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Cost-Effective Management of Patients in the Intensive Care Unit

C.O. Brantigan, M.D.

The intensive care unit should be viewed as a technologic treatment modality, and as such is a very expensive one. Cost per adult survivor may average as high as $80 000.1 While it is clear that the intensive care unit as currently used is inefficient and often used inappropriately and by ritual, it is also clear that critical care, applied to appropriate patients, is cost-effective and that the dehumanizing nature of the experience can be minimized. The goal of this chapter is to provide an ethical yet practical definition of cost effectiveness and then demonstrate how cost effectiveness can be achieved by proper patient selection and by adopting an appropriate philosophical approach to patient management.

The question of whether critical care is ever "cost-effective" is a complex one whose answer depends on definition and then on the patient population selected to receive this technology. Cost effectiveness can be measured in terms of resource payback, quality of life, or on a cost per survivor basis. In terms of optimum use of society's resources, intensive care is practically never cost-effective because only young trauma victims or some heart surgery patients can ever hope to make a contribution to society which approaches the cost of the resources consumed in their care. Patients who are elderly or retired will never repay the resources consumed. Neonates could be more cheaply be replaced by healthier neonates. Third party cost cutting systems, such as the DRG system often include financial pressures against high cost care. This is rationing, and must be identified for the public as such. Increased efficiency so that all legitimate patient needs are met is more difficult than rationing but equally effective financially.

To the extent that our intensive care units are populated with the dying and vegetating, they are not cost-effective when measured by an ethical or quality of life standard. The Intensive Care Unit is a hostile environment. Humans should not be confined there unless there is some expectation of benefit as measured by the patient's value system. Applying this standard would produce substantial cost savings.

Cost effectiveness measured by objective standards is even more difficult to define. We should be able to define a factor such as cost-per-functional-survivor which serves as a measure of cost effectiveness. Thus patients with a uniformly fatal disease would have an infinite cost per survivor and as technologic developments made the disease treatable, the cost would come down. Patients who are not receiving benefit from intensive care could then be objectively excluded because the cost of good care would be less. Even if we accept the concept, definition of the factor is difficult. ICU patients in the 1980's have a complex set of physiologic derangements making selection of a representative study group impossible. When simple groups have been defined, as in heart attack patients with arrythmias, postoperative heart patients, or young trauma patients critical care has been shown cost effective. Most ICU patients have much more complicated physiologic patterns. Perhaps multivariate analysis could be applied to cost per survivor statistics on complex patients.

The evolution of the care of neonates illustrates the problems associated with the attempt to measure cost effectiveness. Unlike their adult counterparts, neonates begin as a relatively homogeneous group. In 1917 LaFetra reported the fate of 200 consecutive premature infants of various birth weights admitted to the hospital.2 Ninety died in the first 24 hours, 118 in the first 72 hours, and only 30 ultimately survived (15%). Early deaths were related to dehydration and hypothermia, and late deaths to infection. In contrast to these figures, we now expect most 1000g infants to survive. In 1914 Allegheny General Hospital became the first hospital to have air conditioning. The Carrier Corporation built a glassed in room to house 4 four pound infants. Temperature control, ventilation, air cleaning and high humidity were provided by the unit. The cost was astronomical for the time - $1221 (for the whole unit, not for each patient). The engineer who designed the system wrote "I trust you will not have heart failure when you find enclosed herewith a copy of proposal, estimate, etc on the above."3 While there was concern about cost effectiveness of this new technology, prematures no longer had to die of the environmental factors which dispatched so many of these patients. Antibiotics have now, of course, eliminated the organisms responsible for most of the late deaths in LaFetra's series.

Technology has evolved since that time, and now we have respirators, monitors, open heart surgery and dialysis. By 1968 our goal was not just to keep premature infants alive, but to make 1000g infants survive. This was accomplished at great cost-$40 000 or so per survivor by 1978,4 and many of these children were developmentally compromised. In 1984 most of these infants survive at a cost of $33,000 per survivor, and the profession is concentrating on the 600g infant with a cost per survivor of $171,000. Cost of long term care can be used as an index to quality of the survivor- it is only $8,000 in the 950g infant, but $192,000 in the 650g infant. While a cost of $363,000 to make a 650g infant survive until adulthood is a lot of money, it still calculates as cost effective by our definition because ten years ago none survived, making the cost per survivor infinite. It is estimated that among survivors in the less than 1000g group 59% are developmentally normal, 12% minimally handicapped, 10% moderately handicapped, and 16% severely handicapped.5 We tend to lose sight of the victories and concentrate on the enormous cost. We forget that the infants that used to die of hypothermia and dehydration have gone home. We forget that the patients who used to die of common bacterial pathogens have gone home. We focus on the compromised premature infants dying of an unusual infection (the devils worse than the ones already cast out) and ask if it is worth it.

Is critical care cost effective? Measured on a cost per survivor basis in the premature intensive care unit it is. We, as physicians apply proven technology to smaller and smaller infants. Who is to pay the $362 000 required to raise a 650 g infant? Who is to pay for renal dialysis or for renal transplants, both modalities which have been proven by the same criteria. We are now able to address many physiologic abnormalities in a specific way. As the number of abnormalities increases and the number of standard, non-experimental individually cost-effective modalities employed increases, the cost increases exponentially. Cost effective critical care may still be extraordinarily expensive.

We as individual physicians cannot ethically make the decision to deny available technology to individual patients who are our responsibility any more than we can decide that the funds expended on one artificial heart patient should be spent on unwed expectant mothers. We do have the responsibility to see that cost cutting is accomplished by making cost-effective decisions. Nowhere is this more important that in the intensive care unit, where many patients reside without good medical reason. Unless the physician has a clear idea of what is to be accomplished in the unit and a clear idea of how it can be accomplished there rather than on the ward, the patient doesn't belong there. Criteria for admission include: Physiology which is unstable or which may become unstable and/or condition requiring technologic intensive care nursing in a patient with a reasonable life expectancy. Patients who do not belong there include patients admitted to rule out myocardial infarction whose chance of having had one are low, patients who are terminal or have hopeless diseases, patients who remain there because of physician interpersonal relations.

The group of patients who will do just as well without intensive care unit is relatively large, as has been shown in studies of ICU bed shortages.6 The patients suspected of having had a myocardial infarction is the prototype of a larger group of patients whose diagnosis can not be made with certainty, and who might potentially develop findings requiring intensive care. Some need monitoring in an ICU; some do not. All possible modalities, even expensive ones, should be used to make the diagnosis. The decision to admit or not to admit the patient should then be based on a responsible physician's assessment of the probabilities. Errors will be made, but if the location of admission (ICU, monitored bed, ward, 24 hour holding area, etc.) is appropriate to the patient, the risk to the patient of an incorrect assessment is minimal.7 Such an approach places additional responsibility on the physician, as it requires active decision making rather than a cookbook approach ("all rule out MI's go to the unit").

Patients who are terminally ill do not belong in the unit. Decisions need to be made on an individual basis within this group, and the patient's social situation must be considered. Some patients with terminal cancer, for example, might be sustained thru an acute illness so that they have a few more months of quality life. For some patients and families these few months are of inestimable value. For some patients and families a few days may be just as important. Cost cutting zeal must be tempered with compassion. However, as soon as it is clear that the prognosis is hopeless, the patient should be moved elsewhere in the hospital. Care is more appropriate in a less intense (and less expensive) setting, and family visiting privileges are generally more liberal.

Interpersonal relationships among doctors account for inappropriate admissions or inappropriate retention of patients in the ICU. There is an increasing tendency for such patients to be managed by a committee without a chairman. This tendency is fostered by medical and nonmedical considerations. In a tertiary care hospital many specialists bring to bear an exceptional expertise needed in complex patients. However, there is a growing tendency for every patient who has a respirator to have a respiratory doctor, for every patient who has a heart problem to have a cardiologist, and every patient with diabetes to have an endocrinologist. In fact, every physician practicing in the intensive care unit should have the knowledge to manage respirators, heart problems, and diabetes in their usual manifestations or they shouldn't be practicing there. There is a tendency of physicians uncomfortable in the critical care setting, who for economic and social reasons do not want to give up control of their patients, to manage them by calling in a phalanx of one organ specialists. This approach is encouraged in residency training, where consultations are ordered like lab tests. In the private world, consultations beget other consultations from the consulted physician. Referring internists may remain on the case during the postoperative trip to the intensive care unit for pecuniary as well as medical reasons. The decision to transfer awaits the chairmanless committee.

The final non-medical factor increasing the use of the intensive care unit is the tendency of physicians to become emotionally involved to the point that to deem a patient unsalvageable is a threat to their self-images. Physicians, patients, families and lawyers must understand that a decision not to give pressors, not to insert a balloon pump or not to use a respirator is not necessarily a decision not to treat. It is rather a decision that, all things considered, the best treatment for the patient as a whole human being does not include these modalities. The family who "wants everything possible done" to save Aunt Tillie, may be feeling guilt or be feeling that loss of Aunt Tillie is a threat to the family's image. The physician with good rapport and bedside manner should be able to explain that addition of a respirator will prolong her suffering rather than her life, if indeed this is the case.

Once a patient is admitted to the unit the physician should switch to a problem solving mode. Each patient should become a study in physiology. There must be one physician in charge. This physician coordinates the care given by whatever specialists might be required, and sees that the treatments ordered by the cardiologists, for example, don't conflict with the treatments required by the vascular surgeon. The patient's course should be planned and a time line established. Certainly complications and setbacks will occur, but the physician in charge must have firmly in his mind the criteria for discharge and a plan for how he will achieve these criteria.

Since the intensive care unit has been re-defined as a physiology laboratory, all tests should be ordered only to answer a question pertinent to the patient's care. The unusual diagnosis is made by a thinking physician with insight, not by a battery of screening tests. If the test ordered will not lead to a decision it should not be ordered. The highest yielding test should be employed from the beginning without the hedge of supplementary examinations.8 Tests should be ordered based on cost effectiveness rather than simple cost. If a CAT scan or pulmonary arteriogram is the best way to provide data required to treat the patient, blood gases, lung scans, chest x-rays, and nuclear venograms should not be ordered first because they are less expensive or less invasive. Nutritional support should be used early and aggressively for its long term beneficial effects, and invasive monitoring should be used aggressively, as precise definition of physiology is critical if precise physiologic decisions are to be made. Fortunately if we define the critical care patient as an experiment in physiology and define treatment accordingly, we will be cost effective, as defined above, and also will be practicing quality medicine.

Routine tests and treatments ordered "by the book" have a devastating effect on the hospital bill. Many post-operative patients receive a blood count, electrolytes and blood gasses upon arrival in the Intensive Care Unit. The cost is $150.15. Most general surgery patients need only part of this battery, perhaps only a hematocrit. Lab tests specified in our parenteral nutrition protocol cost 322.55 in the first week. Many of these tests are ordered by protocol, leading to duplication of chemistries ordered for other indications. Patients with chest tubes do not need daily routine chest x-rays. A daily portable chest x-ray costs $65.55 (not including interpretation) whereas a PA film in the department costs $39. Physical examination is free. Respirator changes generally trigger another set of blood gases, which cost $67.45 (Some of this cost is accounted for by a fee paid a physician to overread the computers interpretation of the results. Blood gasses should be ordered only when you need to know the pH or pCO2. If the patient is adequately ventilated and a change is made in the FIO2 an arterial saturation is sufficient monitoring and costs only $16.65. Respiratory therapy can be an important modality, but when ordered as a routine without a defined stopping point, the costs mount. Incentive spirometry administered by a therapist costs $14.60 per session or $87.60 if ordered every four hours and may not even be effective. That is more than Medicare pays the physician. Tests and therapies should be ordered with a specific goal in mind.

The above philosophy can be applied to each modality used in the Intensive Care Unit. For illustrative purposes only invasive monitoring, nutritional support and respirators will be considered here.

Invasive monitoring using the Swan Ganz catheter allows definition of the patients cardiovascular and oxygen transport physiology. Patients can be classified into subsets according to their physiology. Decisions can then be made and treatments administered and assessed based on the measurements. It is well known that these classifications can not be made accurately in any other way, and hence controlled studies of the effect of use of monitoring will never be done. Remember that monitoring is not treatment, any more than measuring serum sodium is treatment. Having a Swan Ganz catheter in place is not somehow protective. The user of this modality must be expert, as it is associated with a definite complication rate. More importantly erroneous data can lead to the wrong decision. Digital displays can be a particular source of error.9 The physician using this modality must be expert in inserting the catheter, and expert in error trapping and interpretation. He must not follow a cookbook approach to the data. If the data is not internally consistent or is in conflict with other data available on the same patient it must be rejected. Swan data can be rejected as erroneous just as easily as a low hematocrit can be dismissed as a lab error.

Assuming that the practice of medicine in the intensive care unit should be scientific, and that scientific principles are applied as noted above, many studies have documented the effectiveness of invasive monitoring. DelGuercio in 1980 examined 148 elderly candidates for elective surgery who had been medically "cleared". Sixty-three percent had a significant physiologic defect which could be corrected preoperatively. Twenty three patients had incorrigible defects. Of the patients in this category operated, all died. Li et al studied the effect of the advent of a critical care specialist in an ICU.10 There was a 20% increase in the use of invasive monitoring with an increased survival rate, an increased one year survival rate, a decrease in length of stay and a decrease in the readmission rate. Such statistics indicate that cost effective treatment requires immediate use of expensive modalities when they provide definitive information needed for patient management.

Cost effective mechanics of the Swan Ganz Catheter will vary from institution. In our institution many physicians routinely use fluoroscopy to insert the catheter. This in an unnecessary use of resources in most cases. Our studies have shown that residents with supervision can insert 90% of these catheters in 15 minutes using wave forms for position control. In our institution, however, cost for fluoroscopy is $65 per hour, and this roughly the same as the cost for a portable chest x ray. (This is probably a cost warp as demand for this service in our hospital often exceeds supply.) Most physicians obtain a chest x ray after insertion for a "permanent record," and this in unnecessary if fluoroscopy has been used. Other physicians often use the fluoro in the cardiac cath lab to insert the catheter, and this adds the cost of a cath lab procedure ($902.53). Two trays are available for use in our hospital, a "Subclavian tray," and a "Swan tray." The "Subclavian tray is generally sufficient. The Swan tray includes enough instruments to perform an appendectomy and costs $230 more. Most physicians now agree that percutaneous insertion of the catheter using the Seldinger technique is fastest and safest. The route chosen must be individualized, however. If a physician is uncomfortable with the percutaneous approaches, a cut down may be the safest and fastest approach for his patient. Each physician should be aware of the cost consequences of variations in his technique. Monitoring lines should be removed when no longer required.

Parenteral nutrition accounts for enormous costs. Often there is little perceived benefit in spite of the large decrease in survival rate of malnourished patients. Aside from recent emphasis on the needle jejunostomy and associated use of elemental diets, little information is available concerning the cost effective use of the large numbers of specialized mixtures available. These formulations vary drastically in price. (Table 1) Some basic principles emerge, however.

Enteral nutrition is better than parenteral nutrition. It is more physiologic, less associated with metabolic complications, and less expensive. Patients not expected to be able to eat for days after laparotomy should have a needle jejunostomy inserted at the time of surgery unless there is a contraindication. If nutrition becomes a problem postoperatively, nutrition can be provided at a cost of $10 per 1000 cal. Nasoenteric tubes can be used, of course, but they are associated with dislodgment and aspiration. Parenteral nutrition can be used, but costs $70 dollars per 1000 calories excluding the bill for lab work.

More specialized mixtures have their place, but it is a limited role that they should appropriately play. Renal failure mixtures (e.g. Nephramine) are of value in supporting patients and keeping them off of dialysis. Once the decision has been made to implement dialysis, however, a more standard mixture should be given, and dialysis used to control the metabolic consequences. Renal failure, per se is not an indication for use of the more expensive renal failure formulas. A similar argument applies to hepatic failure formulations such as Hepatamine. Hepatic encephalopathy is an indication for such a mix, whereas jaundice per se is not (jaundice in a patient on parenteral nutrition is more commonly a manifestation of excess glucose calories rather than liver failure. There may be no clear role for the stress formulations, which are also quite expensive. Specialized nutrients should be selected only with clear indication.

Nutrients and amounts should be selected rationally. In our hospital some physicians push intravenous nutrition to tolerance, administering up to 6000 calories per day ($420) to all sick patients. Other physicians give each patient a bolus of intravenous fat each day ($80) to boost the calories, not understanding that there is a hierarchy of substrate use and if the body is provided with sufficient glucose calories it will simply store the additional lipid given. Indirect calorimetry is currently the best way of determining amounts and proportions of nutrients. It is required in some intensive care patients. The Wilmore normogram is sufficient for all but the complicated patients. Nitrogen balance studies should follow as soon as the patient is on a stable regimen to be sure the regimen is appropriate. In some patients administration of inappropriate intravenous nutrition will increase stay in the intensive care unit (Figure 1). High carbohydrate mixtures, especially given in excess, cause the body to synthesize fat which produces a high respiratory quotient. This produces large amounts of CO2 and leads to a higher minute ventilation.11 In a marginal patient this may lead to prolonged respirator dependency and an astronomical hospital bill. The respirator rents for $286 per day (excluding lab and physician charges). These patients should have their needs determined by indirect calorimetry and a large proportion of these needs should be met using lipid as the calorie source. In this way nutrition can be optimized and CO2 production minimized. Stressed septic patients seem to have peculiar needs as well, in particular, an obligate need for IV fat.12

Respirator rituals account for many unnecessary costs. Blood gasses are obtained on a routine basis or after each respirator setting change. We often ignore the simple expedient of asking the conscious patient how he is breathing. X Rays are obtained for "tube placement" forgetting that many tubes have distance markings which can be used to be sure the tube is not inserted too far. When patients on ventilators are in obvious distress we reflexly order blood gasses. It is more appropriate and more cost effective to identify and treat the problem and then order blood gasses to confirm the effectiveness of our therapy. Respirators are becoming more and more sophisticated. Remember that most patients who are ventilated do not need this degree of sophistication. Using SIMV to wean such a patient only prolongs the time on the machine and increases monitoring costs. IMV, SIMV, CPAP, PEEP, and other components of the respirator alphabet soup have their place. Each modality should be used when there is a specific need, but not by routine. Immense amounts of money can be saved by using respirators and respiratory care only while in a problem solving mode.

Cost effectiveness as I have defined it means minimizing the cost per normal survivor of patients confined in the ICU. In this context, a non-survivor increases the cost. The ICU should be a laboratory of human physiology. The physician in charge of patient care must always be in the problem solving mode. Tests and therapies will be cost effective only if used to solve defined problems. Patients who are not studies in physiology don't belong in the ICU.

Dr Brantigan wrote this article in 1985. The references are incomplete and the cost data is dated, but the philosophy expressed is valid to this day

Bibliography

1. Civetta

2. LaFetra, L.E., The hospital care of premature infants. Arch Ped 1917, (34) 21-31.

3. Copy of invoice and correspondence provided by George Wratney of Carrier Corporation.

4. Pomerance Pediatrics 1978 (61) 908.

5. Walker, D.J.B., Feldman, A., Vohr, B.R., Oh, W., Cost-benefit analysis of neonatal intensive care for infants weighing less than 1000 grams at birth. Pediatrics 1984 (74) 20-25

6. Singer, D.E., Carr, P.L., Mulley, A.G., Thibault, G.E. rationing intensive care. Physician responses to a resource shortage. New Engl J Med 1983 (309) 1155-1160.

7. Fineberg, H.V., Scadden, D., Goldman, L., Care of patients with a low probability of acute myocardial infarction, New Engl J Med 198? (310) 1301-6.

8. Palmer, P.E.S., Cockshott, W.P., The appropriate use of diagnostic imaging. JAMA 1984 (252) 2753-4.

9. Schmitt, E., Brantigan, C.O.

10. Li, T.C., Phillips, M.C., Shaw, L., Cook, E.F., Nathanson, C., Goldman, L., On-site physician staffing in a community hospital intensive care unit. JAMA 1984 (252) 2023-7.

11. increased co2 from glucose

12. obligate need for fat.


2003-2004 Dr. Charles Brantigan,  Vascular Surgery Practice
2253 Downing Street, Denver, CO 80205
303.830.8822 fax: 303.830.7068 or 800.992.4676  inquiries@drbrantigan.com

Last Updated: 07/15/2004