Early childhood attachment stability and change: a meta-analysis.

Examining degrees of stability in attachment throughout early childhood is important for understanding developmental pathways and for informing intervention. Updating and building upon all prior meta-analyses, this study aimed to determine levels of stability in all forms of attachment classifications across early childhood. Attachment stability was assessed between three developmental epochs within early childhood: infancy, toddlerhood, and preschool/early school. To ensure data homogeneity, only studies that assessed attachment with methods based on the strange situation procedure were included. Results indicate moderate levels of stability at both the four-way (secure, avoidant, resistant, and disorganised; κ = 0.23) and secure/insecure (r = 0.28) levels of assessment. Meta-regression analysis indicated security to be the most stable attachment organisation. This study also found evidence for publication bias, highlighting a preference for the publication of significant findings.

Antenatal caregiving representations and perinatal behavior in mothers with severe lifetime psychopathology.

Psychopathology poses a risk for optimal parenting. The current study explored antenatal caregiving representations as markers for later risk of nonoptimal maternal behavior among mothers with severe mental illness. Sixty-five mothers diagnosed with psychosis, bipolar disorder, depression (psychopathology group), and nonclinical controls participated in a longitudinal study from pregnancy to 16 weeks after birth. Mental health diagnoses and caregiving representations were assessed during pregnancy. Maternal behavior was assessed during the 5-min recovery phase of the still-face paradigm at 16 weeks. Mothers with psychopathology reported significantly higher levels of "heightened" caregiving representations (i.e., separation anxiety from the child) than did controls. The only significant diagnostic group difference in perinatal maternal behavior was that mothers diagnosed with depression exhibited more overriding-intrusive behavior than did nonclinical control mothers. Regression modeling results showed that antenatal caregiving representations of "role reversal" predicted significantly lower levels of sensitivity and higher levels of overriding-intrusive behavior independent of the effect of psychopathology. The findings can be interpreted in the context of representational transformation to motherhood during pregnancy. The results provide preliminary evidence for the potential of a new questionnaire measure of caregiving representations as a screening instrument for antenatal representational risk.

La sicopatología presenta un riesgo para la crianza óptima. El presente estudio exploró las representaciones antenatales de la prestación de cuidado como señales para un posterior riesgo de conducta materna no óptima entre madres con una enfermedad mental severa. Sesenta y cinco madres con diagnosis de sicosis, trastorno bipolar, depresión (grupo de sicopatología), así como madres en el grupo control no clínico participaron en un estudio longitudinal desde el embarazo hasta 16 semanas después del nacimiento. Se evaluaron los diagnósticos de salud mental y las representaciones de la prestación de cuidado durante el embarazo. La conducta materna fue evaluada durante la fase de cinco minutos de recuperación del paradigma de la Cara Inmóvil a las 16 semanas. Las madres con sicopatología reportaron niveles significativamente más altos de representaciones "agudizadas" de la prestación de cuidado (v.g. ansiedad de estar separadas de su niño) que las madres del grupo de control. La única significativa diferencia de grupo de diagnóstico en cuanto a la conducta materna perinatal fue que las madres con diagnosis de depresión presentaron una conducta predominantemente más intrusa que las madres del grupo de control no clínico. Los resultados del uso de modelos de regresión mostraron que las representaciones antenatales de la prestación de cuidado en cuanto al 'cambio de roles' predijeron niveles significativamente más bajos de sensibilidad y niveles más altos de conductas predominantemente intrusas, independiente del efecto de la sicopatología. Se pueden interpretar los resultados en el contexto de la transformación de representación hacia la maternidad durante el embarazo. Los resultados aportan evidencia preliminar para la posibilidad de una nueva medida de cuestionario sobre las representaciones de la prestación de cuidado como instrumento de detección del riesgo de la representación antenatal.

La psychopathologie pose un risque pour le parentage optimal. Cette étude a exploré les représentations de soin anténatal en tant que marqueurs de risque ultérieur de comportement maternel non-optimal chez les mères atteintes d'une maladie mentale sérieuse. Soixante-cinq mères ayant été diagnostiquées avec une psychose, un trouble maniaco-dépressif, une dépression (groupe psychopathologie) et des contrôles non-cliniques ont participé à une étude longitudinale de la grossesse à 16 semaines après la naissance. Les diagnostics de santé mentale et les représentations de soin ont été évaluées durant la grossesse. Le comportement maternel a été évalué durant la phase de récupération de cinq minutes du paradigme de Visage Immobile à 16 semaines. Les mères avec une psychopathologie ont fait état de niveaux bien plus élevés de représentations 'accrues' de soin (anxiété de séparation d'avec l'enfant) que les contrôles. La seule différence importante de diagnostic de groupe dans le comportement maternel périnatal était que les mères diagnostiquées avec une dépression ont fait preuve de plus de comportement prépondérant-intrusif que les mères du groupe de contrôle non-clinique. Les résultats du modèle de régression ont montré que les représentations anténatales de soin de 'l'inversion des rôles' ont prédit des niveaux de sensibilité bien plus bas et des niveaux de comportement prépondérant-intrusif bien plus élevés quel que soit l'effet de la psychopathologie. Les résultats peuvent être interprétés dans le contexte de la transformation représentationnelle de la maternité durant la grossesse. Les résultats offrent des preuves préliminaires quant au potentiel d'un nouveau questionnaire comme mesure de représentations de soin en tant qu'instrument de dépistage du risque représentationnel anténatal.

Adult attachment and birth experience: importance of a secure base and safe haven during childbirth.

OBJECTIVE: Examine connections between mothers' adult attachment and subjective birth experience in the context of parity and mode of delivery. BACKGROUND: Research has established a clear connection between adult attachment and birth experience. This study extended previous research with an in-depth self-report attachment measure examining different dimensions of mothers' attachment representations and their relation to subjective birth experience.  Interactions between mode of delivery and parity were also considered. Method: Participants were 257 mothers who gave birth 4 days to 12 months prior to the study. Mothers' mean age was 30.5 years, 61% primiparas, and 26% delivered by caesarean.  Participants completed an online survey with the Birth Experience Questionnaire, the Reciprocal Attachment Questionnaire, and demographic information. RESULTS: Hierarchical moderated regression analyses showed direct effects from adult attachment dimensions to mothers' subjective birth experiences, specifically perceived availability, feared loss, separation protest, angry withdrawal, and compulsive careseeking. Interactions emerged for parity and/or mode of delivery for overall subjective birth experience, perceived control, perceived social support, and satisfaction. CONCLUSION: Adult attachment representations related to subjective birth experience, indicating that attachment figures serve as secure bases and safe havens for mothers during childbirth. These results have implications for practitioners and provide direction for future research.

Antenatal caregiving representations among expectant mothers with severe mental illness: a cross-sectional study.

Objective: The study explores predictors of antenatal caregiving representations among mothers with a history of severe mental illness (SMI). Background: Attachment research has demonstrated that multifactorial assessment of antenatal caregiving representations predicts later maternal behaviour and child attachment. However, the field lacks research among clinical groups. Knowledge of factors influencing caregiving representations during pregnancy can contribute to our understanding of caregiving risk among SMI-mothers and inform intervention decisions. Method: The current study is a cross-sectional subsample of the WARM study. Participants were 65 Danish or Scottish pregnant women with a history of either schizophrenia, bipolar disorder, moderate-severe depression, or non-clinical controls. Caregiving representations, adverse childhood experiences, social support and current symptom severity were assessed during pregnancy. Results: Symptom severity was associated with more non-optimal caregiving representations expecting less parental enjoyment, more difficulties separating from the child, and more feelings of caregiving helplessness. Lack of social support and adverse childhood experiences served as independent predictors of caregiving representations. Parental mental illness during own childhood predicted role reversed expectations. Conclusion: Antenatal caregiving representations can be assessed with a time-efficient self-report measure that assesses caregiving as a multidimensional construct. Prenatal treatment planning should target individual difficulties in undertaking transformation of the caregiving system.

UNDERSTANDING THE CONNECTION BETWEEN ATTACHMENT TRAUMA AND MATERNAL SELF-EFFICACY IN DEPRESSED MOTHERS.

Maternal self-efficacy predicts sensitive and responsive caregiving. Low maternal self-efficacy is associated with a higher incidence of postpartum depression. Maternal self-efficacy and postpartum depression can both be buffered by social support. Maternal self-efficacy and postpartum depression have both been linked independently, albeit in separate studies, to the experience of violent trauma, childhood maltreatment, and spousal abuse. This study proposed a model in which postpartum depression mediates the relation between attachment trauma and maternal self-efficacy, with emotional support as a moderator. Participants were 278 first-time mothers of infants under 14 months. Cross-sectional data were collected online. Mothers completed questionnaires on attachment trauma, maternal self-efficacy, postpartum depression, and emotional support. A moderated mediation model was tested in a structural equation modeling framework using Mplus' estimate of indirect effects. Postpartum depression fully mediated the relation between trauma and maternal self-efficacy. Emotional support moderated only the pathway between postpartum depression and maternal self-efficacy. Attachment trauma's implications for maternal self-efficacy should be understood in the context of overall mental health. Mothers at the greatest risk for low maternal self-efficacy related to attachment trauma also are those suffering from postpartum depression. Emotional support buffered mothers from postpartum depression, though, which has implications for intervention and future research.

Assessing Attachment Representations in Adolescents: Discriminant Validation of the Adult Attachment Projective Picture System.

The contribution of attachment to human development and clinical risk is well established for children and adults, yet there is relatively limited knowledge about attachment in adolescence due to the poor availability of construct valid measures. The Adult Attachment Projective Picture System (AAP) is a reliable and valid instrument to assess adult attachment status. This study examines for the first time the discriminant validity of the AAP in adolescents. In our sample of 79 teenagers between 15 and 18 years, 42 % were classified as secure, 34 % as insecure-dismissing, 13 % as insecure-preoccupied and 11 % as unresolved. The results demonstrated discriminant validity for using the AAP in that age group, with no associations between attachment classifications and verbal intelligence, social desirability, story length or sociodemographic variables. These results poise the AAP to be used in clinical intervention and large-scale research investigating normative and atypical developmental correlates and sequelae of attachment, including psychopathology in adolescence.

Birth and motherhood: childbirth experience and mothers' perceptions of themselves and their babies.

Childbirth is a major experience in a woman's life, but the relation between childbirth experiences and later mother-infant outcomes has been understudied. This study examined the relation between mode of delivery and subjective birth experience (e.g., perception of control, social support during labor and delivery), and mothers' descriptions of their babies and their maternal self-esteem, both powerful predictors of maternal caregiving behavior. This study had three questions: (a) Do mode of delivery and subjective birth experience predict mothers' descriptions of their babies and maternal self-esteem? (b) Are the effects of mode of delivery on mothers' descriptions and maternal self-esteem mediated by subjective birth experience? (c) Does infant age moderate any of these pathways? The sample consisted of 269 mothers of full-term, healthy infants who gave birth in the year prior to the study. Mode of delivery showed a direct effect on how mothers describe their babies, but not maternal self-esteem, which was not mediated by subjective birth experience. Subjective birth experience had direct effects on both outcomes. Infant age did not moderate any of these pathways. Results point to the subjective aspects of childbirth as important components of women's experience of labor and delivery. Implications are discussed.

Developing a secure base in family intervention: using the adult attachment projective system to assess attachment in family relationships.

Families are core to human well-being. Therapeutic intervention may be needed in the context of family disruptions. Attachment theory conceptualizes parents as the secure base and safe haven that support children's optimal development. Parents who have experienced their own attachment difficulties or traumas may not provide quality caregiving necessary for balanced secure parent-child attachment relationships. Following Bowlby's original thinking (1988), an attachment approach to family intervention views the therapist as a secure base that enables families to explore individual and system problems to restore equilibrium. Attachment informed therapy uses attachment theory to understand family functioning. However, the unavailability of valid economical assessment for examining attachment representations has constricted the practical utility of attachment theory in family therapy beyond applications of general concepts. This chapter describes the Adult Attachment Projective Pictures System (AAP) and explores its use as an efficient manner for assessing attachment representations within families that allows therapists to understand problematic interactions, disabling defensive processes, make predictions concerning negative patterns, and create targets for change and restorative intervention. Consolidating three decades of attachment and caregiving system research, we describe how distinct patterns of AAP responses for each adult attachment group map onto expected parenting and family system expectations and behaviors to provide a concise and informative framework. In addition to the traditional adult attachment patterns (Secure, Dismissing, Preoccupied, Unresolved), we describe for the first time expectations for two additional forms of incomplete pathological mourning (Failed Mourning and Preoccupied with Personal Suffering) that have been overlooked in the field.

Therapeutic assessment case study: treatment of a woman diagnosed with metastatic cancer and attachment trauma.

This article presents a Therapeutic Assessment (TA) case study of a woman recovering from 4 years of intense medical treatment for stage IV cancer. The inclusion and utility of using the Adult Attachment Projective Picture System (AAP) in the TA is highlighted. The client's attachment classification as unresolved helped identify that her current experiences with dissociation and problems restructuring her life following cancer remission were related to severe childhood sexual abuse, which she had suppressed for decades. The AAP also provided information regarding the unconscious defensive processes the client employed to cope with attachment distress and her inability to find comfort and support from others. These findings were instrumental in guiding the subsequent psychotherapy. The TA process, particularly the assessor-client relationship, facilitated an experience of containing her previously unintegrated and dysregulated affect. A single-case experiment using daily measurements suggested that participation in TA coincided with symptomatic improvements in multiple domains. These improvements were maintained during 4 months of biweekly psychotherapy after the completion of the TA. This case illustrates the applicability of the TA model in health care settings, demonstrates the usefulness of the AAP in the context of TA, and provides empirical support for the effectiveness of the TA model in initiating symptom improvement.

The Adult Attachment Projective Picture System: integrating attachment into clinical assessment.

This article summarizes the development and validation of the Adult Attachment Projective System (AAP), a measure we developed from the Bowlby-Ainsworth developmental tradition to assess adult attachment status. The AAP has demonstrated excellent concurrent validity with the Adult Attachment Interview (George, Kaplan, & Main, 1984/1985/1996; Main & Goldwyn, 1985-1994; Main, Goldwyn, & Hesse, 2003), interjudge reliability, and test-retest reliability, with no effects of verbal intelligence or social desirability. The AAP coding and classification system and application in clinical and community samples are summarized. Finally, we introduce the 3 other articles that are part of this Special Section and discuss the use of the AAP in therapeutic assessment and treatment.

A Novel Think Tank Program to Promote Innovation and Strategic Planning in Ophthalmic Surgery.

BACKGROUND: Continuous quality improvement is a pillar of all surgical groups. Innovation is a critical aspect to continuously improve, but traditional staff retreats have several disadvantages which limit their utility in identifying needs and developing innovative solutions. To address these challenges, we designed the novel Think Tank Program to spur innovation and strategic planning for an academic ophthalmology department including the Kellogg Eye Center 6 operating rooms. METHODS: The Think Tank program is a structured seven-phase program for faculty in small teams to identify, innovate, and implement meaningful change. Participants brainstormed problems and possible solutions to those problems, formed teams, acquired data, and implemented meaningful change in clinical care, research, education, and administration. RESULTS: The program generated 19 novel proposals and significant faculty engagement and discussion in improving the department. A case example of improving the operating room (OR) utilization resulted in improved OR utilization from 63.8% to 74.6% over a 3 month period before and after implementation. It also resulted in a reduction of cancelled or rescheduled surgeries within 2 weeks or surgery from 29.8% to 15.2%. This resulted in an estimated positive financial margin of over $141,000 to the institution in addition to improvement in patient, surgeon, and staff satisfaction with the quality of care. CONCLUSIONS: Engaged faculty, critical data analysis, and value proposition analysis with data-driven metrics and accountability can result in a significant increase in OR utilization and reduction in surgical cancellations. Think Tank serves as a model transformative program to assist practices and institutions to best fulfill their mission while actively engaging and retaining their members.

Early blood glucose control and mortality in critically ill patients in Australia.

OBJECTIVE: To measure temporal trends in blood glucose (BG) control and describe their association with hospital mortality in a cohort of critically ill patients from Australia. DESIGN: Interrogation of prospectively collected data from the Australia New Zealand Intensive Care Society Adult Patient Database. SETTING: Twenty-four intensive care units (ICU) across Australia. PATIENTS AND PARTICIPANTS: A cohort of 66,184 adult ICU admissions for >or=24 hours from January 1, 2000, to December 31, 2005. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Highest and lowest BG values within 24 hours of ICU admission, standard demographic, clinical, and physiologic data, and hospital mortality. Medical, mechanically ventilated surgical, cardiac surgical, and septic subgroups were evaluated. Average BG was evaluated as a continuous variable and by quartiles (low [<5.6 mmol/L], near normal [5.6-8.69 mmol/L], high [8.69-11.79 mmol/L], and highest [>11.79 mmol/L]). There were 132,368 BG values, with a mean (95% confidence intervals) value 8.69 mmol/L (8.66-8.73). There was no trend in BG for the entire cohort (p = 0.66) over the study period; yet, BG increased after 2002 (0.17 mmol/L, p < 0.0001). The mechanically ventilated surgical and cardiac surgical subgroups had decreasing trends in BG (p < 0.001), whereas the septic subgroup had an increasing BG trend (p < 0.001). BG in the low, high, and highest quartiles, compared with the near-normal quartile, were consistently associated with higher hospital mortality in crude (odds ratio 1.31, 1.58, and 2.00) and multivariable analysis (odds ratio 1.29, 1.07, and 1.10), respectively. This association was similarly shown for the mechanically ventilated surgical and cardiac surgical subgroups. CONCLUSIONS: In a large cohort of ICU patients from Australia, there was no significant change in early glycemic control from 2000 to 2005. There were differences in selected subgroups. Average BG decreased in surgical subgroups, whereas it increased in septic patients. Both high and early low BG values were independently associated with hospital mortality.

Very old patients admitted to intensive care in Australia and New Zealand: a multi-centre cohort analysis.

INTRODUCTION: Older age is associated with higher prevalence of chronic illness and functional impairment, contributing to an increased rate of hospitalization and admission to intensive care. The primary objective was to evaluate the rate, characteristics and outcomes of very old (age >or= 80 years) patients admitted to intensive care units (ICUs). METHODS: Retrospective analysis of prospectively collected data from the Australian New Zealand Intensive Care Society Adult Patient Database. Data were obtained for 120,123 adult admissions for >or= 24 hours across 57 ICUs from 1 January 2000 to 31 December 2005. RESULTS: A total of 15,640 very old patients (13.0%) were admitted during the study. These patients were more likely to be from a chronic care facility, had greater co-morbid illness, greater illness severity, and were less likely to receive mechanical ventilation. Crude ICU and hospital mortalities were higher (ICU: 12% vs. 8.2%, P < 0.001; hospital: 24.0% vs. 13%, P < 0.001). By multivariable analysis, age >/= 80 years was associated with higher ICU and hospital death compared with younger age strata (ICU: odds ratio (OR) = 2.7, 95% confidence interval (CI) = 2.4 to 3.0; hospital: OR = 5.4, 95% CI = 4.9 to 5.9). Factors associated with lower survival included admission from a chronic care facility, co-morbid illness, nonsurgical admission, greater illness severity, mechanical ventilation, and longer stay in the ICU. Those aged >or= 80 years were more likely to be discharged to rehabilitation/long-term care (12.3% vs. 4.9%, OR = 2.7, 95% CI = 2.6 to 2.9). The admission rates of very old patients increased by 5.6% per year. This potentially translates to a 72.4% increase in demand for ICU bed-days by 2015. CONCLUSIONS: The proportion of patients aged >or= 80 years admitted to intensive care in Australia and New Zealand is rapidly increasing. Although these patients have more co-morbid illness, are less likely to be discharged home, and have a greater mortality than younger patients, approximately 80% survive to hospital discharge. These data also imply a potential major increase in demand for ICU bed-days for very old patients within a decade.

Landmark survival as an end-point for trials in critically ill patients--comparison of alternative durations of follow-up: an exploratory analysis.

INTRODUCTION: Interventional ICU trials have followed up patients for variable duration. However, the optimal duration of follow-up for the determination of mortality endpoint in such trials is uncertain. We aimed to determine the most logical and practical mortality end-point in clinical trials of critically ill patients. METHODS: We performed a retrospective analysis of prospectively collected data involving 369 patients with one of the three specific diagnoses (i) Sepsis (ii) Community acquired pneumonia (iii) Non operative trauma admitted to the Royal Perth Hospital ICU, a large teaching hospital in Western Australia (WA cohort). Their in-hospital and post discharge survival outcome was assessed by linkage to the WA Death Registry. A validation cohort involving 4609 patients admitted during same time period with identical diagnoses from 55 ICUs across Australia (CORE cohort) was used to compare the patient characteristics and in-hospital survival to look at the Australia-wide applicability of the long term survival data from the WA cohort. RESULTS: The long term outcome data of the WA cohort indicate that mortality reached a plateau at 90 days after ICU admission particularly for sepsis and pneumonia. Mortality after hospital discharge before 90 days was not uncommon in these two groups. Severity of acute illness as measured by the total number of organ failures or acute physiology score was the main predictor of 90-day mortality. The adjusted in-hospital survival for the WA cohort was not significantly different from that of the CORE cohort in all three diagnostic groups; sepsis (P = 0.19), community acquired pneumonia (P = 0.86), non-operative trauma (P = 0.47). CONCLUSIONS: A minimum of 90 days follow-up is necessary to fully capture the mortality effect of sepsis and community acquired pneumonia. A shorter period of follow-up time may be sufficient for non-operative trauma.

The impact of early hypoglycemia and blood glucose variability on outcome in critical illness.

INTRODUCTION: In critical illness, the association of hypoglycemia, blood glucose (BG) variability and outcome are not well understood. We describe the incidence, clinical factors and outcomes associated with an early hypoglycemia and BG variability in critically ill patients. METHODS: Retrospective interrogation of prospectively collected data from the Australia New Zealand Intensive Care Society Adult Patient Database on 66184 adult admissions to 24 intensive care units (ICUs) from 1 January 2000 to 31 December 2005. Primary exposure was hypoglycemia (BG < 4.5 mmol/L) and BG variability (BG < 4.5 and >or= 12.0 mmol/L) within 24 hours of admission. Primary outcome was all-cause mortality. RESULTS: The cumulative incidence of hypoglycemia and BG variability were 13.8% (95% confidence interval (CI) = 13.5 to 14.0; n = 9122) and 2.9% (95%CI = 2.8 to 3.0, n = 1913), respectively. Several clinical factors were associated with both hypoglycemia and BG variability including: co-morbid disease (P < 0.001), non-elective admissions (P < 0.001), higher illness severity (P < 0.001), and primary septic diagnosis (P < 0.001). Hypoglycemia was associated with greater odds of adjusted ICU (odds ratio (OR) = 1.41, 95% CI = 1.31 to 1.54) and hospital death (OR = 1.36, 95% CI = 1.27 to 1.46). Hypoglycemia severity was associated with 'dose-response' increases in mortality. BG variability was associated with greater odds of adjusted ICU (1.5, 95% CI = 1.4 to 1.6) and hospital (1.4, 95% CI = 1.3 to 1.5) mortality, when compared with either hypoglycemia only or neither. CONCLUSIONS: In critically ill patients, both early hypoglycemia and early variability in BG are relatively common, and independently portend an increased risk for mortality.

Couple relationships and the family system: commentary from a behavioral systems perspective.

This commentary examines papers in this special issue on couple attachment from the behavioral systems perspective that serves as the foundation of John Bowlby's attachment theory.

Designing and implementing an Australian and New Zealand intensive care data audit study.

PURPOSE: The aim of this pilot audit study is to develop and test a model to examine existing adult patient database (APD) data quality. DESIGN/METHODOLOGY/APPROACH: A database was created to audit 50 records per site to determine accuracy. The audited records were randomly selected from the calendar year 2004 and four sites participated in the pilot audit study. A total of 41 data elements were assessed for data quality--those elements required for APACHE II scoring system. FINDINGS: Results showed that the audit was feasible; missing audit data were an unplanned problem; analysis was complicated owing to the way the APACHE calculations are performed and 50 records per site was too time-consuming. ORIGINALITY/VALUE: This is the first audit study of intensive care data within the ANZICS APD and demonstrates how to determine data quality in a large database containing individual patient records.

Mortality and length-of-stay outcomes, 1993-2003, in the binational Australian and New Zealand intensive care adult patient database.

OBJECTIVE: Intensive care unit (ICU) outcomes have been the subject of controversy. The objective was to model hospital mortality and ICU length-of-stay time-change of patients recorded in the Australian and New Zealand Intensive Care Society adult patient database. DESIGN: Retrospective, cohort study of prospectively collected data on index patient admissions. SETTING: Australian and New Zealand ICUs, 1993-2003. PATIENTS: The Australian and New Zealand Intensive Care Society adult patient database, which contains data for 223,129 patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Hospital mortality and ICU length of stay were modeled using logistic and linear regression, respectively, with determination (80%) and validation (20%) data sets. Model adequacy was assessed by discrimination (receiver operating characteristic curve area, AZ) and calibration (Hosmer-Lemeshow C) for mortality and R2 for length of stay. Predictor variables included patient demographics, severity score, surgical and ventilation status, ICU categories, and geographical locality. The data set comprised 223,129 patients: Their mean (SD) age was 59.2 (18.9) yrs, 41.7% were female, their mean (SD) Acute Physiology and Chronic Health Evaluation (APACHE) III score was 53 (31), they had 16.1% overall mortality rate, and 45.7% were mechanically ventilated. ICU length of stay was 3.6 (5.6) days. A(Z), C statistic, and R2 for developmental and validation model data sets were 0.88, 17.64 (p = .02), and 0.18; and 0.88, 12.32 (p = .26), and 0.18, respectively. Variables with mortality impact (p < or = .001) were age (odds ratio [OR] 1.023), gender (OR 1.16; males vs. females), APACHE III score (OR 1.06), mechanical ventilation (OR 1.66), and surgical status (elective, OR 0.17; emergency, OR 0.47; compared with nonsurgical). ICU level and locality had significant mortality-time effects. Similar variables were found to predict length of stay. Risk-adjusted mortality declined, during 1993-2003, from 0.19 (95% confidence interval 0.17-0.21) to 0.15 (0.13-0.16) and similarly for ventilated patients: 0.26 (0.24-0.29) to 0.23 (0.21-0.25). Predicted mean ICU length of stay (days) demonstrated minimal overall time-change: 3.4 (2.2) in 1993 to 3.5 (2.7) in 2003, peaking at 3.7 (2.4) in 2000. CONCLUSIONS: Overall hospital mortality rate in patients admitted to Australian and New Zealand ICUs decreased 4% over 11 yrs. A similar trend occurred for mechanically ventilated patients. Length of stay changed minimally over this period.