096 (11%) <0.01
Diabetes 680 (6%) 716 (7%) <0.01
Neurological disorders 1,090 (10%) 832 (9%) 0.01
Renal failure 833 (7%) 758 (8%) 0.21
Liver disease 232 (2%) 197 (2%) 0.93
Admission source, No. (%) <0.01
Emergency department 7,343 (65%) 6,514 (68%)
Direct admission 2,873 (26%) 2,459 (25%)
Outside hospital transfer 1,046 (9%) 667 (7%)
Unknown 6 (<1%) 11 (<1%)
Surgical MS-DRG, No. (%) 4,140 (37%) 3,626 (38%) 0.22
Weekend admission, No. (%) 3,022 (27%) 2,618 (27%) 0.62
30-day mortality, No. (%) 4,840 (43%) 4,016 (42%) 0.05
Discharged to home 2,184 (19%) 1,856 (19%) 0.78
Hospital length of stay†, median (IQR) 11 (6-18) 10 (5-19) <0.01‡
All comparisons used chi-square tests to estimate significance, except as indicated.
*As classified according to Elixhauser, only if coded as present on admission
†Total number of calendar days in the hospital (e.g., admission and discharge on the same day would be one calendar day)
‡Wilcoxon rank sum test to estimate p-value

Page 33 of 37
Figure E1: Duration and volume of physician experience are not correlated.
This figure includes 329 physicians, for whom data are available for both variables. Red lines indicate median values.

Page 34 of 37
Table E2: Full model results for the primary outcome of 30-day mortality
Variable Definition of physician experience

Physician characteristics
Experience 1.00 1.00-1.01 0.11 1.00 1.00-1.00 0.82
IM specialty background 1.09 0.90-1.32 0.38 1.09 0.90-1.32 0.39
Foreign med school 0.92 0.81-1.04 0.17 0.88 0.78-0.99 0.03
Hospital characteristics
Metropolitan location 0.92 0.68-1.26 0.62 0.93 0.69-1.23 0.60
Number of beds
<100 beds Reference Reference
100-300 beds 0.98 0.61-1.57 0.93 0.93 0.60-1.44 0.60
>300 beds 0.93 0.56-1.53 0.77 0.86 0.54-1.37 0.54
CC program affiliation
None Reference Reference
Some training program 0.99 0.85-1.16 0.85 1.01 0.87-1.18 0.89
Primary CC program 1.10 0.90-1.33 0.90 1.13 0.92-1.38 0.24
Hospital volume*
Spline variable 1 1.01 1.00-1.01 0.06 1.01 1.00-1.01 0.04
Spline variable 2 0.89 0.73-1.08 0.23 0.87 0.71-1.05 0.15
Spline variable 3 1.28 0.78-2.09 0.33 1.36 0.83-2.23 0.23
Spline variable 4 0.88 0.61-1.26 0.49 0.85 0.59-1.23 0.29
Proportion of patients with intensivist claims*
Spline variable 1 1.10 0.36-3.36 0.89 1.22 0.42-3.56 0.72
Spline variable 2 0.55 0.09-3.33 0.52 0.45 0.08-2.58 0.37
Patient demographic and clinical variables
Age
>74 Reference Reference
65-74 0.61 0.55-0.67 <0.01 0.60 0.55-0.66 <0.01
55-64 0.44 0.38-0.51 <0.01 0.44 0.38-0.51 <0.01
45-54 0.35 0.29-0.43 <0.01 0.35 0.29-0.43 <0.01
<45 0.24 0.18-0.31 <0.01 0.24 0.18-0.31 <0.01
Female gender 0.87 0.80-0.94 <0.01 0.87 0.80-0.95 <0.01
Non-white race 0.92 0.81-1.04 0.18 0.93 0.82-1.05 0.24
Medical diagnosis 2.80 2.56-3.07 <0.01 2.81 2.57-3.08 <0.01
Weekend admission 1.03 0.94-1.13 0.50 1.03 0.94-1.13 0.53
Admission source
Direct admission Reference Reference
Emergency department 0.98 0.90-1.10 0.96 1.00 0.90-1.10 0.96
Outside hospital transfer 1.04 0.89-1.23 0.62 1.04 0.89-1.23 0.62
Unknown 0.87 0.15-5.17 0.88 0.87 0.15-5.17 0.88
*Modeled using restricted cubic splines. For the proportion of patients with intensivist claims, the third and fourth spline
variables were non-significant and uninterpretable due to very large confidence intervals and are not reported.
(Continued on next page)

6

Page 35 of 37
Table E2: Full model results for the primary outcome of 30-day mortality (continued)
Variable Definition of physician experience

Acute organ failure score components
Sepsis 1.32 1.14-1.52 <0.01 1.32 1.14-1.52 <0.01
Acute respiratory failure 0.86 0.76-0.98 0.01 0.87 0.77-0.98 0.03
Acute renal failure 1.00 0.87-1.15 0.97 0.99 0.86-1.13 0.86
Acute hematological abnormality 2.02 0.97-4.27 0.06 2.00 0.93-4.28 0.08
Acute metabolic abnormality 1.10 0.87-1.38 0.44 1.13 0.89-1.43 0.30
Acute neurologic abnormality 3.24 2.42-4.33 <0.01 3.24 2.41-4.34 <0.01
Acute hepatic abnormality 0.71 0.39-1.30 0.27 0.68 0.37-1.24 0.21
Elixhauser comorbidities
Congestive heart failure 0.89 0.78-1.02 0.11 0.90 0.79-1.03 0.13
Cardiac arrhythmias 1.16 1.00-1.36 0.05 1.15 0.99-1.35 0.06
Valvular disease 0.78 0.57-1.07 0.12 0.76 0.56-1.04 0.09
Pulmonary circulation disorders 1.34 0.98-1.83 0.06 1.31 0.96-1.79 0.09
Peripheral vascular disorders 0.87 0.65-1.17 0.36 0.87 0.64-1.16 0.34
Hypertension, uncomplicated 0.92 0.78-1.09 0.35 0.95 0.81-1.12 0.54
Paralysis 0.90 0.68-1.18 0.44 0.92 0.69-1.21 0.53
Other neurological disorders 0.54 0.42-0.69 <0.01 0.53 0.42-0.69 <0.01
Chronic pulmonary disease 0.67 0.58-0.78 <0.01 0.68 0.58-0.79 <0.01
Diabetes, uncomplicated 0.73 0.59-0.88 <0.01 0.73 0.60-0.89 <0.01
Diabetes, complicated 1.01 0.66-1.56 0.96 1.07 0.70-1.66 0.75
Hypothyroidism 0.79 0.58-1.07 0.12 0.77 0.57-1.05 0.10
Renal failure 1.22 0.97-1.52 0.08 1.21 0.97-1.52 0.09
Liver disease 1.80 1.09-2.99 0.02 1.91 1.15-3.19 0.01
Peptic ulcer without bleeding 0.94 0.30-2.93 0.92 0.94 0.30-2.93 0.92
AIDS/HIV 1.23 0.48-3.13 0.67 1.28 0.49-3.32 0.61
Lymphoma 1.37 0.82-2.29 0.23 1.30 0.77-2.21 0.32
Metastatic cancer 1.67 1.20-2.32 <0.01 1.64 1.18-2.29 <0.01
Solid tumor without metastasis 1.38 1.08-1.76 0.01 1.37 1.07-1.75 0.01
Collagen vascular disease 1.04 0.62-1.76 0.88 1.09 0.65-1.83 0.75
Coagulopathy 0.73 0.38-1.40 0.34 0.72 0.36-1.41 0.34
Obesity 0.62 0.40-0.98 0.04 0.61 0.39-0.95 0.03
Weight loss 0.88 0.73-1.06 0.19 0.89 0.74-1.06 0.20
Fluid and electrolyte disorders 0.96 0.81-1.13 0.61 0.94 0.80-1.11 0.49
Blood loss anemia 0.62 0.28-1.35 0.23 0.62 0.28-1.35 0.23
Deficiency anemia 1.26 0.63-2.53 0.51 1.37 0.38-2.77 0.38
Alcohol abuse 0.63 0.27-1.48 0.29 0.56 0.21-1.28 0.17
Psychoses 0.94 0.52-1.69 0.83 1.01 0.56-1.83 0.97
Depression 0.52 0.37-0.74 <1.01 0.53 0.38-0.75 <0.01
Hypertension, complicated 0.88 0.69-1.13 0.31 0.90 0.70-1.15 0.41

Page 36 of 37
Table E3: There were no significant interactions in risk-adjusted analyses of 30-day mortality.
Interaction term Definition of physician experience

Duration Volume
Experience*Med-surg status 1.00 0.99-1.01 0.61 1.00 1.00-1.00 0.98
Experience* Hospital volume 1.00 1.00-1.00 0.58 1.00 1.00-1.00 0.83
Duration*Physician volume 1.00 0.90-1.00 0.73 (NA)

Page 37 of 37
Table E4: Sensitivity analyses for association of experience with mortality yielded similar results as the primary analyses.
Sensitivity analysis Duration of physician experience Volume of physician experience

Patients Physicians OR p-value Patients Physicians OR p-value
(95% CI) (95% CI)
Defining eligible physicians as only those with CC board 1.01 1.00
11,434 311 0.08 11,467 312 0.48
certification in 2008 or 2009 (1.00-1.01) (1.00-1.00)
Restricted to admissions assigned to a physician with 100% 0.99 1.00
4,445 185 0.21 4478 187 0.85
of CC claims by eligible physician (0.98-1.01) (1.00-1.00)
Including physicians and hospitals with less than 10 1.00 1.00
12,967 843 0.27 12,322 433 0.56
assigned patients (1.00-1.01) (1.00-1.00)
Using MediQual predicted probability of mortality for 1.00 1.00
9,841 334 0.17 9877 331 0.45
acute severity of illness risk adjustment (1.00-1.01) (1.00-1.00)
Modeling exposure variables using restricted cubic splines*
Spline variable 1 0.99 1.00

0.62 0.92
(0.93-1.04) (0.99-1.01)

0.18 0.85
11,119 339 (0.84-2.50) 11, 152 335 (0.87-1.12)

0.11 0.91
(0.07-1.32) (0.72-1.42)

0.07 0.92
(0.92-13.1) (0.71-1.46)
*Restricted cubic splines utilized five knots, resulting in four new variables to permit a continuous smooth function. That all variables have non-significant p-values indicates that
there is no association between the exposure and mortality.

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ANNALSATS Articles in Press. Published on 28-December-2017 as 10.1513/AnnalsATS.

Physician-Level Variation in Outcomes of Mechanically Ventilated Patients

Running Head: Intensivist experience and patient outcomes

Subject Category: 4.6 ICU Management/Outcome

Word Count: 3442

Copyright © 2017 by the American Thoracic Society

specific contribution to the outcomes remains uncertain.

Objective: To determine variation in outcomes of mechanically ventilated patients among

intensivists, as well as associations between intensivist experience and patient outcomes.

Methods: We performed a retrospective cohort study of mechanically ventilated Medicare fee-

patient and hospital characteristics. We tested for independent association of physician

completion (“duration”) and annual number of mechanically ventilated patients (“volume”).

Copyright © 2017 by the American Thoracic Society

Conclusions: Intensivists independently contribute to outcomes of Medicare patients who

undergo mechanical ventilation, as evidenced by the variation in risk-adjusted mortality across

Abstract Word Count: 323

Copyright © 2017 by the American Thoracic Society

remain highly variable.13,14

outcomes.15-17 Therefore, better understanding the role of physicians in outcome of

mechanically ventilated patients may inform strategies to improve their care.

experience-outcome relationship: hospitalists achieve better outcomes for medical inpatients

mechanical ventilation, achieve better outcomes than lower-volume hospitals;14,18,21-30 and

Copyright © 2017 by the American Thoracic Society

physician experience would be associated with improved patient outcomes.

We performed a retrospective cohort study of patients undergoing mechanical ventilation in an

Review Board of the University of Pennsylvania.

Copyright © 2017 by the American Thoracic Society

Supplement provides further details of the data sources.

Medicare fee-for-service beneficiaries aged 18 years or older. We identified patients who

underwent invasive mechanical ventilation according to the presence of International

Copyright © 2017 by the American Thoracic Society

date), because these admissions would be unlikely to be affected by an individual physician.

Physician Assignment Strategy

critical care board certification). In the absence of a gold-standard definition of an “intensivist,”

ICU patients. Next, we assigned an intensivist to an admission in based on Current Procedural

either of these steps were excluded.

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outcomes were hospital length-of-stay and hospital discharge destination.

We identified potential confounders among patient, hospital, and physician variables a

or surgical according to the Medicare Severity-Diagnosis Related Group (MS-DRG). Because we

were admitted and underwent mechanical ventilation in 2008.

Copyright © 2017 by the American Thoracic Society

as patient characteristics, to outcomes. Last, we estimated the intracluster correlation, which

compares within- and between-physician variance, as a final way to examine physician-

attributable contributions to patients’ 30-day mortality.

Copyright © 2017 by the American Thoracic Society

We performed five pre-specified sensitivity analyses. First, we restricted the definition

Copyright © 2017 by the American Thoracic Society

knots according to percentiles as recommended by Harrell.44

We considered a two-sided p-value of 0.05 as the threshold for statistical significance in

Role of the Funding Source

and in the decision to submit the paper for publication.

Among 23,545 admissions of mechanically ventilated, fee-for-service Medicare patients to

the primary strategy were similar (Table E1).

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0.06, p=0.21; Figure E1).

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this population, physician experience in managing mechanically ventilated patients is not

variable institutional experience and volume of mechanically ventilated patients, or in any of

hospital length of stay or likelihood of being discharged to home.

role of physicians in outcomes of mechanically ventilated patients, a population at high risk of

Copyright © 2017 by the American Thoracic Society

morbidity and mortality. Furthermore, it includes a large number of organizationally diverse

related to unmeasured confounding. However, in the face of such confounding it would be