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. |
