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Role of Attending Practice Variability in Prone Positioning Initiation: A Retrospective Cohort Study
Anna K Barker1, Emily A Harlan1,2, Meeta Prasad Kerlin3,4
1Division of Pulmonary and Critical Care Medicine, University of Michigan.
CHEST Critical Care
|November 28, 2025
Summary
Prone positioning use varies significantly among attending physicians, impacting patient outcomes. Interventions targeting attending physicians and healthcare systems are needed to improve prone positioning rates.
Area of Science:
- Critical Care Medicine
- Respiratory Therapy
- Health Services Research
Background:
- Prone positioning improves mortality in mechanically ventilated patients but remains underutilized.
- Patient-specific factors influencing prone positioning are known, but attending physician contributions are unclear.
Purpose of the Study:
- To determine if significant variability in prone positioning utilization exists among attending physicians.
- To identify attending physician variability as a predictor of prone positioning.
Main Methods:
- Retrospective cohort study of 514 adult ICU patients requiring mechanical ventilation.
- Inclusion criteria: Pao2/Fio2 ratio ≤ 150, Fio2 ≥ 60%, PEEP ≥ 5 cm H2O.
- Mixed-effects logistic regression analyzed attending-level variability, adjusting for patient factors and ICU location.
Main Results:
- Only 17% (87/514) of eligible patients received prone positioning.
- Significant attending-level variability observed, with adjusted rates from 14.9% to 74.2% (median OR 2.6).
- Attending variability was a stronger predictor than changes in Pao2/Fio2 ratio; COVID-19 status, code status, and Pao2/Fio2 ratio also predicted use.
Conclusions:
- Substantial variation in prone positioning practices exists among attending physicians.
- Future interventions should focus on attending-level and system-wide strategies to enhance prone positioning rates.
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