Total Intensive Care Unit Costs Research Articles

Cost comparisons and factors related to cost per stay in intensive care units in Belgium

BackgroundGiven the variability of intensive care unit (ICU) costs in different countries and the importance of this information for guiding clinicians to effective treatment and to the organisation of ICUs at the national level, it is of value to gather data on this topic for analysis at the national level in Belgium. The objectives of the study were to assess the total cost of ICUs and the factors that influence the cost of ICUs in hospitals in Belgium.MethodsThis was a retrospective cohort study using data collected from the ICUs of 17 Belgian hospitals from January 01 to December 31, 2018. A total of 18,235 adult ICU stays were included in the study. The data set was a compilation of inpatient information from analytical cost accounting of hospitals, medical discharge summaries, and length of stay data. The costs were evaluated as the expenses related to the management of hospital stays from the hospital’s point of view. The cost from the hospital perspective was calculated using a cost accounting analytical methodology in full costing. We used multivariate linear regression to evaluate factors associated with total ICU cost per stay. The ICU cost was log-transformed before regression and geometric mean ratios (GMRs) were estimated for each factor.ResultsThe proportion of ICU beds to ward beds was a median [p25-p75] of 4.7% [4.4–5.9]. The proportion of indirect costs to total costs in the ICU was 12.1% [11.4–13.3]. The cost of nurses represented 57.2% [55.4–62.2] of direct costs and this was 15.9% [12.0-18.2] of the cost of nurses in the whole hospital. The median cost per stay was €4,267 [2,050–9,658] and was €2,160 [1,545–3,221] per ICU day. The main factors associated with higher cost per stay in ICU were Charlson score, mechanical ventilation, ECMO, continuous hemofiltration, length of stay, readmission, ICU mortality, hospitalisation in an academic hospital, and diagnosis of coma/convulsions or intoxication.ConclusionsThis study demonstrated that, despite the small proportion of ICU beds in relation to all services, the ICU represented a significant cost to the hospital. In addition, this study confirms that nursing staff represent a significant proportion of the direct costs of the ICU. Finally, the total cost per stay was also important but highly variable depending on the medical factors identified in our results.

Examination of Impact of After-Hours Admissions on Hospital Resource Use, Patient Outcomes, and Costs.

Nighttime and weekends in hospital and intensive care unit (ICU) contexts are thought to present a greater risk for adverse events than daytime admissions. Although some studies exist comparing admission time with patient outcomes, the results are contradictory. No studies currently exist comparing costs with the time of admission. We investigated the differences in-hospital mortality, ICU length of stay, ICU mortality, and cost between daytime and nighttime admissions. All adult patients (≥18 years of age) admitted to a large academic medical-surgical ICU between 2011 and 2015 were included. Admission cohorts were defined as daytime (8:00-16:59) or nighttime (17:00-07:59). Student's t-tests and chi-squared tests were used to test for associations between days spent in the ICU, days on mechanical ventilation, comorbidities, diagnoses, and cohort membership. Regression analysis was used to test for associations between patient and hospitalization characteristics and in-hospital mortality and total ICU costs. The majority of admissions occurred during nighttime hours (69.5%) with no difference in the overall Elixhauser comorbidity score between groups (p=0.22). Overall ICU length of stay was 7.96 days for daytime admissions compared to 7.07 days (p=0.001) for patients admitted during nighttime hours. Overall mortality was significantly higher in daytime admissions (22.5% vs 20.6, p=0.012); however, ICU mortality was not different. The average MODS was 2.9 with those admitted during the daytime having a significantly higher MODS (3.0, p=0.046). Total ICU cost was significantly higher for daytime admissions (p=0.003). Adjusted ICU mortality was similar in both groups despite an increased rate of adverse events for nighttime admissions. Daytime admissions were associated with increased cost. There was no difference in all hospital total cost or all hospital direct cost between groups. These findings are likely due to the higher severity of illness in daytime admissions. Daytime admissions were associated with a higher severity of illness, mortality rate, and ICU cost. To further account for the effect of staffing differences during off-hours, it may be beneficial to compare weekday and weeknight admission times with associated mortality rates.

Direct Medical Costs of Tetanus, Dengue, and Sepsis Patients in an Intensive Care Unit in Vietnam.

BackgroundCritically ill patients often require complex clinical care by highly trained staff within a specialized intensive care unit (ICU) with advanced equipment. There are currently limited data on the costs of critical care in low-and middle-income countries (LMICs). This study aims to investigate the direct-medical costs of key infectious disease (tetanus, sepsis, and dengue) patients admitted to ICU in a hospital in Ho Chi Minh City (HCMC), Vietnam, and explores how the costs and cost drivers can vary between the different diseases.MethodsWe calculated the direct medical costs for patients requiring critical care for tetanus, dengue and sepsis. Costing data (stratified into different cost categories) were extracted from the bills of patients hospitalized to the adult ICU with a dengue, sepsis and tetanus diagnosis that were enrolled in three studies conducted at the Hospital for Tropical Diseases in HCMC from January 2017 to December 2019. The costs were considered from the health sector perspective. The total sample size in this study was 342 patients.ResultsICU care was associated with significant direct medical costs. For patients that did not require mechanical ventilation, the median total ICU cost per patient varied between US$64.40 and US$675 for the different diseases. The costs were higher for patients that required mechanical ventilation, with the median total ICU cost per patient for the different diseases varying between US$2,590 and US$4,250. The main cost drivers varied according to disease and associated severity.ConclusionThis study demonstrates the notable cost of ICU care in Vietnam and in similar LMIC settings. Future studies are needed to further evaluate the costs and economic burden incurred by ICU patients. The data also highlight the importance of evaluating novel critical care interventions that could reduce the costs of ICU care.

Costs and Healthcare Resource Utilization Associated with Idarucizumab or Andexanet Alfa Oral Anticoagulant Reversal in Patients Hospitalized with Life-Threatening Bleeds.

Purpose: To assess costs and healthcare resource utilization (HCRU) associated with the use of idarucizumab for the reversal of dabigatran and andexanet alfa for the reversal of direct oral Factor Xa inhibitors. Methods: This retrospective study utilizing Premier Healthcare Database (PHD) included patients aged ≥18 years on direct oral anticoagulants (DOACs) who experienced life-threatening bleeds, discharged from the hospital during 5/1/2018–6/30/2019, and received idarucizumab or andexanet alfa. Inverse of treatment probability weighting (IPTW) method was used to balance patient and clinical characteristics between treatment cohorts. Results: Idarucizumab patients were older than andexanet alfa patients (median age 81 vs 77 years; p < 0.001), and less likely to experience intracranial hemorrhage (ICH) (37.1%vs 73.8%; p = 0.001). After IPTW adjustment, idarucizumab patients incurred lower mean total hospital costs ($30,413 ± $33,028 vs $44,477 ± $30,036; p < 0.001),and mean intensive care unit (ICU) cost ($25,114 ± $30,433 vs $43,484 ± $29,335; p < 0.001). Conclusions: Anticoagulant reversal therapy with idarucizumab was associated with significantly lower adjusted mean total hospital and ICU costs compared with andexanet alfa. However, a higher prevalence of ICH bleeds was noted in the andexanet alfa group. Trial Registration: Not applicable.

Health Care Costs of Target Attainment for Beta-Lactam Antibiotics in Critically Ill Patients: A Retrospective Analysis of the EXPAT Study.

Optimizing beta-lactam antibiotic treatment is a promising method to reduce the length of intensive care unit (ICU) stay and therefore reduce ICU costs. We used data from the EXPAT trial to determine whether beta-lactam antibiotic target attainment is a cost determinant in the ICU. Patients included in the EXPAT trial were divided into target attainment and target nonattainment based on serum antibiotic levels. All hospital costs were extracted from the hospital administration system and categorized. In total, 79 patients were included in the analysis. Target attainment showed a trend toward higher total ICU costs (€44,600 versus €28,200, P = 0.103). This trend disappeared when correcting for ICU length of stay (€2680 versus €2700). Renal replacement therapy was the most important cost driver. Target attainment for beta-lactam antibiotics shows a trend toward higher total costs in ICU patients, which can be attributed to the high costs of a long stay in the ICU and renal replacement therapy.

Abstract P403: Healthcare Resource Utilization and Costs Associated With Oral Anticoagulant Reversal With Idarucizumab or Andexanet Alfa for Patients Hospitalized With Life-Threatening Bleeding Events

Introduction: This study compared healthcare resource utilization and costs associated with the use of idarucizumab for the reversal of dabigatran, and andexanet alfa for the reversal of rivaroxaban/apixaban, in nonvalvular atrial fibrillation (NVAF) and venous thromboembolism (VTE) patients hospitalized with life-threatening bleeds. Methods: This retrospective observational study utilizing the Premier Hospital Database included NVAF and VTE patients aged ≥18 years with a major life-threatening bleed discharged between May 1, 2018 and June 30, 2019 who received idarucizumab or andexanet alfa. Key study outcomes included total hospital and Intensive Care Unit (ICU) length of stay (LOS) and costs, and percentage of patients with an ICU admission. The inverse probability of treatment weighting (IPTW) method was employed to adjust for potential differences in demographic, hospital, visit, and clinical characteristics between treatment cohorts. Results: Idarucizumab patients were older compared with andexanet alfa patients (median age 81 vs. 77 years; p&lt;0.001). Idarucizumab patients were less likely to experience an intracranial hemorrhage (ICH) (73.8% vs. 37.1%; p=0.001), but more likely to have a gastrointestinal bleed (56.3% vs. 24.6%, p&lt;0.001). Idarucizumab patients incurred lower IPTW-adjusted mean total hospital costs compared with andexanet alfa patients ($30,413 ± $33,028 vs. $44,477 ± $30,036; p&lt;0.001). The adjusted mean ICU cost among those with ICU admission was also significantly lower in idarucizumab patients ($25,114 ± $30,433 vs. $43,484 ± $29,335; p&lt;0.001). Notably, the adjusted percentage of ICU admissions, mean hospital and also ICU LOS did not differ appreciably between both cohorts (Table). Conclusions and Discussion: While LOS measures did not differ significantly between patient cohorts, reversal therapy with idarucizumab was associated with lower total hospital and ICU costs as compared with those treated with andexanet alfa.

Assessment of Costs of Avoidable Delays in Intensive Care Unit Discharge

Delays in transfer for discharge-ready patients from the intensive care unit (ICU) are increasingly described and contribute to strained capacity. To describe the epidemiological features and health care costs attributable to potentially avoidable delays in ICU discharge in a large integrated health care system. This population-based cohort study was performed in 17 adult ICUs in Alberta, Canada, from June 19, 2012, to December 31, 2016. Participants were patients 15 years or older admitted to a study ICU during the study period. Data were analyzed from October 19, 2018, to May 20, 2020. Avoidable time in the ICU, defined as the portion of total ICU patient-days accounted for by avoidable delay in ICU discharge (eg, waiting for a ward bed). The primary outcome was health care costs attributable to avoidable time in the ICU. Secondary outcomes were factors associated with avoidable time, in-hospital mortality, and measures of use of health care resources, including the number of hours in the ICU and the number of days of hospitalization. Multilevel mixed multivariable regression was used to assess associations between avoidable time and outcomes. In total, 28 904 patients (mean [SD] age, 58.3 [16.8] years; 18 030 male [62.4%]) were included. Of these, 19 964 patients (69.1%) had avoidable time during their ICU admission. The median avoidable time per patient was 7.2 (interquartile range, 2.4-27.7) hours. In multivariable analysis, male sex (odds ratio [OR], 0.92; 95% CI, 0.87-0.98), comorbid hemiplegia or paraplegia (OR 1.47; 95% CI, 1.23-1.75), liver disease (OR 1.20; 95% CI, 1.04-1.37), admission Acute Physiology and Chronic Health Evaluation II score (OR, 1.03; 95% CI, 1.02-1.03), surgical status (OR, 0.90; 95% CI, 0.82-0.98), medium community hospital type (OR, 0.12; 95% CI, 0.04-0.32), and admission year (OR, 1.16; 95% CI, 1.13-1.19) were associated with avoidable time. The cumulative avoidable time was 19 373.9 days, with estimated attributable costs of CAD$34 323 522. Avoidable time accounted for 12.8% of total ICU bed-days and 6.4% of total ICU costs. Patients with avoidable time before ICU discharge showed higher unadjusted in-hospital mortality (1115 [5.6%] vs 392 [4.4%]; P < .001); however, in multivariable analysis, avoidable time was associated with reduced in-hospital mortality (adjusted hazard ratio, 0.74; 95% CI, 0.64-0.85). Results were similar in sensitivity analyses. In this study, potentially avoidable discharge delay occurred for most patients admitted to ICUs across a large integrated health system and translated into substantial associated health care costs.

Reduced dose thrombolysis with ultrasound-facilitated catheter-directed administration for acute pulmonary embolism reduces length of stay.

The optimal dose and duration of tissue plasminogen activator (tPA) administered with ultrasound-facilitated catheter-directed thrombolysis (USCDT) to patients with acute PE remains to be determined. Our institution recently adopted a shorter duration (4h) of USCDT and lower dosing strategy (tPA 1mg/h) based on data from the OPTALYSE PE Trial. The purpose was to evaluate the implementation at our institution of shorter duration (4h) of USCDT and lower dosing strategy (tPA 1mg/h) as outlined by OPTALYSE PE Trial. This was a retrospective, single-center, observational study included patients from 01/01/2017 to 12/31/2018 in a large, academic medical center. Group 1 represented patients who underwent USCDT prior to 01/18/18. Group 2 represented patients who underwent USCDT after 01/18/18 and received 4h of USCDT and tPA 1mg/h/catheter. The primary outcome was intensive care unit (ICU) length of stay (LOS). Secondary outcomes were the proportion of patients experiencing a composite of major adverse events (death, recurrent PE, major bleeding, or stroke), change in right ventricle size/function and pulmonary artery pressures, need for mechanical respiratory or hemodynamic support, hospital LOS and drug cost. A total of 31 patients were included in the study: twenty patients in Group 1 and eleven patients in Group 2. Median ICU LOS was 3.5days in Group 1 and 1day in Group 2. Group 2 had reduced MACE, requirement for mechanical respiratory or hemodynamic support, hospital LOS, drug costs and adverse events. Implementation of a shorter duration of USCDT and lower dosing strategy for tPA in patients with acute PE may be one strategy to reduce the total ICU LOS and costs associated with care.

Pediatric Intensive Care Resource Utilization Following Hematopoietic Cell Transplantation in Children with Acute Leukemia

Pediatric Intensive Care Resource Utilization following Hematopoietic Cell Transplantation in Children with Acute Leukemia Baldes C1, Wetzel M3, McCraken C3, Saber W4, Arnold SD2. Introduction: Hematopoietic cell transplantation (HCT) is one of the mainstays of treatment of acute leukemia in children. While previous studies have calculated the overall healthcare resource utilization following this treatment, to date there is limited analysis regarding intensive care resource utilization specifically. The goal of this research is to investigate the costs associated with and potential patient drivers of intensive care resource utilization following hematopoietic cell transplantation in children with acute leukemia. Methods: Retrospective study of U.S. patients aged 1-20 years who received HCT for acute lymphoblastic leukemia (ALL) or acute myelogenous leukemia (AML) from 2004-2011 using data merged from the Pediatric Health Information System (PHIS) and the Center for International Blood and Marrow Transplant Research (CIBMTR). We investigated the primary outcome of total intensive care unit (ICU) cost and total ICU cost per day survived from initial HCT through 100-day post-transplant as well as through two-year follow-up using paired comparisons with Wilcoxon rank sums tests for differences in costs between groups. Results: We identified 202 patients with at least one ICU admission in the first 100 days and 292 in the two years following HCT. At day 100, ICU cost per day survived and total ICU cost were lower for secondary AML (P=0.019; P=0.022, respectively) when compared to AML but no significant difference was identified for ALL patients (P=0.186 ;P=0.064, respectively) compared to AML. Cytomegalovirus (CMV) seropositivity compared to seronegativity (P=0.027; P=0.027, respectively) had higher ICU cost per day survived and total ICU cost at day 100 and at 2-years post-HCT (P=0.026; P=0.045, respectively) (Table 1). At 2-years post-HCT, disease status also showed a statistically significant relationship between ICU cost per day survived and total ICU cost for intermediate disease status at transplant (p&amp;lt;0.001; P=0.018) and ICU cost per day survived for advanced disease (P=0.042) compared to early disease status. Females transplant recipients (P=0.042) and, when compared to matched unrelated donor, unrelated cord blood transplants (P=0.029) also had significantly higher ICU cost per day but not total ICU cost (Table 2). Conclusion: Among patients with at least one ICU visit, patients who are CMV negative generate less ICU costs and costs per day survived at both time intervals. While disease status, donor type, and gender become significant at two-years post HCT. This analysis may help identify patient specific risks that could be mitigated by surveillance or supportive care measures. Ultimately, further investigation of pre-transplant diagnosis, donor type, gender, and disease status at transplant is needed to better determine specific factors influencing these cost outcomes. 1. Department of Pediatrics, Emory University, Atlanta, Georgia. 2. Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia. 3. Pediatric Biostatistics Core, Emory University, Atlanta, Georgia. 4. CIBMTR (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI. Disclosures No relevant conflicts of interest to declare.

Cost Analysis on Intensive Care Unit Costs Based on the Length of Stay.

The present study aimed to determine the profit/loss ratio and the service costs in intensive care unit (ICU) based on the length of ICU stay. This retrospective study reviewed the medical records of 458 patients who were admitted to ICU between August 2016 and August 2017. Depending on the length of their ICU stay, the patients were divided into six groups: (I) 1 day, (II) 2 days, (III) 3 days, (IV) 4 days, (V) 5 days and (VI) more than 5 days. These charges were evaluated under six categories: surgery, laboratory tests, drugs, tools and equipment, radiographic workup and others. This study reviewed the medical records of patients including 273 (59.6%) men and 185 (40.4%) women. The mean age of the patients was 53.87±22.6 years. The profit/loss ratio was in favour of loss in group I (12,870.82 TL), group II (9,384.61 TL) and group III (371.18 TL). The ration was in favour of profit in group IV (16,505.4 TL). Total service costs comprised 38.51% drug costs, 24.45% tools/equipment, 13.14% laboratory tests, 10% other costs, 4.92% surgical costs and 3.1% radiographic tests. The cost analysis based on the service costs in ICU with regards to the length of ICU stay revealed that due to the greater use of diagnostic, surgical and medical tools and equipment and laboratory and radiographic tests, the profit/loss ratio was in favour of loss within the first three days in ICU. This ratio turned to profit beginning from day 4 in ICU due to the decrease in the use of these equipment and tests. Moreover, total ICU costs comprised 38.51% drug costs and 24.45% medical tools and equipment.

Evaluating intensive care unit medication charges in a teaching hospital in Jordan

ABSTRACTBackground: Intensive Care Unit (ICU) medication costs contribute to a large portion of the total ICU costs. Evaluating ICU drug expenditures is essential for optimal resource use especially in countries with limited resources. Considering the dearth of data regarding ICU medication expenses in the Middle East, we sought to evaluate ICU medication charges at a large academic hospital in Jordan.Methods: ICU drug charges were extracted from the hospital administration database at King Abdullah University Hospital for 2014–2015 fiscal years (FYs). ICU drug charges were compared to non-ICU drug charges that were incurred during the same patient admissions. ICU medications with the most significant charges were identified. The most frequent diagnoses with the highest ICU medication charges were described.Results: Average ICU medication charges per day were approximately twice that of non-ICU medication charges ($121.5 versus $55.7 in 2014 and $100.2 versus $52.2 in 2015; p < 0.001 in both FYs). Meropenem and human albumin were the most expensive ICU medications. Drug charge allocation was most expensive for sepsis, motor vehicle accidents and respiratory failure.Conclusion: Drug charges in the ICU are considerably higher than non-ICU drug charges, thus requiring more vigilant cost containment approaches. Further research is needed to evaluate the appropriateness of expensive ICU medications.

Electronic Health Record Tool to Promote Team Communication and Early Patient Mobility in the Intensive Care Unit.

Intensive care unit early mobility programs improve patients' outcomes while reducing costs for both patients and institutions. Inadequate interprofessional communication is a known barrier to achieving good early mobility program outcomes. Electronic health record communication tools promoting interprofessional communication have demonstrated improved patient outcomes, but have not been evaluated for mobility in the intensive care unit. To implement an early mobility collaboration program in an existing early mobility program, consisting of protocol education and an electronic health record tool designed to improve interprofessional communication and collaboration. In phase 1, staff members viewed an online educational module, the existing mobility protocol, and the "Mobility Levels" grading scale. In phase 2, an electronic health record communication tool displayed recently recorded mobility levels to all care providers. Staff knowledge of the early mobility program and perceptions of mobility-related communication were assessed by survey; patient outcomes including mobility goals, mechanical ventilation time, length of intensive care unit stay, and cost were assessed by records review. Statistically significant increases were found for staff satisfaction with mobility-related communication (P < .001) and communication frequency (P = .02), but not for staff knowledge (P = .28). Hours to achievement of mobility goal (P = .02) and length of intensive care unit stay (P = .02) decreased significantly. Average ventilation time decreased by 27 hours. Discharge recommendations at higher functional levels increased. Total intensive care unit cost decreased significantly (-39.5%; P = .04). Interprofessional communication and collaboration can lead to improved outcomes. Combining routine educational reviews and an electronic health record communication tool may improve patient and system outcomes for intensive care unit early mobility program patients.

Association between patient classification systems and nurse staffing costs in intensive care units: An exploratory study

ObjectivesNurse staffing costs represent approximately 60% of total intensive care unit costs. In order to analyse resource allocation in intensive care, we examined the association between nurse staffing costs and two patient classification systems: the nursing activities score (NAS) and nine equivalents of nursing manpower use score (NEMS). Research methodology/designA retrospective descriptive correlational analysis of nurse staffing costs and data of 6390 patients extracted from a data warehouse. SettingThree intensive care units in a university hospital and one in a regional hospital in Norway. Main outcome measuresNurse staffing costs, NAS and NEMS. ResultsFor merged data from all units, the NAS was more strongly correlated with monthly nurse staffing costs than was the NEMS. On separate analyses of each ICU, correlations were present for the NAS on basic costs and external overtime costs but were not significant. The annual mean nurse staffing cost for 1% of NAS was 20.9–23.1 euros in the units, which was comparable to 53.3–81.5 euros for 1 NEMS point. ConclusionA significant association was found between monthly costs, NAS, and NEMS. Cost of care should be based on individual patients’ nursing care needs. The NAS makes nurses’ workload visible and may be a helpful classification system in future planning and budgeting of intensive care resources.

The impact of reducing intensive care unit length of stay on hospital costs: evidence from a tertiary care hospital in Canada

To use theoretical modelling exercises to determine the effect of reduced intensive care unit (ICU) length of stay (LOS) on total hospital costs at a Canadian centre. We conducted a retrospective cost analysis from the perspective of one tertiary teaching hospital in Canada. Cost, demographic, clinical, and LOS data were retrieved through case-costing, patient registry, and hospital abstract systems of The Ottawa Hospital Data Warehouse for all new in-patient ward (30,483) and ICU (2,239) encounters between April 2012 and March 2013. Aggregate mean daily variable direct (VD) costs for ICU vs ward encounters were summarized by admission day number, LOS, and cost centre. The mean daily VD cost per ICU patient was $2,472 (CAD), accounting for 67.0% of total daily ICU costs per patient and $717 for patients admitted to the ward. Variable direct cost is greatest on the first day of ICU admission ($3,708), and then decreases by 39.8% to plateau by the fifth day of admission. Reducing LOS among patients with ICU stays ≥ four days could potentially result in an annual hospital cost saving of $852,146 which represents 0.3% of total in-patient hospital costs and 1.2% of ICU costs. Reducing ICU LOS has limited cost-saving potential given that ICU costs are greatest early in the course of admission, and this study does not support the notion of reducing ICU LOS as a sole cost-saving strategy.

Monitoring intensive care unit performance—impact of a novel individualised performance scorecard in critical care medicine: a mixed-methods study protocol

IntroductionPatients admitted to a critical care medicine (CCM) environment, including an intensive care unit (ICU), are susceptible to harm and significant resource utilisation. Therefore, a strategy to optimise provider performance...

Evaluating the Economic Impact of Palliative and End-of-Life Care Interventions on Intensive Care Unit Utilization and Costs from the Hospital and Healthcare System Perspective.

ICU length of stay (LOS) and associated costs of care are common and important outcome measures, but must be analyzed properly to yield valid conclusions. There is significant variation in costs by day of stay in the ICU with only modest differences between an ICU day at the end of a stay and the first day on the acute care floor; this variation must be appropriately accounted for analytically. Furthermore, reporting direct variable costs, in addition to total ICU costs, is needed to understand short-term and long-term impact of a reduction in LOS. Importantly, incentives for the hospital to realize savings vary depending on reimbursement policies. ICU utilization and costs are common outcomes in studies evaluating palliative care interventions. Accurate estimation and interpretation are key to understanding the economic implications of palliative care interventions.

COST OF INTENSIVE CARE IN INDIA.

The majority of patients in India access private sector providers for curative medical services. However, there is scanty information on the cost of treatment of critically ill patients in this setting. The study evaluates the cost and extent of financial subsidy required for patients admitted to an intensive care unit (ICU) in India. Data on direct medical, direct nonmedical, and indirect cost were prospectively collected from critically ill patients admitted to a tertiary teaching hospital in India. Willingness-to-pay (WTP) amount was obtained from the next-of-kin following admission and the actual cost paid by the family at discharge was recorded. The main diagnoses (n = 499) were infection (26 percent) and poisoning (21 percent). The mean APACHE-II score was 13.9 (95 percent confidence interval [CI], 13.3-14.5); 86 percent were ventilated. ICU stay was 7.8 days (95 percent CI, 7.3-8.3). Hospital mortality was 27.9 percent. Direct medical cost accounted for 77 percent (US$ 2164) of the total treatment cost (US$ 2818). Indirect cost and direct nonmedical cost contributed to 19 percent (US$ 547.5) and 4 percent (US$ 106.5), respectively. Average total and daily ICU cost were US$ 1,897 and US$ 255, respectively. Although the family's WTP was 53 percent (US$ 1146; 95 percent CI, 1090-1204) of direct medical cost, their final contribution was 67.7 percent (US$ 1465; 95 percent CI, 1327-1604). The cost of an ICU admission in our setting is US$ 2818. Although the family's contribution to expenses exceeded their initial WTP, a substantial subsidy (33 percent) is still required. Alternate financing strategies for the poor and optimization of ICU resources are urgently required.

Dexmedetomidine versus standard care sedation with propofol or midazolam in intensive care: an economic evaluation.

IntroductionDexmedetomidine was shown in two European randomized double-blind double-dummy trials (PRODEX and MIDEX) to be non-inferior to propofol and midazolam in maintaining target sedation levels in mechanically ventilated intensive care unit (ICU) patients. Additionally, dexmedetomidine shortened the time to extubation versus both standard sedatives, suggesting that it may reduce ICU resource needs and thus lower ICU costs. Considering resource utilization data from these two trials, we performed a secondary, cost-minimization analysis assessing the economics of dexmedetomidine versus standard care sedation.MethodsThe total ICU costs associated with each study sedative were calculated on the basis of total study sedative consumption and the number of days patients remained intubated, required non-invasive ventilation, or required ICU care without mechanical ventilation. The daily unit costs for these three consecutive ICU periods were set to decline toward discharge, reflecting the observed reduction in mean daily Therapeutic Intervention Scoring System (TISS) points between the periods. A number of additional sensitivity analyses were performed, including one in which the total ICU costs were based on the cumulative sum of daily TISS points over the ICU period, and two further scenarios, with declining direct variable daily costs only.ResultsBased on pooled data from both trials, sedation with dexmedetomidine resulted in lower total ICU costs than using the standard sedatives, with a difference of €2,656 in the median (interquartile range) total ICU costs—€11,864 (€7,070 to €23,457) versus €14,520 (€7,871 to €26,254)—and €1,649 in the mean total ICU costs. The median (mean) total ICU costs with dexmedetomidine compared with those of propofol or midazolam were €1,292 (€747) and €3,573 (€2,536) lower, respectively. The result was robust, indicating lower costs with dexmedetomidine in all sensitivity analyses, including those in which only direct variable ICU costs were considered. The likelihood of dexmedetomidine resulting in lower total ICU costs compared with pooled standard care was 91.0% (72.4% versus propofol and 98.0% versus midazolam).ConclusionsFrom an economic point of view, dexmedetomidine appears to be a preferable option compared with standard sedatives for providing light to moderate ICU sedation exceeding 24 hours. The savings potential results primarily from shorter time to extubation.Trial registrationClinicalTrials.gov NCT00479661 (PRODEX), NCT00481312 (MIDEX).Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-015-0787-y) contains supplementary material, which is available to authorized users.

Cost savings of universal decolonization to prevent intensive care unit infection: implications of the REDUCE MRSA trial.

To estimate and compare the impact on healthcare costs of 3 alternative strategies for reducing bloodstream infections in the intensive care unit (ICU): methicillin-resistant Staphylococcus aureus (MRSA) nares screening and isolation, targeted decolonization (ie, screening, isolation, and decolonization of MRSA carriers or infections), and universal decolonization (ie, no screening and decolonization of all ICU patients). Cost analysis using decision modeling. We developed a decision-analysis model to estimate the health care costs of targeted decolonization and universal decolonization strategies compared with a strategy of MRSA nares screening and isolation. Effectiveness estimates were derived from a recent randomized trial of the 3 strategies, and cost estimates were derived from the literature. In the base case, universal decolonization was the dominant strategy and was estimated to have both lower intervention costs and lower total ICU costs than either screening and isolation or targeted decolonization. Compared with screening and isolation, universal decolonization was estimated to save $171,000 and prevent 9 additional bloodstream infections for every 1,000 ICU admissions. The dominance of universal decolonization persisted under a wide range of cost and effectiveness assumptions. A strategy of universal decolonization for patients admitted to the ICU would both reduce bloodstream infections and likely reduce healthcare costs compared with strategies of MRSA nares screening and isolation or screening and isolation coupled with targeted decolonization.

Cost effectiveness of a benzodiazepine vs a nonbenzodiazepine-based sedation regimen for mechanically ventilated, critically ill adults

PurposeNonbenzodiazepine sedation (eg, dexmedetomidine or propofol) may be more cost effective than benzodiazepine (BZ) sedation despite its higher acquisition cost. Materials and methodsA cost effectiveness (CE) analysis of noncardiac surgery, critically ill adults requiring at least 1 day of mechanical ventilation (MV) and administered either BZ or non-BZ sedation, that cycled health states and costs daily using a Markov model accounting for daily MV use until intensive care unit (ICU) discharge, was conducted from a third-party perspective. Transition probabilities were obtained from a published meta-analysis, and costs were estimated from best evidence. Sensitivity analyses were run for all extubation and discharge probabilities, for different cost estimates and for the specific non-BZ administered. ResultsWhen non-BZ rather than BZ sedation was used, the incremental cost-effectiveness ratio to avert 1 ICU day while MV or while either MV or non-MV was $3406 and $3136, respectively. The base-case analysis revealed that non-BZ sedation (vs BZ sedation) resulted in higher drug costs ($1327 vs $65) but lower total ICU costs (percent accounted for MV need): $35380 (71.0%) vs $45394 (70.6%). Sensitivity analysis revealed that BZ sedation would only be less costly if the daily rate of extubation was at least 16%, and the daily rate of ICU discharge without MV was at least 77%. The incremental CE ratio to avert 1 ICU day while MV or non-MV was similar between the dexmedetomidine and propofol non-BZ options. ConclusionsAmong MV adults, non-BZ sedation has a more favorable CE ratio than BZ sedation over most cost estimates.