Acute respiratory failure requiring mechanical ventilation is an enormous clinical and financial burden on the health system, affecting over 750,000 patients in the United States each year. These patients experience substantial morbidity and mortality, particularly in small hospitals with low annual caseloads. To improve outcomes for these patients, many experts propose a regionalized approach to mechanical ventilation, analogous to the United States trauma system. Under regionalization, mechanically ventilated patients admitted to small, resource-poor hospitals would be systematically triaged to large regional referral hospitals. Regionalization has potential to save lives and increase access to high-quality critical care for patients requiring mechanical ventilation. Yet, implementation efforts face significant barriers, most notably the lack of empirical data demonstrating that centralizing care in regional hospitals of excellence actually improves outcomes. Although many studies demonstrate that mechanical ventilation outcomes are better at high-volume hospitals compared to low-volume hospitals, these studies fail to fully uncover the implications of regionalized care, which involves not only increasing case volume at some hospitals but also decreasing it at others. Prior to moving forward, clinicians and policy makers require empirical data on the implications of regionalized critical care in real-world settings. The overall goal of this project is to empirically evaluate the outcome benefit of regionalized critical care for patiets with acute respiratory failure.
In Aim 1 we will define novel critical care referral regions as a geographic foundation for quantifying regional care delivery.
In Aim 2 we will identify regional factors associated with greater centralization of care for acute respiratory failure.
In Aim 3 we will determine the association between centralized critical care and outcomes for patients with acute respiratory failure. Completion of these Aims will both advance our knowledge of the relationship between regionalization and outcomes for acute respiratory failure, as well as provide a scientific foundation for future efforts to centralize care for other high-risk patients.The research plan will be augmented by intensive mentoring by experts in the field and didactic research training at the University of Pittsburgh and Carnegie Mellon University. Together, the research project, mentoring and coursework described herein will provide the primary investigator with essential career development in the areas of: (1) spatial epidemiology and health care geographical information systems analysis, (2) advanced hierarchical statistical modeling and (3) organizational science and health care market analysis. Ultimately, this work will set the stage for research evaluating centralized care of other time-sensitive conditions in a comprehensive R01-funded project and uniquely position the primary investigator as a future leader in the use of geographic modeling to improve outcomes for critically ill patients.

Public Health Relevance

Acute respiratory failure requiring mechanical ventilation affects over 750,000 patients annually in the United States and is associated with high morbidity and mortality. Efforts are needed to understand how to best organize health care delivery for these patients at the regional level, including regional care coordination through the systematic triage and transfer of selected patients to high-volume hospital centers of excellence. By empirically evaluating the outcome benefits of regionalized critical care for patients requiring mechanical ventilation, this project will directly inform efforts to reorganize critical care and improve health care quality for this high-risk patient population.

National Institute of Health (NIH)
National Heart, Lung, and Blood Institute (NHLBI)
Clinical Investigator Award (CIA) (K08)
Project #
Application #
Study Section
Special Emphasis Panel (ZHL1)
Program Officer
Colombini-Hatch, Sandra
Project Start
Project End
Budget Start
Budget End
Support Year
Fiscal Year
Total Cost
Indirect Cost
University of Pittsburgh
Internal Medicine/Medicine
Schools of Medicine
United States
Zip Code
Wallace, David J; Seymour, Christopher W; Kahn, Jeremy M (2017) Hospital-Level Changes in Adult ICU Bed Supply in the United States. Crit Care Med 45:e67-e76
Mohan, Deepika; Rosengart, Matthew R; Fischhoff, Baruch et al. (2017) Using incentives to recruit physicians into behavioral trials: lessons learned from four studies. BMC Res Notes 10:776
Wallace, David J (2016) Nighttime physician staffing improves patient outcomes: yes. Intensive Care Med 42:1467-8
Mohan, Deepika; Rosengart, Matthew R; Fischhoff, Baruch et al. (2016) Testing a videogame intervention to recalibrate physician heuristics in trauma triage: study protocol for a randomized controlled trial. BMC Emerg Med 16:44
Coppler, Patrick J; Rittenberger, Jon C; Wallace, David J et al. (2016) Billing diagnoses do not accurately identify out-of-hospital cardiac arrest patients: An analysis of a regional healthcare system. Resuscitation 98:9-14
Chen, Lujie; Dubrawski, Artur; Wang, Donghan et al. (2016) Using Supervised Machine Learning to Classify Real Alerts and Artifact in Online Multisignal Vital Sign Monitoring Data. Crit Care Med 44:e456-63
Wallace, David J; Angus, Derek C; Seymour, Christopher W et al. (2015) Critical care bed growth in the United States. A comparison of regional and national trends. Am J Respir Crit Care Med 191:410-6
Wallace, David J; Kahn, Jeremy M (2015) Florence Nightingale and the Conundrum of Counting ICU Beds. Crit Care Med 43:2517-8
Nguyen, Yên-Lan; Wallace, David J; Yordanov, Youri et al. (2015) The Volume-Outcome Relationship in Critical Care: A Systematic Review and Meta-analysis. Chest 148:79-92
Costa, Deena Kelly; Wallace, David J; Kahn, Jeremy M (2015) The Association Between Daytime Intensivist Physician Staffing and Mortality in the Context of Other ICU Organizational Practices: A Multicenter Cohort Study. Crit Care Med 43:2275-82

Showing the most recent 10 out of 12 publications