Research article

Perceived barriers to the regionalization of adult critical care in the United States: a qualitative preliminary study

Jeremy M Kahn^1,2,3 , Rebecca J Asch¹ , Theodore J Iwashyna⁴ , Gordon D Rubenfeld⁵ , Derek C Angus⁶ and David A Asch^2,7

¹  Division of Pulmonary, Allergy & Critical Care, University of Pennsylvania School of Medicine, 3400 Spruce Street, Philadelphia PA 19104, USA

²  Leonard Davis Institute of Health Economics, University of Pennsylvania, 3641 Locust Walk, Philadelphia PA 19104, USA

³  Center for Clinical Epidemiology & Biostatistics, University of Pennsylvania School of Medicine, 423 Guardian Drive, Philadelphia PA 19104, USA

⁴  Division of Pulmonary and Critical Care Medicine, University of Michigan, 3A23 300 NIB, SPC 5419, 300 North Ingalls, Ann Arbor MI 48109, USA

⁵  Program in Trauma, Emergency, and Critical Care, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto ON, Canada M4N 3M5

⁶  Department of Critical Care Medicine, CRISMA Laboratory, University of Pittsburgh School of Medicine, 3550 Terrace Street, Pittsburgh PA, USA

⁷  Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center, 3900 Woodland Avenue, Philadelphia PA 19104, USA

author email corresponding author email

BMC Health Services Research 2008, 8:239doi:10.1186/1472-6963-8-239

Published:	17 November 2008

Abstract

Background

Regionalization of adult critical care services may improve outcomes for critically ill patients. We sought to develop a framework for understanding clinician attitudes toward regionalization and potential barriers to developing a tiered, regionalized system of care in the United States.

Methods

We performed a qualitative study using semi-structured interviews of critical care stakeholders in the United States, including physicians, nurses and hospital administrators. Stakeholders were identified from a stratified-random sample of United States general medical and surgical hospitals. Key barriers and potential solutions were identified by performing content analysis of the interview transcriptions.

Results

We interviewed 30 stakeholders from 24 different hospitals, representing a broad range of hospital locations and sizes. Key barriers to regionalization included personal and economic strain on families, loss of autonomy on the part of referring physicians and hospitals, loss of revenue on the part of referring physicians and hospitals, the potential to worsen outcomes at small hospitals by limiting services, and the potential to overwhelm large hospitals. Improving communication between destination and source hospitals, provider education, instituting voluntary objective criteria to become a designated referral center, and mechanisms to feed back patients and revenue to source hospitals were identified as potential solutions to some of these barriers.

Conclusion

Regionalization efforts will be met with significant conceptual and structural barriers. These data provide a foundation for future research and can be used to inform policy decisions regarding the design and implementation of a regionalized system of critical care.