Cost Of Intensive Care Research Articles

Effects of a patient/family-centered practice change on the quality and cost of intensive care: research protocol

This paper is a description of a protocol for studying the impact of a patient/family-centered, evidence-based practice change on the quality, cost and use of services for critically ill patients at the end of life. International attention currently is focused on the quality and cost/use of intensive care services. Empirical literature and expert opinion suggest that early, enhanced communication among the clinical team and the patient and family results in higher quality and less costly care at the end of life. Our Medical Intensive Care Unit practice change involves three components: teaching sessions for all Registered Nurses and physicians assigned to the unit; patient/family meetings held in 72 hours of the patient's admission to the unit; and formal documentation to support communication among clinicians. Ethical approval was obtained in April 2009. A two-group post-test design is used, with one group comprising patients hospitalized before the practice change and their families, and the second group of patients/families after the practice change. Data comprise medical record information and families' responses to surveys. Final analytic models will result from multivariable regression techniques. The study represents translational research in that interventions are brought to the bedside to reach the people for whom the interventions were designed. The practice change is likely to endure after the study because our research team is composed of both clinicians and scientists. Also, direct care clinicians endorse and are responsible for the practice change.

Resource Use in the Last 6 Months of Life Among Medicare Beneficiaries With Heart Failure, 2000-2007

Heart failure is a common cause of death among Medicare beneficiaries, but little is known about health care resource use at the end of life. In a retrospective cohort study of 229,543 Medicare beneficiaries with heart failure who died between January 1, 2000, and December 31, 2007, we examined resource use in the last 180 days of life, including all-cause hospitalizations, intensive care unit days, skilled nursing facility stays, home health, hospice, durable medical equipment, outpatient physician visits, and cardiac procedures. We calculated overall costs to Medicare and predictors of costs. Approximately 80% of patients were hospitalized in the last 6 months of life; days in intensive care increased from 3.5 to 4.6 (P<.001). Use of hospice increased from 19% to nearly 40% of patients (P<.001). Unadjusted mean costs to Medicare per patient rose 26% from $28,766 to $36,216 (P<.001). After adjustment for age, sex, race, comorbid conditions, and geographic region, costs increased by 11% (cost ratio, 1.11; 95% confidence interval, 1.10-1.13). Increasing age was strongly and independently associated with lower costs. Renal disease, chronic obstructive pulmonary disease, and black race were independent predictors of higher costs. Among Medicare beneficiaries with heart failure, health care resource use at the end of life increased over time with higher rates of intensive care and higher costs. However, the use of hospice services also increased markedly, representing a shift in patterns of care at the end of life.

Long‐Term Impact of a Multifaceted Prevention Program on Ventilator‐Associated Pneumonia in a Medical Intensive Care Unit

Ventilator-associated pneumonia (VAP), the most common hospital-acquired infection in intensive care units, increases mortality and health care costs. We describe the long-term impact of a multifaceted program for decreasing VAP rates that markedly improved compliance with 8 targeted preventive measures. We compared VAP rates during a 45-month baseline period and a 30-month intervention period in a cohort of patients who received mechanical ventilation for > 48 h. VAP was diagnosed on the basis of quantitative cultures of distal specimens. VAP incidence density rates were expressed as total VAP episodes over total mechanical ventilation duration and as first VAP episodes over mechanical ventilation duration at VAP or hospital discharge. We used segmented regression analysis and a Cox proportional hazard model to assess the impact of the program on first VAP occurrence. Baseline and intervention VAP rates were 22.6 and 13.1 total VAP episodes over total mechanical ventilation duration per 1000 ventilation-days, respectively, and 26.1 and 14.9 first VAP episodes over mechanical ventilation duration at VAP or hospital discharge per 1000 procedure-days, respectively (P < .001). VAP rates decreased by 43% in both statistical analyses and remained significant after adjustment for confounders (Cox adjusted hazard ratio, 0.58; 95% confidence interval, 0.46-0.72; P < .001). Daily VAP hazard rates on ventilation days 5, 10, and 15 were 2.6%, 3.5%, and 3.4%, respectively, during the baseline period and 1.4%, 2.3%, and 2%, respectively, during the intervention period. Our preventive program produced sustained VAP rate decreases in the long term. However, VAP rates remained substantial despite high compliance with preventive measures, suggesting that eliminating VAP in the intensive care unit may be an unrealistic goal.

An official American Thoracic Society systematic review: the association between health insurance status and access, care delivery, and outcomes for patients who are critically ill.

One in three Americans under 65 years of age does not have health insurance during some portion of each year. Patients who are critically ill and lack health insurance may be at particularly high risk of morbidity and mortality due to the high cost of intensive care. To systematically review the medical and nonmedical literature to determine whether differences in critical care access, delivery, and outcomes are associated with health insurance status. Nine electronic databases (inception to 11 April 2008) were independently screened and abstracted in duplicate. From 5,508 citations, 29 observational studies met eligibility criteria. Among the general U.S. population, patients who were uninsured were less likely to receive critical care services than those with insurance (odds ratio [OR], 0.56; 95% confidence interval [CI], 0.55-0.56). Once admitted to the intensive care unit, patients who were uninsured had 8.5% (95% CI, 6.0-11.1) fewer procedures, were more likely to experience hospital discharge delays (OR 4.51; 95% CI, 1.46-13.93), and were more likely to have life support withdrawn (OR 2.80; 95% CI, 1.12-7.02). Lack of insurance may confer an independent risk of death for patients who are critically ill (OR 1.16; 95% CI, 1.01-1.33). Patients in managed care systems had 14.3% (95% CI, 11.5-17.2) fewer procedures in intensive care, but were also less likely to receive "potentially ineffective" care. Differences in unmeasured confounding factors may contribute to these findings. Patients in the United States who are critically ill and do not have health insurance receive fewer critical care services and may experience worse clinical outcomes. Improving preexisting health care coverage, as opposed to solely delivering more critical care services, may be one mechanism to reduce such disparities.

Relationship between intensive care complications and costs and initial 24 h events of trauma patients with severe haemorrhage

Background:The correlation between the events occurring in the initial 24 h following traumatic injury and the outcome of patients presenting with hypovolaemic shock is not clear.Methods:27 patients who presented to...

Cost analysis of two approaches to parenteral nutrition in critically ill children*

In pediatric intensive care, two approaches to parenteral nutrition are available: individualized admixtures or commercial standard solutions. Even though individualized admixtures can be tailored to sometimes highly intricate requirements, standard solutions are able to meet the demands of the majority of pediatric patients. To address the growing importance of costs in intensive care, we investigated whether relevant differences between individualized admixtures and standard solutions in terms of costs can be found. Retrospective analysis. University-affiliated intensive care unit. Fifty consecutively admitted pediatric patients requiring parenteral nutrition. None. Comparison of actual costs of individualized admixtures and theoretical costs of standard solutions. Mean actual costs of individualized admixtures of Euro 81.78 (+/- 16.33) per patient and day were significantly higher than the theoretical costs of standard solutions of Euro 61.21 (+/- 6.55). Cost differences increased with patients' body weights. Parenteral nutrition with standard solutions offers the potential of a relevant cost reduction compared with individualized admixtures in critically ill children.

Procalcitonin to guide duration of antibiotic therapy in intensive care patients: a randomized prospective controlled trial.

IntroductionThe development of resistance by bacterial species is a compelling issue to reconsider indications and administration of antibiotic treatment. Adequate indications and duration of therapy are particularly important for the use of highly potent substances in the intensive care setting. Until recently, no laboratory marker has been available to differentiate bacterial infection from viral or non-infectious inflammatory reaction; however, over the past years, procalcitonin (PCT) is the first among a large array of inflammatory variables that offers this possibility. The present study aimed to investigate the clinical usefulness of PCT for guiding antibiotic therapy in surgical intensive care patients.MethodsAll patients requiring antibiotic therapy based on confirmed or highly suspected bacterial infections and at least two concomitant systemic inflammatory response syndrome criteria were eligible. Patients were randomly assigned to either a PCT-guided (study group) or a standard (control group) antibiotic regimen. Antibiotic therapy in the PCT-guided group was discontinued, if clinical signs and symptoms of infection improved and PCT decreased to <1 ng/ml or the PCT value was >1 ng/ml, but had dropped to 25 to 35% of the initial value over three days. In the control group antibiotic treatment was applied as standard regimen over eight days.ResultsA total of 110 surgical intensive care patients receiving antibiotic therapy after confirmed or high-grade suspected infections were enrolled in this study. In 57 patients antibiotic therapy was guided by daily PCT and clinical assessment and adjusted accordingly. The control group comprised 53 patients with a standardized duration of antibiotic therapy over eight days. Demographic and clinical data were comparable in both groups. However, in the PCT group the duration of antibiotic therapy was significantly shorter than compared to controls (5.9 +/- 1.7 versus 7.9 +/- 0.5 days, P < 0.001) without negative effects on clinical outcome.ConclusionsMonitoring of PCT is a helpful tool for guiding antibiotic treatment in surgical intensive care patients. This may contribute to an optimized antibiotic regimen with beneficial effects on microbial resistance and costs in intensive care medicine.AnnotationResults were previously published in German in Anaesthesist 2008; 57: 571–577 (PMID: 18463831).Trial registrationISRCTN10288268

Could benefits of epidural analgesia following oesophagectomy be measured by perceived perioperative patient workload?

A controversy exists whether beneficial analgesic effects of epidural analgesia over intravenous analgesia influence the rate of post-operative complications and the length of hospital stay. There is some evidence that favours epidural analgesia following major surgery in high-risk patients. However, there is a controversy as to whether epidural analgesia reduces the intensive care resources following major surgery. In this study, we aimed at comparing the post-operative costs of intensive care in patients receiving epidural or intravenous analgesia. Clinical data and rates of post-operative complications were extracted from a previously reported trial following thoraco-abdominal oesophagectomy. Cost data for individual patients included in that trial were retrospectively obtained from administrative records. Two separate phases were defined: costs of pain treatment and the direct cost of intensive care. Higher calculated costs of epidural vs. intravenous pain treatment, 1,037 vs. 410 Euros / patient, were outweighed by lower post-operative costs of intensive care 5,571 vs. 7,921 Euros / patient (NS). Higher costs and better analgesic effects of epidural analgesia compared with intravenous analgesia do not reduce total costs for post-operative care following major surgery.

Similar Cost for Elective Open and Endovascular AAA Repair in a Population-Based Setting

To compare cost differences between elective open repair (OR) and endovascular repair (EVAR) of abdominal aortic aneurysm in a population-based setting. Clinical data and hospital-related costs (pre-, peri-, and postoperative) were analyzed for 109 consecutive AAA procedures (98 men; mean age 73 years, range 48-95; mean aneurysm diameter 61 mm, range 42-120) performed from 2001 to 2005 (58 OR, 51 EVAR) in our primary catchment area. Data were obtained through case records and hospital accounting systems. Nonparametric bootstrap was used for cost comparison. EVAR patients were older (76 versus 70 years, p<0.001) and had more comorbidities (ASA class 2.6 versus 2.3, p = 0.025). OR patients more often had anatomically complex aneurysms (52% versus 14%, p<0.001). Comparison of data with diagnosis-based reimbursement levels nationally and internationally indicated adequate cost level in the study. No difference was observed in total cost between OR and EVAR (euro29,786 versus euro26,382; p = 0.336). Preoperative cost was lower for OR compared to EVAR (euro661 versus euro1494, p = 0.002). OR patients had higher cost of intensive care [36% (euro8921) of perioperative cost versus 7% (euro1460), p = 0.001], while EVAR had higher implant cost [36% (euro7468) versus 2% (euro448), p<0.001]. Mean follow-up was 2.5 years (range 0.5-5.4). Mean postoperative cost was similar (OR euro4613 versus EVAR euro4403, p = 0.209; 16% and 17% of total cost, respectively). Postoperative cost after OR was high early on, with lower cost thereafter. Postoperative cost after EVAR was more homogeneously distributed, leveling off at euro500 to euro1000 annually over 5 years. In a population-based setting, total cost was similar for OR and EVAR. There were, however, important differences in patient characteristics and cost structure.

Cost of intensive care in India

Critical care is often described as expensive care. However, standardized methodology that would enable determination and international comparisons of cost is currently lacking. This article attempts to review this important issue and develop a framework through which cost of critical care in India could be analyzed.

The cost of vacuum-assisted closure therapy in treatment of deep sternal wound infection

Objectives. Surgical sites infections are very expensive and the total costs for coronary artery bypass grafting (CABG) surgery followed by deep sternal wound infection (DSWI) with conventional therapy are estimated to be 2.8 times that for normal, CABG surgery. Promising results have been reported with vacuum-assisted closure (VAC) therapy in patients with DSWI. This study presents the cost of VAC therapy in patients with DSWI after CABG surgery. Design. Thirty-eight CABG patients with DSWI, between 2001 and 2005, were treated with VAC therapy. The cost of surgery, intensive care, ward care, laboratory tests and other costs were analyzed. Results. No three-month mortality or recurrent infection was observed. The average cost of CABG procedure and treatment of DSWI was 2.5 times higher than the mean cost of CABG alone. No significant correlations were found between the preoperative EuroSCORE and the cost of DSWI therapy. Conclusions. VAC therapy for patients who underwent CABG surgery followed by DSWI seems to be cost effective, and has low mortality rate.

Outcome and quality of life after cardiovascular surgery of critical ill patients with prolonged intensive medical care

Cardiovascular surgery might be followed by a complicated post-operative course with prolonged intensive medical care (PIMC) and extensive costs. The outcome after PIMC is unclear. Therefore the aim of this retrospective study is to ascertain the outcome and quality of life of the survivors.

Intensive care costs of acute poisoning cases

Aim. To examine the costs of acute poisoning patients admitted to an intensive care unit. Methods. Retrospective review of intensive care unit records of patients admitted for treatment of acute poisoning from January 1, 2002 to September 30, 2006. Results. The study group consisted of 94 patients and 18.1% of them died in the intensive care unit. The 62 suicidal cases were significantly younger than the accidental cases (p = 0.006). The average cost per intensive care unit stay was US $821 ± 1149 (US $711 ± 695 for suicidal and US $1,036 ± 1,713 for accidental cases). Conclusions. Poisoned patients admitted to an intensive care unit represent a considerable cost for the health care system in Turkey.

Nursing Activities Score in the intensive care unit: Analysis of the related factors

High costs of intensive care as well as quality of care and patient safety demand measurement of nursing workload in order to determine nursing staff requirements. It is also important to be aware of the factors related to high patient care demands in order to help forecast staff requirements in intensive care units (ICUs). To describe nursing workload using the Nursing Activities Score (NAS); to explore the association between NAS and patients variables, i.e. gender, age, length of stay (LOS), ICU discharge, treatment in the ICU, Simplified Acute Physiology Score II (SAPS II) and Therapeutic Interventions Scoring System-28 (TISS-28). NAS, demographic data, SAPS II and TISS-28 were analysed among 200 patients from four different ICUs in a private hospital in São Paulo, Brazil. NAS median were 66.4%. High NAS scores (> 66.4%) were associated with death (p-value 0.006) and LOS (p-value 0.015). Logistic regression analysis demonstrated that TISS-28 scores above 23 and SAPS II scores above 46.5 points, classified as high, increased 5.45 and 2.78 times, respectively, the possibility of a high workload as compared to lower values of the same indexes. This study shows that the highest NAS scores were associated with increased mortality, LOS, severity of the patient illness (SAPS II), and particularly to TISS-28 in the ICU.

The cost effectiveness and health outcomes of in vitro fertilization (IVF) as a mandated benefit

Although there are multiple causes and many methods of treating infertility, none is as broadly applicable, nor has grown as rapidly as in vitro fertilization (IVF). With IVF come high costs, multiple pregnancies, and perinatal complications. US employers, already losing their competitive edge due to the high cost of health care, are faced with legislation mandating IVF as part of a health benefits package. A literature review was performed in order to determine the effect of adding an IVF benefit to member premiums. Retrospective literature review. The Centers for Disease Control (CDC) and Society for Assisted Reproductive Technology (SART) report, a national database of U.S. IVF treatment programs, was used to ascertain how utilization has increased in this country. Secondly, a manual literature search using the references from the NEJM paper entitled, “Insurance coverage and Outcome of In Vitro Fertilization” was performed and articles studying the affect of adding an IVF benefit were selected. The average cost of an IVF cycle in the US is $9,226. Despite its relatively increased usage and apparent popularity, ART accounts for only 0.03% of US healthcare costs. Among policies that provide IVF services, the increase in premium per member per month ranges from $0.87 to $10. In states where coverage is mandated, the multiple gestation rate is lower. This appears to reflect the transfer of fewer embryos and translates to markedly decreased costs of neonatal intensive care. When IVF is provided as a mandated benefit within employee or private health plans, the cost per member per month will increase a negligible amount. Secondly, states with mandated benefits have lower multiple gestation rates. This effect results in reduced utilization of expensive care associated with prematurity, low birth weight and other intensive neonatal support. In sum, these findings suggest that mandated IVF benefits are likely to enhance newborn health and thus result in lower overall health costs.

Measurement of Extravascular Lung Water in Critically Ill Patients

In critically ill patients, capillary leakage often occurs which in the lungs may lead to pulmonary edema by increased microvascular pressure and permeability. However, clinical assessment of the extent of pulmonary capillary leakage and pulmonary edema is difficult. Several decades ago, the transpulmonary double indicator (thermo-dye) dilution technique has been introduced for quantification of extravasastion of fluids in the lungs by determination of the extravascular lung water (EVLW). The thermo-dye is based on simultaneous central venous injection of a freely diffusible indicator (‘cold’) and a plasma-bound indicator (indocyanine green). This technique has been extensively validated in animal experiments using post-mortem gravimetry and in humans using radionuclide techniques. However, the thermo-dye dilution technique is relatively expensive and time consuming therefore assessment of EVLW is increasingly performed by single transpulmonary thermodilution, which according to animal experimental and clinical studies is sufficiently accurate for estimation of EVLW. Using EVLW to guide the management of patients with both cardiac and non-cardiac pulmonary edema (ARDS) has been shown to reduce the duration of mechanical ventilation, length of stay in the intensive care unit and potentially intensive care costs. EVLW-guided therapy also reduced mortality in those patients with congestive heart failure and ARDS. Recent clinical studies have shown that in critically ill patients EVLW correlates with the severity of lung injury and that it does have a prognostic value. Thus, monitoring EVLW can be a useful additional tool in the goaldirected therapy of critically ill patients, especially those with severe sepsis and sepsis-induced acute lung injury. Keywords: Pulmonary edema, extravascular lung water, acute lung injury, critically ill patients

Cost effectiveness of adult intensive care in the UK

We wished to investigate whether intensive care represents good value for money to the National Health Service in the UK using cost-effectiveness analysis. We developed a cost-effectiveness model using secondary data sources to estimate the incremental cost per quality adjusted life year gained of treatment in intensive care vs non-intensive care treatment in adults. Estimates of hospital mortality with and without intensive care were obtained from seven published studies and from data published by the Intensive Care National Audit and Research Centre. Quality of life estimates were obtained from a literature review and NHS reference costs were used. Relative to non-intensive care treatment, the incremental cost per quality adjusted life year gained of treatment in intensive care is 7010 pounds. This figure is sensitive to the mortality risk reduction associated with intensive care. Despite the high daily cost of intensive care, its cost-effectiveness is excellent and compares favourably with other commonly used health interventions. Our findings suggest that adult intensive care represents good value for money.

The Most Fragile of Newborns

Baby at Risk . The Uncertain Legacies of Medical Miracles for Babies, Families, and Society. By Ruth Levy Guyer . Capital Books, Sterling, VA, 2006. 181 pp. $22.95. ISBN 9781933102269. Guyer discusses the benefits and costs of neonatal intensive care and examines the question of who should make the decisions about high-tech interventions.

Sistemas de classificação de pacientes como instrumentos de gestão em Unidades de Terapia Intensiva

Trata-se de uma abordagem teórica sobre diferentes instrumentos de medida assistenciais e gerenciais utilizados para a determinação da gravidade dos pacientes, quantificação das demandas de cuidados, estimativa da real necessidade de profissionais de enfermagem e custo da assistência intensiva, o que os torna recursos facilitadores de gestão. Neste artigo, apresentam-se diferentes instrumentos de medida voltados à classificação de pacientes em unidades de Terapia Intensiva (UTIs), considerando-se tanto os índices de gravidade quanto os de carga de trabalho de enfermagem. Discutem-se facilidades e dificuldades inerentes à implementação desses instrumentos.

Cost evaluation in the intensive care units of Trinidad applying the cost‐blocks method – an international comparison*

This study evaluated the costs of intensive care in Trinidad applying the cost-blocks method. Data regarding demographics, severity of illness, therapeutic interventions and length of stay were prospectively recorded for 111 patients admitted to four intensive care units during a 3-month period. Annual costs, cost per admission, cost per patient-day and cost per therapeutic intervention score point were derived. The cost-block for staff, especially medical staff, was the largest proportion of the expenditure. Process of care and outcome were comparable, whereas costs were lower than the developed countries. The median cost per intensive care unit bed per year and cost per patient per day in Trinidad were 133,117 pounds and 366 pounds, respectively, in comparison with 265,163 pounds and 904 pounds in the UK. The cost-blocks method is a useful framework for evaluating the costs of intensive care and for comparing costs between countries.