Today's Managing Health Care Costs Number is $130 billion
| | Priority 1 | Priority 2 | Priority 3 | Priority 4 | All |
| Description | ICU Appropriate | Discretionary ICU | ICU Futile | ICU Unnecessary | All Studied Patients |
| Number | 379 | 189 | 169 | 53 | 808 |
| Percent of Patients | 47% | 23% | 21% | 7% | 100% |
| Died in ICU | 13.4% | 4.2% | 47.3% | 2.8% | 17.5% |
| Died in Hospital | 19.6% | 10.6% | 61.9% | 7.0% | 25.2% |
Health Leaders has picked up a research letter from JAMA Internal Medicine suggesting that over half of all ICU stays are medically not necessary.
Back of the envelope - ICU stays could cost about $130 billion (5.7m admissions, 3.8days, $6000 per day. Sourcefor utilization. Source for cost). Does this mean that we could save $65 billion on ICUs?
Absolutely not!
The researchers reviewed medical records for 808 people admitted to the UCLA ICU in 2015-2016. They categorized these admissions as:
- Appropriate for ICU (47%)
- Could have been monitored outside of the ICU (23%)
- So sick that they would likely not benefit from the ICU (21%)
- Manageable outside of the ICU (7%)
So - the first category is appropriate -and the other categories are arguably either discretionary, futile, or unnecessary. The discretionary (Category 2) cases are a matter of judgment - so we shouldn't count on savings there. The futile cases aren't about ICU triage - they are about appropriate end of life care. We can make a difference here- but we have to have end of life discussions long before someone is being evaluated for transfer to (or admission to) an ICU. The last category is the smallest -and these ICU stays should certainly be interdicted. Keep in mind that these less ill patients likely have lower costs than the "average" ICU patients - so the total cost savings will be substantially less than 7% of the costs of ICU care.
The other consideration is hospital fixed costs. In the real world, admission to the ICU is highly dependent on ICU availability. Exceptionally sick patients unlucky enough to be in a hospital when there is a shortage of ICU beds will be stabilized in a less intense setting. Slightly less ill patients will be triaged to the ICU if it is staffed and there are empty beds. Nursing schedules can't be flexed day to day -so if a hospital optimized ICU assignment and left 5 empty (but staffed) ICU beds, the hospital would see lower revenue and wouldn't necessarily be able to fully reassign those resources to non-ICU care.
Intensive care has increased dramatically over the last two decades. This is in part because we can save lives now that we could not save years ago. It's also because ICUs, like many other high technology elements of medical care, are like the Field of Dreams. If we build ICU beds, they will be filled.
If we want to lower the aggregate cost of intensive care, we should have proactive end of life discussions with terminally ill patients and their families, and we should build fewer intensive care beds.
EmoticonEmoticon