Quantifying nurse and physician clinical performance for mechanically ventilated patients

OBJECTIVE: Expanding on previous research applying value-added modeling to clinician performance measurement, we quantified simultaneous nurse and physician performance among mechanically ventilated patients.

STUDY SETTING AND DESIGN: In a retrospective cohort spanning five academic hospitals, we used multiple linear regression to determine relationships between nurse and physician assignments and changes in patient illness severity (Laboratory-based Acute Physiology Score) during intensive care unit (ICU) admission. Individual clinician performance was derived from regression coefficients. Collective clinician contribution to disease severity variance was assessed by comparing the coefficient of determination across clinician-only and joint-clinician models. Consistency of clinician performance estimates was cross-validated using random 1:1 partitions of the patient population using Pearson’s correlation.

DATA SOURCES AND ANALYTIC SAMPLE: Electronic health record data were extracted from mechanically ventilated patients at study ICUs between 2018 and 2022.

PRINCIPAL FINDINGS: Among 17,082 clinical encounters, 215 physicians, and 1719 nurses, nurse and physician assignments improved model fit. Together, they attributed 7% of variability in disease severity trajectory; separately, nurse assignments accounted for greater variance than physician assignments (6% vs. 4%, respectively). Cross-partition clinician performance was moderately correlated (r = 0.31 [nurses], r = 0.4 [physicians], p < 0.001 for both comparisons).

CONCLUSIONS: Individual nurse and physician care independently contribute to disease severity trajectory among mechanically ventilated patients.

What is known on this topic:

• Interprofessional team-based care is a guideline-recommended delivery model for patients receiving mechanical ventilation; however, the attributable contributions of specific roles among interdisciplinary teams have yet to be characterized.
• Value-added modeling is a validated econometric technique that can quantify the performance of workers involved with a process and has previously been used to determine relationships between nurse performance and illness trajectory in hospitalized patients.

What this study found:

• Clinician-specific value-add based on assigned patients’ illness trajectories can be reliably and independently quantified for nurse and physician roles in the context of acute hospital care for mechanically ventilated patients.
• Illness trajectory may be more strongly associated with variability associated with nurse as opposed to physician care.

National Heart, Lung, and Blood Institute

Christopher F Chesley, Yingying Lu, Rachel Kohn, Hayley B Gershengorn, Kelly C Vranas, Catherine L Hough, Olga Yakusheva, Deena Kelly Costa, Deanna J Marriott, David A Asch, Aerielle Belk, Stefania Scott, Wei Wang, Meeta Kerlin