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September 18, 1996, Vol 276, No. 11 >
ARTICLE | September 18, 1996

The Effectiveness of Right Heart Catheterization in the Initial Care of Critically III Patients FREE

Alfred F. Connors, Jr, MD; Theodore Speroff, PhD; Neal V. Dawson, MD; Charles Thomas; Frank E. Harrell, Jr, PhD; Douglas Wagner, PhD; Norman Desbiens, MD; Lee Goldman, MD, MPH; Albert W. Wu, MD; Robert M. Califf, MD; William J. Fulkerson, Jr, MD; Humberto Vidaillet, MD; Steven Broste, MS; Paul Bellamy, MD; Joanne Lynn, MD; William A. Knaus, MD
[+] Author Affiliations

School of Medicine, Charlottesville, and Dr Speroff is now with the Magic Valley Medical Center, Twin Falls, Idaho.

A complete list of the SUPPORT Investigators appears in JAMA. 1995;274:1591-1598; correction JAMA. 1996; 275:1232.

The opinions and findings contained in this article are those of the authors and do not necessarily represent the views of the Robert Wood Johnson Foundation or its Board of Trustees.

Reprints: Alfred F. Connors, Jr, MD, Division of Health Services and Outcomes Research, Department of Health Evaluation Sciences, University of Virginia School of Medicine, Health Sciences Center, Box 600, Charlottesville, VA 22908.

Concepts in Emergency and Critical Care section editor: Roger C. Bone, MD, Consulting Editor, JAMA.

Advisory Panel: Bart Chernow, MD, Baltimore, Md; David Dantzker, MD, New Hyde Park, NY; Jerrold Leiken, MD, Chicago, Ill; Joseph E. Parrillo, MD, Chicago, Ill; William J. Sibbald, MD, London, Ontario; and Jean-Louis Vincent, MD, PhD, Brussels, Belgium.


JAMA. 1996;276(11):889-897. doi:10.1001/jama.1996.03540110043030
Text Size: A A A
Published online
Article
References

Objective.  —To examine the association between the use of right heart catheterization (RHC) during the first 24 hours of care in the intensive care unit (ICU) and subsequent survival, length of stay, intensity of care, and cost of care.

Design.  —Prospective cohort study.

Setting.  —Five US teaching hospitals between 1989 and 1994.

Subjects.  —A total of 5735 critically ill adult patients receiving care in an ICU for 1 of 9 prespecified disease categories.

Main Outcome Measures.  —Survival time, cost of care, intensity of care, and length of stay in the ICU and hospital, determined from the clinical record and from the National Death Index. A propensity score for RHC was constructed using multivariable logistic regression. Case-matching and multivariable regression modeling techniques were used to estimate the association of RHC with specific outcomes after adjusting for treatment selection using the propensity score. Sensitivity analysis was used to estimate the potential effect of an unidentified or missing covariate on the results.

Results.  —By case-matching analysis, patients with RHC had an increased 30-day mortality (odds ratio, 1.24; 95% confidence interval, 1.03-1.49). The mean cost (25th, 50th, 75th percentiles) per hospital stay was $49300 ($17000, $30500, $56600) with RHC and $35700 ($11 300, $20600, $39200) without RHC. Mean length of stay in the ICU was 14.8 (5,9, 17) days with RHC and 13.0 (4,7, 14) days without RHC. These findings were all confirmed by multivariable modeling techniques. Subgroup analysis did not reveal any patient group or site for which RHC was associated with improved outcomes. Patients with higher baseline probability of surviving 2 months had the highest relative risk of death following RHC. Sensitivity analysis suggested that a missing covariate would have to increase the risk of death 6-fold and the risk of RHC 6-fold for a true beneficial effect of RHC to be misrepresented as harmful.

Conclusion.  —In this observational study of critically ill patients, after adjustment for treatment selection bias, RHC was associated with increased mortality and increased utilization of resources. The cause of this apparent lack of benefit is unclear. The results of this analysis should be confirmed in other observational studies. These findings justify reconsideration of a randomized controlled trial of RHC and may guide patient selection for such a study.

REFERENCES

1 +
Connors AF Jr, McCaffree DR, Gray BA.  Evaluation of right heart catheterization in the critically ill patient without acute myocardial infarction . N Engl J Med . 1983;;308:263-267.
2 +
Eisenberg PR, Jaffe AS, Schuster DP.  Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients . Crit Care Med . 1984;;12:549-553.
3 +
Connors AF Jr, Dawson NV, Shaw PK, Montenegro HD, Nara AR, Martin L.  Hemodynamic status in critically ill patients with and without acute heart disease . Chest . 1990;;98:1200-1206.
4 +
Mimoz O, Rauss A, Rekik N, Brun-Buisson C, Lemaire F, Brochard L.  Pulmonary artery catheterization in critically ill patients: a prospective analysis of outcome changes associated with catheter-prompted changes in therapy . Crit Care Med . 1994;;22:573-579.
5 +
Guyatt G, Ontario Intensive Care Group.  A randomized control trial of right-heart catheterization in critically ill patients . J Intensive Care Med . 1991;;6:91-95.
6 +
Wu AW, Rubin HR, Rosen MJ.  Are elderly people less responsive to intensive care? J Am Geriatr Soc . 1990;;38:621-627.
7 +
Gore JM, Goldberg RJ, Spodick DH, Alpert JS, Dalen JE.  A community-wide assessment of the use of pulmonary artery catheters in patients with acute myocardial infarction . Chest . 1987;;92:721-727.
8 +
Zion MM, Balkin J, Rosenmann D, et al.  Use of pulmonary artery catheters in patients with acute myocardial infarction: analysis of experience in 5841 patients in the SPRINT registry . Chest . 1990;;98:1331-1335.
9 +
Greenland P, Reicher-Reiss H, Goldbourt U, Behar S, Israel Sprint Investigators.  In-hospital and 1-year mortality in 1524 women after myocardial infarction: comparison with 4315 men . Circulation . 1991;;83:484-491.
10 +
Blumberg MS, Binns GS.  Swan-Ganz catheter use and mortality of myocardial infarction patients . Health Care Financ Rev . 1994;;15:91-103.
11 +
Greenland S, Neutra R.  Control of confounding in the assessment of medical technology . Int J Epidemiol . 1980;;9:361-367.
12 +
Rosenbaum PR, Rubin DB.  The central role of the propensity score in observational studies for causal effects . Biometrika . 1983;;70:41-55.
13 +
Rosenbaum PR, Rubin DB.  Reducing bias in observational studies using subclassification on the propensity score . J Am Stat Assoc . 1984;;79:516-524.
14 +
Murphy DJ, Cluff LE.  SUPPORT: Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments—study design . J Clin Epidemiol . 1990;;43( (suppl) ):1S-123S.
15 +
SUPPORT Principal Investigators.  A controlled trial to improve care for seriously ill hospitalized patients: the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) . JAMA . 1995;;274:1591-1598.
16 +
Correction: JAMA . 1996;;275:1232.
17 +
Knaus WA, Wagner DP, Draper EA, et al.  The APACHE III prognostic system: risk prediction of hospital mortality for critically ill hospitalized adults . Chest . 1991;;100:1619-1636.
18 +
Knaus WA, Harrell FE, Lynn J, et al.  The SUPPORT prognostic model: prediction of survival for seriously ill hospitalized adults . Ann Intern Med . 1995;;122:191-203.
19 +
Keene RA, Cullen DJ.  Therapeutic intervention scoring system: update 1983 . Crit Care Med . 1983;;11:1-3.
20 +
Knaus WA, Wagner DP, Draper EA, Lawrence DE, Zimmerman JE.  The range of intensive care services today . JAMA . 1981;;246:2711-2716.
21 +
Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW.  Studies of illness in the aged—the index of ADL: a standardized measure of biological and psychosocial function . JAMA . 1963;;185:914-919.
22 +
Hlatky MA, Boineau RE, Higginbotham MB, et al.  A brief self-administered questionnaire to determine functional capacity (the Duke Activity Status Index) . Am J Cardiol . 1989;;64:651-654.
23 +
Walker SH, Duncan DB.  Estimation of the probability of an event as a function of several independent variables . Biometrika . 1967;;54:167-178.
24 +
Rosenbaum PR, Rubin DB.  Assessing sensitivity to an unobserved binary covariate in an observational study with binary outcome . J R Stat Soc . 1983;;45:212-218.
25 +
Cox DR.  Regression models and life-tables (with discussion) . J R Stat Soc B . 1972;;34:187-220.
26 +
Hastie TJ, Botha JL, Schnitzler CM.  Regression with an ordered categorical response . Stat Med . 1989;;8:785-794.
27 +
Snapinn SM, Small RD.  Tests of significance using regression models for ordered categorical data . Biometrics . 1986;;42:583-592.
28 +
Wright SP.  Adjusted p-values for simultaneous inference . Biometrics . 1992;;48:1005-1013.
29 +
Mermel LA, Maki DG.  Infectious complications of Swan-Ganz pulmonary artery catheters: pathogenesis, epidemiology, prevention, and management . Am J Respir Crit Care Med . 1994;;149:1020-1036.
30 +
Mermel LA, McCormick RD, Springman SR, Maki DG.  The pathogenesis and epidemiology of catheter-related infection with pulmonary artery Swan-Ganz catheters: a prospective study utilizing molecular subtyping . Am J Med . 1991;;91:197S-205S.
31 +
Chastre J, Cornud F, Bouchama A, Benacerraf R, Gibert C.  Thrombosis as a complication of pulmonary-artery catheterization via the internal jugular vein . N Engl J Med . 1982;;306:278-281.
32 +
Connors AF Jr, Castele RJ, Farhut N, Tomashefski JF.  Complications of right heart catheterization: a prospective autopsy study . Chest . 1985;;88:567-575.
33 +
Rose R, Hunting KJ, Townsend TR, Wenzel RP.  Morbidity, mortality and economics of hospital-acquired blood stream infections: a controlled study . South Med J . 1977;;70:1267-1269.
34 +
Spengler RF, Greenough WB.  Hospital costs and mortality attributed to nosocomial bacteremia . JAMA . 1978;;240:2455-2458.
35 +
Wenzel RP.  The mortality of hospital-acquired bloodstream infections: need for a new vital statistic? Int J Epidemiol . 1988;;17:225-227.
36 +
Haley RW, Schaberg DR, Crossley KB, von Allmen SD, McGowan JE Jr.  Extra charges and prolongation of stay attributable to nosocomial infections: a prospective interhospital comparison . Am J Med . 1981;;70:51-58.
37 +
Iberti TJ, Fischer EP, Leibowitz AB, et al.  A multicenter study of physician's knowledge of the pulmonary artery catheter . JAMA . 1990;;264:2928-2932.
38 +
Mitchell JP, Schuller D, Calandrino FS, Schuster DP.  Improved outcome based on fluid management in critically ill patients requiring pulmonary artery catheterization . Am Rev Respir Dis . 1992;;145:990-998.
39 +
Humphrey H, Hall J, Szajder I, Silverstein M, Wood LD.  Improved survival in ARDS patients associated with a reduction in pulmonary capillary wedge pressure . Chest . 1990;;97:1176-1180.
40 +
Fleming A, Bishop M, Shoemaker W, et al.  Prospective trial of supranormal values as goals of resuscitation in severe trauma . Arch Surg . 1992;;127:1175-1181.
41 +
Shoemaker WC, Kram HB, Appel PL, Fleming AW.  The efficacy of central venous and pulmonary artery catheters and therapy based upon them in reducing mortality and morbidity . Arch Surg . 1990;;125:1332-1337.
42 +
Hayes MA, Timmins AC, Yau EHS, Pallazo M, Hinds CJ, Watson D.  Elevation of systemic oxygen delivery in the treatment of critically ill patients . N Engl J Med . 1994;;330:1717-1722.
43 +
Gattinoni L, Brazzi L, Pelosi P, et al.  A trial of goal-oriented hemodynamic therapy in critically ill patients . N Engl J Med . 1995;;333:1025-1032.
44 +
Cook EF, Goldman L.  Asymmetric stratification: an outline for an efficient method for controlling confounding in cohort studies . Am J Epidemiol . 1988;;127:626-639.
45 +
Miettinen OS.  Stratification by a multivariate confounder score . Am J Epidemiol . 1976;;104:609-620.
46 +
Robins JM, Mark SD, Newey WK.  Estimating exposure effects by modelling the expectation of exposure conditional on confounders . Biometrics . 1992;;48:479-495.
47 +
Shoemaker WC.  Use and abuse of the balloon tip pulmonary artery (Swan-Ganz) catheter: are patients getting their money's worth? Crit Care Med . 1990;;18:1294-1296.
48 +
Tuman KJ, McCarthy RJ, Speiss BD, et al.  Effect of pulmonary artery catheterization on outcome in patients undergoing coronary artery surgery . Anesthesiology . 1989;;70:199-206.
49 +
Swan HJC, Ganz W.  Guidelines for use of the balloon-tipped catheter . Am J Cardiol . 1974;;34:119-120.
50 +
Guidelines Committee, Society for Critical Care Medicine.  Guidelines for the care of patients with hemodynamic instability associated with sepsis . Crit Care Med . 1992;;20:1057-1059.
51 +
European Society of Intensive Care Medicine.  Expert panel: the use of the pulmonary artery catheter . Intensive Care Med . 1991;;17:I-VIII.
52 +
The American Society of Anesthesiologists Task Force on Pulmonary Artery Catheterization.  Practice guidelines for pulmonary artery catheterization . Anesthesiology . 1993;;78:380-394.
53 +
Yarzebski J, Goldberg RJ, Gore JM, Alpert JS.  Temporal trends and factors associated with pulmonary artery catheterization in patients with acute myocardial infarction . Chest . 1994;;105:1003-1008.

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Connors AF Jr, McCaffree DR, Gray BA.  Evaluation of right heart catheterization in the critically ill patient without acute myocardial infarction . N Engl J Med . 1983;;308:263-267.
2 +
Eisenberg PR, Jaffe AS, Schuster DP.  Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients . Crit Care Med . 1984;;12:549-553.
3 +
Connors AF Jr, Dawson NV, Shaw PK, Montenegro HD, Nara AR, Martin L.  Hemodynamic status in critically ill patients with and without acute heart disease . Chest . 1990;;98:1200-1206.
4 +
Mimoz O, Rauss A, Rekik N, Brun-Buisson C, Lemaire F, Brochard L.  Pulmonary artery catheterization in critically ill patients: a prospective analysis of outcome changes associated with catheter-prompted changes in therapy . Crit Care Med . 1994;;22:573-579.
5 +
Guyatt G, Ontario Intensive Care Group.  A randomized control trial of right-heart catheterization in critically ill patients . J Intensive Care Med . 1991;;6:91-95.
6 +
Wu AW, Rubin HR, Rosen MJ.  Are elderly people less responsive to intensive care? J Am Geriatr Soc . 1990;;38:621-627.
7 +
Gore JM, Goldberg RJ, Spodick DH, Alpert JS, Dalen JE.  A community-wide assessment of the use of pulmonary artery catheters in patients with acute myocardial infarction . Chest . 1987;;92:721-727.
8 +
Zion MM, Balkin J, Rosenmann D, et al.  Use of pulmonary artery catheters in patients with acute myocardial infarction: analysis of experience in 5841 patients in the SPRINT registry . Chest . 1990;;98:1331-1335.
9 +
Greenland P, Reicher-Reiss H, Goldbourt U, Behar S, Israel Sprint Investigators.  In-hospital and 1-year mortality in 1524 women after myocardial infarction: comparison with 4315 men . Circulation . 1991;;83:484-491.
10 +
Blumberg MS, Binns GS.  Swan-Ganz catheter use and mortality of myocardial infarction patients . Health Care Financ Rev . 1994;;15:91-103.
11 +
Greenland S, Neutra R.  Control of confounding in the assessment of medical technology . Int J Epidemiol . 1980;;9:361-367.
12 +
Rosenbaum PR, Rubin DB.  The central role of the propensity score in observational studies for causal effects . Biometrika . 1983;;70:41-55.
13 +
Rosenbaum PR, Rubin DB.  Reducing bias in observational studies using subclassification on the propensity score . J Am Stat Assoc . 1984;;79:516-524.
14 +
Murphy DJ, Cluff LE.  SUPPORT: Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments—study design . J Clin Epidemiol . 1990;;43( (suppl) ):1S-123S.
15 +
SUPPORT Principal Investigators.  A controlled trial to improve care for seriously ill hospitalized patients: the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) . JAMA . 1995;;274:1591-1598.
16 +
Correction: JAMA . 1996;;275:1232.
17 +
Knaus WA, Wagner DP, Draper EA, et al.  The APACHE III prognostic system: risk prediction of hospital mortality for critically ill hospitalized adults . Chest . 1991;;100:1619-1636.
18 +
Knaus WA, Harrell FE, Lynn J, et al.  The SUPPORT prognostic model: prediction of survival for seriously ill hospitalized adults . Ann Intern Med . 1995;;122:191-203.
19 +
Keene RA, Cullen DJ.  Therapeutic intervention scoring system: update 1983 . Crit Care Med . 1983;;11:1-3.
20 +
Knaus WA, Wagner DP, Draper EA, Lawrence DE, Zimmerman JE.  The range of intensive care services today . JAMA . 1981;;246:2711-2716.
21 +
Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW.  Studies of illness in the aged—the index of ADL: a standardized measure of biological and psychosocial function . JAMA . 1963;;185:914-919.
22 +
Hlatky MA, Boineau RE, Higginbotham MB, et al.  A brief self-administered questionnaire to determine functional capacity (the Duke Activity Status Index) . Am J Cardiol . 1989;;64:651-654.
23 +
Walker SH, Duncan DB.  Estimation of the probability of an event as a function of several independent variables . Biometrika . 1967;;54:167-178.
24 +
Rosenbaum PR, Rubin DB.  Assessing sensitivity to an unobserved binary covariate in an observational study with binary outcome . J R Stat Soc . 1983;;45:212-218.
25 +
Cox DR.  Regression models and life-tables (with discussion) . J R Stat Soc B . 1972;;34:187-220.
26 +
Hastie TJ, Botha JL, Schnitzler CM.  Regression with an ordered categorical response . Stat Med . 1989;;8:785-794.
27 +
Snapinn SM, Small RD.  Tests of significance using regression models for ordered categorical data . Biometrics . 1986;;42:583-592.
28 +
Wright SP.  Adjusted p-values for simultaneous inference . Biometrics . 1992;;48:1005-1013.
29 +
Mermel LA, Maki DG.  Infectious complications of Swan-Ganz pulmonary artery catheters: pathogenesis, epidemiology, prevention, and management . Am J Respir Crit Care Med . 1994;;149:1020-1036.
30 +
Mermel LA, McCormick RD, Springman SR, Maki DG.  The pathogenesis and epidemiology of catheter-related infection with pulmonary artery Swan-Ganz catheters: a prospective study utilizing molecular subtyping . Am J Med . 1991;;91:197S-205S.
31 +
Chastre J, Cornud F, Bouchama A, Benacerraf R, Gibert C.  Thrombosis as a complication of pulmonary-artery catheterization via the internal jugular vein . N Engl J Med . 1982;;306:278-281.
32 +
Connors AF Jr, Castele RJ, Farhut N, Tomashefski JF.  Complications of right heart catheterization: a prospective autopsy study . Chest . 1985;;88:567-575.
33 +
Rose R, Hunting KJ, Townsend TR, Wenzel RP.  Morbidity, mortality and economics of hospital-acquired blood stream infections: a controlled study . South Med J . 1977;;70:1267-1269.
34 +
Spengler RF, Greenough WB.  Hospital costs and mortality attributed to nosocomial bacteremia . JAMA . 1978;;240:2455-2458.
35 +
Wenzel RP.  The mortality of hospital-acquired bloodstream infections: need for a new vital statistic? Int J Epidemiol . 1988;;17:225-227.
36 +
Haley RW, Schaberg DR, Crossley KB, von Allmen SD, McGowan JE Jr.  Extra charges and prolongation of stay attributable to nosocomial infections: a prospective interhospital comparison . Am J Med . 1981;;70:51-58.
37 +
Iberti TJ, Fischer EP, Leibowitz AB, et al.  A multicenter study of physician's knowledge of the pulmonary artery catheter . JAMA . 1990;;264:2928-2932.
38 +
Mitchell JP, Schuller D, Calandrino FS, Schuster DP.  Improved outcome based on fluid management in critically ill patients requiring pulmonary artery catheterization . Am Rev Respir Dis . 1992;;145:990-998.
39 +
Humphrey H, Hall J, Szajder I, Silverstein M, Wood LD.  Improved survival in ARDS patients associated with a reduction in pulmonary capillary wedge pressure . Chest . 1990;;97:1176-1180.
40 +
Fleming A, Bishop M, Shoemaker W, et al.  Prospective trial of supranormal values as goals of resuscitation in severe trauma . Arch Surg . 1992;;127:1175-1181.
41 +
Shoemaker WC, Kram HB, Appel PL, Fleming AW.  The efficacy of central venous and pulmonary artery catheters and therapy based upon them in reducing mortality and morbidity . Arch Surg . 1990;;125:1332-1337.
42 +
Hayes MA, Timmins AC, Yau EHS, Pallazo M, Hinds CJ, Watson D.  Elevation of systemic oxygen delivery in the treatment of critically ill patients . N Engl J Med . 1994;;330:1717-1722.
43 +
Gattinoni L, Brazzi L, Pelosi P, et al.  A trial of goal-oriented hemodynamic therapy in critically ill patients . N Engl J Med . 1995;;333:1025-1032.
44 +
Cook EF, Goldman L.  Asymmetric stratification: an outline for an efficient method for controlling confounding in cohort studies . Am J Epidemiol . 1988;;127:626-639.
45 +
Miettinen OS.  Stratification by a multivariate confounder score . Am J Epidemiol . 1976;;104:609-620.
46 +
Robins JM, Mark SD, Newey WK.  Estimating exposure effects by modelling the expectation of exposure conditional on confounders . Biometrics . 1992;;48:479-495.
47 +
Shoemaker WC.  Use and abuse of the balloon tip pulmonary artery (Swan-Ganz) catheter: are patients getting their money's worth? Crit Care Med . 1990;;18:1294-1296.
48 +
Tuman KJ, McCarthy RJ, Speiss BD, et al.  Effect of pulmonary artery catheterization on outcome in patients undergoing coronary artery surgery . Anesthesiology . 1989;;70:199-206.
49 +
Swan HJC, Ganz W.  Guidelines for use of the balloon-tipped catheter . Am J Cardiol . 1974;;34:119-120.
50 +
Guidelines Committee, Society for Critical Care Medicine.  Guidelines for the care of patients with hemodynamic instability associated with sepsis . Crit Care Med . 1992;;20:1057-1059.
51 +
European Society of Intensive Care Medicine.  Expert panel: the use of the pulmonary artery catheter . Intensive Care Med . 1991;;17:I-VIII.
52 +
The American Society of Anesthesiologists Task Force on Pulmonary Artery Catheterization.  Practice guidelines for pulmonary artery catheterization . Anesthesiology . 1993;;78:380-394.
53 +
Yarzebski J, Goldberg RJ, Gore JM, Alpert JS.  Temporal trends and factors associated with pulmonary artery catheterization in patients with acute myocardial infarction . Chest . 1994;;105:1003-1008.

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