International Programme for Resource Use in Critical Care (IPOC)--a methodology and initial results of cost and provision in four European countries

Mechanical ventilation as a major driver of COVID-19 hospitalization costs: a costing study in a German setting

BACKGROUND

While COVID-19 hospitalization costs are essential for policymakers to make informed health care resource decisions, little is known about these costs in western Europe. The aim of the current study is to analyze these costs for a German setting, track the development of these costs over time and analyze the daily costs.

METHODS

Administrative costing data was analyzed for 598 non-Intensive Care Unit (ICU) patients and 510 ICU patients diagnosed with COVID-19 at the Frankfurt University hospital. Descriptive statistics of total per patient hospitalization costs were obtained and assessed over time. Propensity scores were estimated for length of stay (LOS) at the general ward and mechanical ventilation (MV) duration, using covariate balancing propensity score for continuous treatment. Costs for each additional day in the general ward and each additional day in the ICU with and without MV were estimated by regressing the total hospitalization costs on the LOS and the presence or absence of several treatments using generalized linear models, while controlling for patient characteristics, comorbidities, and complications.

RESULTS

Median total per patient hospitalization costs were €3,010 (Q1 - Q3: €2,224-€5,273), €5,887 (Q1 - Q3: €3,054-€10,879) and €21,536 (Q1 - Q3: €7,504-€43,480), respectively, for non-ICU patients, non-MV and MV ICU patients. Total per patient hospitalization costs for non-ICU patients showed a slight increase over time, while total per patient hospitalization costs for ICU patients decreased over time. Each additional day in the general ward for non-ICU COVID-19 patients costed €463.66 (SE: 15.89). Costs for each additional day in the general ward and ICU without and with mechanical ventilation for ICU patients were estimated at €414.20 (SE: 22.17), €927.45 (SE: 45.52) and €2,224.84 (SE: 70.24).

CONCLUSIONS

This is, to our knowledge, the first study examining the costs of COVID-19 hospitalizations in Germany. Estimated costs were overall in agreement with costs found in literature for non-COVID-19 patients, except for higher estimated costs for mechanical ventilation. These estimated costs can potentially improve the precision of COVID-19 cost effectiveness studies in Germany and will thereby allow health care policymakers to provide better informed health care resource decisions in the future.

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

BACKGROUND

Given 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.

METHODS

This 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.

RESULTS

The 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.

CONCLUSIONS

This 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.

Resource availability, utilisation and cost in the provision of critical care in Tanzania: a protocol for a systematic review

INTRODUCTION

Critical care is essential in saving lives of those that are critically ill, however, provision of critical care can be costly and heterogeneous across lower-resource settings. This paper describes the protocol for a systematic review of the literature that aims to identify the reported costs and resources available for the provision of critical care and the forms of critical care provision in Tanzania.

METHODS AND ANALYSIS

The review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Three databases (MEDLINE, Embase and Global Health) will be searched to identify articles that report the forms of critical care, resources used in the provision of critical care in Tanzania, their availability and the associated costs. The search strategy will be developed from four key concepts; critical care provision, critical illness, resource use, Tanzania. The articles that fulfil the inclusion and exclusion criteria will be assessed for quality using the Reference Case for Estimating the Costs of Global Health Services and Interventions checklist. The extracted data will be summarised using descriptive statistics including frequencies, mean and median of the quantity and costs of resources used in the components of critical care services, depending on the data availability. This study will be carried out between February and November 2021.

ETHICS AND DISSEMINATION

This study is a review of secondary data and ethical clearance was sought from and granted by the Tanzanian National Institute of Medical Research (reference: NIMR/HQ/R.8a/Vol. IX/3537) and London School of Hygiene and Tropical Medicine (ethics ref: 22866). We will publish the review in a peer-reviewed journal as an open access article in addition to presenting the findings at conferences and public scientific gatherings.

PROSPERO REGISTRATION NUMBER

The protocol was registered with PROSPERO; registration number: CRD42020221923.

Factors affecting adult intensive care units costs by using the bottom-up and top-down costing methodology in OECD countries: A systematic review

OBJECTIVES

To review the studies, which calculated the total intensive care unit costs and indicated the main cost drivers in the intensive care by using either top-down, bottom-up approach or the combination of them.

RESEARCH METHODOLOGY/DESIGNS

A systematic review of papers published until October 2020 was conducted. Search was performed on PubMed, Medline, Scopus and Science Direct databases.

SETTING

This review i examined costs in adult intensive care units, in countries belonging to the Organisation for Economic Co-operation and Development (OECD) (medical, surgical or general adult , paediatric and neonatal were not included).

MAIN OUTCOME MEASURES

Eighteen articles were included in the review.

RESULTS

Eight of the studies used the top-down costing methodology, six of them used the bottom-up approach and four of them used both of them. The mean total patient cost per day ranged from €200.75 to €4321.91 (all costs are presented in 2020 values for euro). Human resources were identified as the largest proportion of total costs. Length of stay, mechanical ventilation, continuous haemodialysis and severe illness are the main cost drivers of intensive care unit total costs.

CONCLUSION

There are a variety of methods and study designs used to calculate costs of an intensive care unit stay.t It is necessary to evolve standardised costing methods in order to make comparisons and succeed in cost-effective management.

National registries: Lessons learnt from quality improvement initiatives in intensive care

National clinical quality registries (CQRs) are effective tools for improving the outcomes of patients admitted to the intensive care unit (ICU), and are increasingly important as healthcare needs evolve. A high-quality ICU CQR is built from a foundation of common requirements and challenges. First, performance indicators of the structure, process, or outcomes of patient care should measure what is important. Second, high data quality is essential and can be collected and curated through standardized processes. Third, standardized mortality ratio (SMR) is a cornerstone for benchmarking ICU performance, but application requires a comprehensive understanding of its context and potential pitfalls. Fourth, data collection alone is insufficient. Quality improvement comes from closing the feedback loop by identifying and managing unwarranted practice variation. Fifth, the process of improving healthcare is fundamentally a human enterprise, subject to behavioural change, including those that modify performance. Sixth, ICU CQRs must be dynamic to meet the needs of an evolving healthcare system and stakeholders. Finally, these lessons are far from comprehensive. Sharing perspectives on the development of ICU CQRs can help maximise their value as a powerful platform for informing policy development and improving the outcomes of patients admitted to the ICU.

Impact of mechanical ventilation on the daily costs of ICU care: a systematic review and meta regression

The impact of mechanical ventilation on the daily costs of intensive care unit (ICU) care is largely unknown. We thus conducted a systematic search for studies measuring the daily costs of ICU stays for general populations of adults (age ≥18 years) and the added costs of mechanical ventilation. The relative increase in the daily costs was estimated using random effects meta regression. The results of the analyses were applied to a recent study calculating the excess length-of-stay associated with ICU-acquired (ventilator-associated) pneumonia, a major complication of mechanical ventilation. The search identified five eligible studies including a total of 54 766 patients and ~238 037 patient days in the ICU. Overall, mechanical ventilation was associated with a 25.8% (95% CI 4.7%–51.2%) increase in the daily costs of ICU care. A combination of these estimates with standardised unit costs results in approximate daily costs of a single ventilated ICU day of €1654 and €1580 in France and Germany, respectively. Mechanical ventilation is a major driver of ICU costs and should be taken into account when measuring the financial burden of adverse events in ICU settings.

A Deep Learning Approach for Managing Medical Consumable Materials in Intensive Care Units via Convolutional Neural Networks: Technical Proof-of-Concept Study

BACKGROUND

High numbers of consumable medical materials (eg, sterile needles and swabs) are used during the daily routine of intensive care units (ICUs) worldwide. Although medical consumables largely contribute to total ICU hospital expenditure, many hospitals do not track the individual use of materials. Current tracking solutions meeting the specific requirements of the medical environment, like barcodes or radio frequency identification, require specialized material preparation and high infrastructure investment. This impedes the accurate prediction of consumption, leads to high storage maintenance costs caused by large inventories, and hinders scientific work due to inaccurate documentation. Thus, new cost-effective and contactless methods for object detection are urgently needed.

OBJECTIVE

The goal of this work was to develop and evaluate a contactless visual recognition system for tracking medical consumable materials in ICUs using a deep learning approach on a distributed client-server architecture.

METHODS

We developed Consumabot, a novel client-server optical recognition system for medical consumables, based on the convolutional neural network model MobileNet implemented in Tensorflow. The software was designed to run on single-board computer platforms as a detection unit. The system was trained to recognize 20 different materials in the ICU, while 100 sample images of each consumable material were provided. We assessed the top-1 recognition rates in the context of different real-world ICU settings: materials presented to the system without visual obstruction, 50% covered materials, and scenarios of multiple items. We further performed an analysis of variance with repeated measures to quantify the effect of adverse real-world circumstances.

RESULTS

Consumabot reached a >99% reliability of recognition after about 60 steps of training and 150 steps of validation. A desirable low cross entropy of <0.03 was reached for the training set after about 100 iteration steps and after 170 steps for the validation set. The system showed a high top-1 mean recognition accuracy in a real-world scenario of 0.85 (SD 0.11) for objects presented to the system without visual obstruction. Recognition accuracy was lower, but still acceptable, in scenarios where the objects were 50% covered (P<.001; mean recognition accuracy 0.71; SD 0.13) or multiple objects of the target group were present (P=.01; mean recognition accuracy 0.78; SD 0.11), compared to a nonobstructed view. The approach met the criteria of absence of explicit labeling (eg, barcodes, radio frequency labeling) while maintaining a high standard for quality and hygiene with minimal consumption of resources (eg, cost, time, training, and computational power).

CONCLUSIONS

Using a convolutional neural network architecture, Consumabot consistently achieved good results in the classification of consumables and thus is a feasible way to recognize and register medical consumables directly to a hospital's electronic health record. The system shows limitations when the materials are partially covered, therefore identifying characteristics of the consumables are not presented to the system. Further development of the assessment in different medical circumstances is needed.

Urgent need for standardised guidelines for reporting healthcare costs in ICUs - Results of an integrative review of costing methodologies

OBJECTIVES

Diverse costing methodologies in critical care have produced discrepant results. We aimed to critically review studies addressing critical care patients' costs, to estimate total costs and cost categories and to delineate methodologies used and relevant limitations.

METHODS

Integrative review based on key-word searches of electronic databases targeting primary studies that report estimates of patient cost, in the last 21 years. We assessed the level transparency of reporting and the quality of the studies, by the SIGN tool.

RESULTS

Overall, 12 research articles were included, of which eight studies mentioned the specific approach used to identify the elements of cost. Most studies employed a micro-costing and one study a macro-costing approach. With regard to approaches to valuation of cost components, only one study identified the bottom-up approach. The total patient cost ranged from US$ 487 to US$ 39,300 and human resources was identified as the cost category mostly driving total costs.

CONCLUSIONS

Although valid methodologies to evaluate critical care patients' costs, such as micro-costing, are employed more frequently, a variety of non-standardized methods are still used. There is a pressing need to develop standardised guidelines for reporting of observational studies of cost in healthcare, with particular considerations for critical care.

Determining the Operating Costs of a Medical Surveillance Program for Copper Miners Exposed to High Altitude-Induced Chronic Intermittent Hypoxia in Chile Using a Combination of Microcosting and Time-Driven Activity-Based Costing

BACKGROUND

Copper mining installations in Chile use a large number of workers who do their jobs at high altitudes, exposing them to the conditions of chronic intermittent hypobaric hypoxia. The Chilean Safety Association implements the surveillance program.

OBJECTIVE

This organization, under the sponsorship of the Chilean Superintendency of Social Security, was interested in determining the costs involved in this program to support its decision-making processes and to improve its performance.

METHODS

Direct operating costs of the Hypoxia Medical Surveillance Program were determined through on-site surveys applied to the organization's local agencies in charge. The microcosting method was used, quantifying personnel costs, consumables, and equipment and overhead costs. Time-driven activity-based costing was partially adapted for the allocation of personnel and equipment costs. Costs concerning activities, groups of activities and items, and average cost per exposed worker were determined.

RESULTS

The annual costs of the program were $127 299.58. The highest costs corresponded to the assessment activities, which were $89 192.13, representing 60.06% of the total. The labor factor costs were $77 568.50, which represents 60.93% of the total. The average cost per worker in the program is $21.17.

CONCLUSIONS

The partial adaptation of the time-driven activity-based costing method in combination with the microcosting method provides a suitable solution to determine the total costs of running a healthcare program of this kind. The information generated by this study will aid in the decision-making and management processes of the Hypoxia Medical Surveillance Program.

Resource allocation in ICU: ethical considerations

PURPOSE OF REVIEW

Increasing scarcity of resources on the background of ever improving medical care and prolonged life expectancy has placed a burden on all aspects of health care. In this article we examine the current problems with resource allocation in intensive care and question whether we can find guidance on appropriate resource allocation through ethical models.

RECENT FINDINGS

The problem of fair and ethical resource allocation has perpetually plagued health care. Recent work has looked at value for money, benefits of therapies and how we define futility, but these still fall victim to the same problems that classical schools of ethical thought have tried to tackle.

SUMMARY

Many ethical principles provide a framework on which to allocate resources to certain cohorts of patients, however, most appear too rigid to be fully and primarily utilized for intensive care admission. We suggest a collaboration of principles be applied to achieve a moral, ethical and common sense approach to this issue. Over resourcing and under resourcing is also suggested to be problematic for patients and healthcare workers alike.

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

OBJECTIVES

Nurse 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/DESIGN

A retrospective descriptive correlational analysis of nurse staffing costs and data of 6390 patients extracted from a data warehouse.

SETTING

Three intensive care units in a university hospital and one in a regional hospital in Norway.

MAIN OUTCOME MEASURES

Nurse staffing costs, NAS and NEMS.

RESULTS

For 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.

CONCLUSION

A 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.

Current challenges in the management of sepsis in ICUs in resource-poor settings and suggestions for the future

BACKGROUND

Sepsis is a major reason for intensive care unit (ICU) admission, also in resource-poor settings. ICUs in low- and middle-income countries (LMICs) face many challenges that could affect patient outcome.

AIM

To describe differences between resource-poor and resource-rich settings regarding the epidemiology, pathophysiology, economics and research aspects of sepsis. We restricted this manuscript to the ICU setting even knowing that many sepsis patients in LMICs are treated outside an ICU.

FINDINGS

Although many bacterial pathogens causing sepsis in LMICs are similar to those in high-income countries, resistance patterns to antimicrobial drugs can be very different; in addition, causes of sepsis in LMICs often include tropical diseases in which direct damaging effects of pathogens and their products can sometimes be more important than the response of the host. There are substantial and persisting differences in ICU capacities around the world; not surprisingly the lowest capacities are found in LMICs, but with important heterogeneity within individual LMICs. Although many aspects of sepsis management developed in rich countries are applicable in LMICs, implementation requires strong consideration of cost implications and the important differences in resources.

CONCLUSIONS

Addressing both disease-specific and setting-specific factors is important to improve performance of ICUs in LMICs. Although critical care for severe sepsis is likely cost-effective in LMIC setting, more detailed evaluation at both at a macro- and micro-economy level is necessary. Sepsis management in resource-limited settings is a largely unexplored frontier with important opportunities for research, training, and other initiatives for improvement.

Discharge practices for the intensive care patient: a qualitative exploration in the general ward setting

OBJECTIVE

To explore how registered nurses (RNs) in the general ward perceive discharge processes and practices for patients recently discharged from the intensive care unit (ICU).

BACKGROUND

Patients discharged from the ICU environment often require complicated and multifaceted care. The ward-based RN is at the forefront of the care of this fragile patient population, yet their views and perceptions have seldom been explored.

DESIGN

A qualitative grounded theory design was used to guide focus group interviews with the RN participants.

METHODS

Five semi-structured focus group interviews, including 27 RN participants, were conducted in an Australian metropolitan tertiary referral hospital in 2011. Data analyses of transcripts, field notes and memos used concurrent data generation, constant comparative analysis and theoretical sampling.

RESULTS

Results yielded a core category of 'two worlds' stressing the disconnectedness between ICU and the ward setting. This category was divided into sub categories of 'communication disconnect' and 'remember the family'. Properties of 'what we say', 'what we write', 'transfer' and 'information needs' respectively were developed within those sub-categories.

CONCLUSION

The discharge process for patients within the ICU setting is complicated and largely underappreciated. There are fundamental, misunderstood differences in prioritisation and care of patients between the areas, with a deep understanding of practice requirements of ward based RNs not being understood. The findings of this research may be used to facilitate inter departmental communications and progress practice development.

How is intensive care reimbursed? A review of eight European countries

Reimbursement schemes in intensive care are more complex than in other areas of healthcare, due to special procedures and high care needs. Knowledge regarding the principles of functioning in other countries can lead to increased understanding and awareness of potential for improvement. This can be achieved through mutual exchange of solutions found in other countries. In this review, experts from eight European countries explain their respective intensive care unit reimbursement schemes. Important conclusions include the apparent differences in the countries' reimbursement schemes-despite all of them originating from a DRG system-, the high degree of complexity found, and the difficulties faced in several countries when collecting the data for this collaborative work. This review has been designed to assist the intensivist clinician and researcher in understanding neighbouring countries' approaches and in putting research into the context of a European perspective. In addition, steering committees and decision makers might find this a valuable source to compare different reimbursement schemes.

Monitoring costs in the ICU: a search for a pertinent methodology

Attempts to determine costs in the intensive care unit (ICU) were not successful until now, as they failed to detect differences of costs between patients. The methodology and/or the instruments used might be at the origin of this failure. Based on the results of the European ICUs studies and on the descriptions of the activities of care in the ICU, we gathered and analysed the relevant literature concerning the monitoring of costs in the ICU. The aim was to formulate a methodology, from an economic perspective, in which future research may be framed. A bottom-up microcosting methodology will enable to distinguish costs between patients. The resulting information will at the same time support the decision-making of top management and be ready to include in the financial system of the hospital. Nursing staff explains about 30% of the total costs. This relation remains constant irrespective of the annual nurse/patient ratio. In contrast with other scoring instruments, the nursing activities score (NAS) covers all nursing activities. (1) NAS is to be chosen for quantifying nursing activities; (2) an instrument for measuring the physician's activities is not yet available; (3) because the nursing activities have a large impact on total costs, the standardisation of the processes of care (following the system approach) will contribute to manage costs, making also reproducible the issue of quality of care; (4) the quantification of the nursing activities may be the required (proxy) input for the automated bottom-up monitoring of costs in the ICU.

Direct cost analysis of intensive care unit stay in four European countries: applying a standardized costing methodology

OBJECTIVES

The objective of the present study was to measure and compare the direct costs of intensive care unit (ICU) days at seven ICU departments in Germany, Italy, the Netherlands, and the United Kingdom by means of a standardized costing methodology.

METHODS

A retrospective cost analysis of ICU patients was performed from the hospital's perspective. The standardized costing methodology was developed on the basis of the availability of data at the seven ICU departments. It entailed the application of the bottom-up approach for "hotel and nutrition" and the top-down approach for "diagnostics," "consumables," and "labor."

RESULTS

Direct costs per ICU day ranged from €1168 to €2025. Even though the distribution of costs varied by cost component, labor was the most important cost driver at all departments. The costs for "labor" amounted to €1629 at department G but were fairly similar at the other departments (€711 ± 115).

CONCLUSIONS

Direct costs of ICU days vary widely between the seven departments. Our standardized costing methodology could serve as a valuable instrument to compare actual cost differences, such as those resulting from differences in patient case-mix.

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.

A unique snapshot of intensive care resources in Australia and New Zealand

The objective of this study was to analyse and report on the distribution and attributes of intensive care services in Australia and New Zealand for the 2005/2006 financial year A survey was mailed to 155 Australian and 26 New Zealand intensive care units (ICU) listed on the database of the Australian and New Zealand Intensive Care Society. A descriptive analytical approach was used. Of the 181 ICUs, 177 provided data. In Australia there were 100 public sector and 51 private sector ICUs and in New Zealand, 24 public sector and two private sector ICUs. These units contain 1485 available beds in the public sector and 538 available beds in the private sector Calculations to determine beds per 100,000 population, medical specialists per 1000 patient days and registered nurses per 1000 patient days showed wide variation. International comparisons are limited by lack of data; however it does appear that intensive care patients in Australia and New Zealand have very good outcomes.

Excess mortality, length of stay and cost attributable to candidaemia

BACKGROUND

There were 1967 reports of Candida species isolated from blood specimens in 2007 in the UK (excluding Scotland). Such infections are particularly common in the intensive care unit (ICU). The impact of candidaemia on mortality, length of stay (LOS) and cost in a UK hospital was examined.

METHODS

A retrospective analysis of candidaemia episodes and appropriate matched controls was undertaken based on data from the ICU, high dependency units and hospital wards at Wythenshawe Hospital in Manchester. The study covered the period November 2003-February 2007.

RESULTS

In total, 48 case-patients of candidaemia and 81 control-patients were identified. The attributable mortality due to candidaemia varied from 21.5% to 34.7%. Candidaemia patients spend on average 5.6 days more in the ICU than matched patients and generate mean additional costs of at least 8252 UK pounds per patient, 16,595 pounds in adults only.

CONCLUSION

Candidaemia remains a severe disease associated with high attributable mortality in the UK. In addition, candidaemia leads to additional ICU length of stay and costs. The implication is an attributable cost of at least 16.2 million UK pounds with 683 deaths attributable to candidaemia per year in the UK.

Impact of computerized information systems on workload in operating room and intensive care unit

The number of operating rooms and intensive care departments equipped with a clinical information system (CIS) is rapidly expanding. Amongst the putative advantages of such an installation, reduction in workload for the clinician is one of the most appealing. The scarce studies looking at workload variations associated with the implementation of a CIS, only focus on direct workload discarding indirect changes in workload. Descriptions of the various methods to quantify workload are provided. The hypothesis that a third generation CIS can reduce documentation time for ICU nurses and increase time they spend on patient care, is supported by recent literature. Though it seems obvious to extrapolate these advantages of a CIS to the anesthesiology department or physicians in the intensive care, studies examining this assumption are scarce.

Can outcome prediction data change patient outcomes and organizational outcomes?

PURPOSE OF REVIEW

Intensive care medicine consumes a high share of healthcare costs, and there is growing pressure to use the scarce resources efficiently. Accordingly, organizational issues and quality management have become an important focus of interest in recent years. Here, we will review current concepts of how outcome data can be used to identify areas requiring action.

RECENT FINDINGS

Using recently established models of outcome assessment, wide variability between individual ICUs is found, both with respect to outcome and resource use. Such variability implies that there are large differences in patient care processes not only within the ICU but also in pre-ICU and post-ICU care. Indeed, measures to improve the patient process in the ICU (including care of the critically ill, patient safety, and management of the ICU) have been presented in a number of recently published papers.

SUMMARY

Outcome assessment models provide an important framework for benchmarking. They may help the individual ICU to spot appropriate fields of action, plan and initiate quality improvement projects, and monitor the consequences of such activity.

[Cost of intensive care in a German hospital: cost-unit accounting based on the InEK matrix]

OBJECTIVE

The aim of this study was to determine the actual cost per intensive care unit (ICU) day in Germany based on routine data from an electronic patient data management system as well as analysis of cost-driving factors. A differentiation between days with and without mechanical ventilation was performed.

METHODS

On the ICU of a German focused-care hospital (896 beds, 12 anesthesiology ICU beds), cost per treatment day was calculated with or without mechanical ventilation from the perspective of the hospital. Costs were derived retrospectively with respect to the period between January and October 2006 by cost-unit accounting based on routine data collected from the ICU patients. Patients with a length of stay of at least 2 days on the ICU were included. Demographic, clinical and economical data were analyzed for patient characterization.

RESULTS

Data of 407 patients (217 male and 190 female) were included in the analysis, of which 159 patients (100 male, 59 female) were completely or partially mechanically ventilated. The mean simplified acute physiology (SAPS) II score at the onset of ICU stay was 28.2. Average cost per ICU day was 1,265 EUR and costs for ICU days with and without mechanical ventilation amounted to 1,426 EUR and 1,145 EUR, respectively. Personnel costs (50%) showed the largest cost share followed by drugs plus medicinal products (18%) and infrastructure (16%).

CONCLUSIONS

For the first time, a cost analysis of intensive care in Germany was performed with routine data based on the matrix of the institute for reimbursement in hospitals (InEK). The results revealed a higher resource use on the ICU than previously expected. The large share of personnel costs on the ICU was evident but is comparable to other medical departments in the hospital. The need for mechanical ventilation increases the daily costs of resources by approximately 25%.

A German national prevalence study on the cost of intensive care: an evaluation from 51 intensive care units

Introduction

Intensive care unit (ICU) costs account for up to 20% of a hospital's costs. We aimed to analyse the individual patient-related cost of intensive care at various hospital levels and for different groups of disease.

Methods

Data from 51 ICUs all over Germany (15 primary care hospitals and 14 general care hospitals, 10 maximal care hospitals and 12 focused care hospitals) were collected in an observational, cross-sectional, one-day point prevalence study by two external study physicians (January–October 2003). All ICU patients (length of stay > 24 hours) treated on the study day were included. The reason for admission, severity of illness, surgical/diagnostic procedures, resource consumption, ICU/hospital length of stay, outcome and ICU staffing structure were documented.

Results

Altogether 453 patients were included. ICU (hospital) mortality was 12.1% (15.7%). The reason for admission and the severity of illness differed between the hospital levels of care, with a higher amount of unscheduled surgical procedures and patients needing mechanical ventilation in maximal care hospital and focused care hospital facilities. The mean total costs per day were €791 ± 305 (primary care hospitals, €685 ± 234; general care hospitals, €672 ± 199; focused care hospitals, €816 ± 363; maximal care hospitals, €923 ± 306), with the highest cost in septic patients (€1,090 ± 422). Differences were associated with staffing, the amount of prescribed drugs/blood products and diagnostic procedures.

Conclusion

The reason for admission, the severity of illness and the occurrence of severe sepsis are directly related to the level of ICU cost. A high fraction of costs result from staffing (up to 62%). Specialized and maximum care hospitals treat a higher proportion of the more severely ill and most expensive patients.

Variability in outcome and resource use in intensive care units

OBJECTIVE

To examine variability in outcome and resource use between ICUs. Secondary aims: to assess whether outcome and resource use are related to ICU structure and process, to explore factors associated with efficient resource use.

DESIGN AND SETTING

Cohort study, based on the SAPS 3 database in 275 ICUs worldwide.

PATIENTS

16,560 adults.

MEASUREMENTS AND RESULTS

Outcome was defined by standardized mortality rate (SMR). Standardized resource use (SRU) was calculated based on length of stay in the ICU, adjusted for severity of acute illness. Each unit was assigned to one of four groups: "most efficient" (SMR and SRU < median); "least efficient" (SMR, SRU > median); "overachieving" (low SMR, high SRU), "underachieving" (high SMR, low SRU). Univariate analysis and stepwise logistic regression were used to test for factors separating "most" from "least efficient" units. Overall median SMR was 1.00 (IQR 0.77-1.28) and SRU 1.07 (0.76-1.58). There were 91 "most efficient", 91 "least efficient", 47 "overachieving", and 46 "underachieving" ICUs. Number of physicians, of full-time specialists, and of nurses per bed, clinical rounds, availability of physicians, presence of emergency department, and geographical region were significant in univariate analysis. In multivariate analysis only interprofessional rounds, emergency department, and geographical region entered the model as significant.

CONCLUSIONS

Despite considerable variability in outcome and resource use only few factors of ICU structure and process were associated with efficient use of ICU. This suggests that other confounding factors play an important role.