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Daily cost of an intensive care unit day: The contribution of mechanical ventilation
Abstract
To quantify the mean daily cost of intensive care, identify key factors associated with increased cost, and determine the incremental cost of mechanical ventilation during a day in the intensive care unit.
Retrospective cohort analysis using data from NDCHealth's Hospital Patient Level Database.
A total of 253 geographically diverse U.S. hospitals.
The study included 51,009 patients >/=18 yrs of age admitted to an intensive care unit between October 1, 2002, and December 31, 2002.
None.
Days of intensive care and mechanical ventilation were identified using billing data, and daily costs were calculated as the sum of daily charges multiplied by hospital-specific cost-to-charge ratios. Cost data are presented as mean (+/-sd). Incremental daily cost of mechanical ventilation was calculated using log-linear regression, adjusting for patient and hospital characteristics. Approximately 36% of identified patients were mechanically ventilated at some point during their intensive care unit stay. Mechanically ventilated patients were older (63.5 yrs vs. 61.7 yrs, p < .0001) and more likely to be male (56.1% vs. 51.8%, p < 0.0001), compared with patients who were not mechanically ventilated, and required mechanical ventilation for a mean duration of 5.6 days +/- 9.6. Mean intensive care unit cost and length of stay were 31,574 +/- 42,570 dollars and 14.4 days +/- 15.8 for patients requiring mechanical ventilation and 12,931 +/- 20,569 dollars and 8.5 days +/- 10.5 for those not requiring mechanical ventilation. Daily costs were greatest on intensive care unit day 1 (mechanical ventilation, 10,794 dollars; no mechanical ventilation, 6,667 dollars), decreased on day 2 (mechanical ventilation:, 4,796 dollars; no mechanical ventilation, 3,496 dollars), and became stable after day 3 (mechanical ventilation, 3,968 dollars; no mechanical ventilation, 3,184 dollars). Adjusting for patient and hospital characteristics, the mean incremental cost of mechanical ventilation in intensive care unit patients was 1,522 dollars per day (p < .001).
Intensive care unit costs are highest during the first 2 days of admission, stabilizing at a lower level thereafter. Mechanical ventilation is associated with significantly higher daily costs for patients receiving treatment in the intensive care unit throughout their entire intensive care unit stay. Interventions that result in reduced intensive care unit length of stay and/or duration of mechanical ventilation could lead to substantial reductions in total inpatient cost.
... The cost of patients in ICU is approximately 3.5 times that of patients in regular care [1]. The regular operation of ICU depends on the availability of adequate medical resources [2,3]. In addition, timely treatment of critical patients often involves many factors, such as the accuracy of disease diagnosis, the efficiency of treatment, and the severity of the disease. ...
... (1) A series of preprocessing procedures executed on the public clinical dataset (2) In terms of feature selection, the subset features (SetS) and the transformed feature set (SetT) are developed (3) Several weak learners (AL) based on APACHE severity scoring results are learned using the machine learning methods (4) A mortality prediction model combined with APACHE severity score results is established by using stack integration technique (5) To interpret the correlation between features and the outcome, the SHAP analysis is employed to give the ranking of the importance features ...
... (1) In addition to promising accuracy, the ML-based model has strong model interpretability (2) Compared to the single technique (such as LR, RF, and XGB), stacked ensemble techniques can improve the prediction performance by weighting the various results ...
Artificial intelligence (AI) technology has huge scope in developing models to predict the survival rate of critically ill patients in the intensive care unit (ICU). The availability of electronic clinical data has led to the widespread use of various machine learning approaches in this field. Innovative algorithms play a crucial role in boosting the performance of models. This study uses a stacked ensemble model to predict mortality in ICU by incorporating the clinical severity scoring results, in which several machine learning algorithms are employed to compare the performance. The experimental results show that the stacked ensemble model achieves good performance compared with the model without integrating the severity scoring results, which has the area under curve (AUC) of 0.879 and 0.862, respectively. To improve the performance of prediction, two feature subsets are obtained based on different feature selection techniques, labeled as SetS and SetT. Evaluation performances show that the SEM based on the SetS achieves a higher AUC value (0.879 and 0.860). Finally, the SHapley Additive exPlanations (SHAP) analysis is employed to interpret the correlation between the risk features and the outcome.
... Mechanical ventilation is a respiratory support which up to 36.4% of the patients in the intensive care units receive 1 . In sedated patients, the lung is ventilated by applied volume or pressure through the respirator while the patients' diaphragm remains inactive, which leads to diaphragm atrophy. ...
... However, 30% of the patients are difficult to wean and 10% require prolonged weaning. These patients account for 40% of total patient-days in the intensive care unit and become the most expensive in-house patients in hospitals 1 . We note that the weaning failure, resulting in prolonged mechanical ventilation, causes diaphragmatic atrophy 5 ...
Diaphragm atrophy is a common side effect of mechanical ventilation and results in prolonged weaning. Electric phrenic nerve stimulation presents a possibility to avoid diaphragm atrophy by keeping the diaphragm conditioned in sedated patients. There is a need of further investigation on how to set stimulation parameters to achieve sufficient ventilation. A prototype system is presented with a systematic evaluation for stimulation pattern adjustments. The main indicator for efficient stimulation was the tidal volume. The evaluation was performed in two pig models. As a major finding, the results for biphasic pulses were more consistent than for alternating pulses. The tidal volume increased for a range of pulse frequency and pulse width until reaching a plateau at 80–120 Hz and 0.15 ms. Furthermore, the generated tidal volume and the stimulation pulse frequency were significantly correlated (0.42–0.84, p<0.001\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$p<0.001$$\end{document}). The results show which stimulation parameter combinations generate the highest tidal volume. We established a guideline on how to set stimulation parameters. The guideline is helpful for future clinical applications of phrenic nerve stimulation.
... Furthermore, post-extubation respiratory failure usually leads to prolonged invasive mechanical ventilation and to a higher risk of ventilator-associated pneumonia (VAP), critical weakness and delirium [13][14][15]. Lastly, extubation failure increases resource utilisation and costs, and patient discomfort [13,16]. ...
... Forms of noninvasive respiratory support (NRS), including high-flow nasal oxygen (HFNO), continuous positive airway pressure (CPAP) and bi-level positive airway pressure, commonly referred to as noninvasive ventilation (NIV) [5,17,18,19], have been proposed for avoiding re-intubation secondary to post-extubation failure, by maintaining adequate gas exchange, breathing pattern, inspiratory effort and tracheobronchial secretion clearance [10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26]. ...
Background:
The effect of noninvasive respiratory support (NRS), including high-flow nasal oxygen, bi-level positive airway pressure and continuous positive airway pressure (noninvasive ventilation (NIV)), for preventing and treating post-extubation respiratory failure is still unclear. Our objective was to assess the effects of NRS on post-extubation respiratory failure, defined as re-intubation secondary to post-extubation respiratory failure (primary outcome). Secondary outcomes included the incidence of ventilator-associated pneumonia (VAP), discomfort, intensive care unit (ICU) and hospital mortality, ICU and hospital length of stay (LOS), and time to re-intubation. Subgroup analyses considered "prophylactic" versus "therapeutic" NRS application and subpopulations (high-risk, low-risk, post-surgical and hypoxaemic patients).
Methods:
We undertook a systematic review and network meta-analysis (Research Registry: reviewregistry1435). PubMed, Embase, CENTRAL, Scopus and Web of Science were searched (from inception until 22 June 2022). Randomised controlled trials (RCTs) investigating the use of NRS after extubation in ICU adult patients were included.
Results:
32 RCTs entered the quantitative analysis (5063 patients). Compared with conventional oxygen therapy, NRS overall reduced re-intubations and VAP (moderate certainty). NIV decreased hospital mortality (moderate certainty), and hospital and ICU LOS (low and very low certainty, respectively), and increased discomfort (moderate certainty). Prophylactic NRS did not prevent extubation failure in low-risk or hypoxaemic patients.
Conclusion:
Prophylactic NRS may reduce the rate of post-extubation respiratory failure in ICU patients.
... However, burdened costs of transfusion and ICU stay also include expenses like human resources, machinery, facility maintenance, transport, storage, side effects, and follow-up costs which should be considered [35]. Thereby, according to other authors [36][37][38][39], the saving per patient treated with HAR may reach the amount of 2741.94 $ (Table 5). ...
... While the elimination of cases with clinical records compliant with criteria may have Abbreviations: ATT: Average treatment effect on treated, RBC: red blood cells, PT: platelets, FP: fresh plasma, ICU > 2d: intensive care unit costs after the 2nd day of stay. *Overall cost per process was obtained from [36][37][38][39]. ...
Background: New era of cardiac surgery aims to provide an enhanced postoperative recovery by the implementation of every step of the process. Thus, perfusion strategy should adopt evidence-based measures to reduce the impact of cardiopulmonary bypass (CPB). Hematic Antegrade Repriming (HAR) provides a standardized procedure combining several measures to reduce haemodilutional priming to 300 mL. Once the safety of the procedure in terms of embolic release has been proven, the evaluation of its beneficial effects in terms of transfusion and ICU stay should be assessed to determine if could be considered for inclusion in Enhanced Recovery After Cardiac Surgery (ERACS) programs. Methods: Two retrospective and non-randomized cohorts of high-risk patients, with similar characteristics, were assessed with a propensity score matching model. The treatment group (HG) (n=225) received the HAR. A historical cohort, exposed to a conventional priming with 1350 mL of crystalloid conformed the control group (CG) (n=210). Results: Exposure to any transfusion was lower in treated (66,75% vs 6,88%, p<0.01). Prolonged mechanical ventilation (>10h) (26.51% vs 12.62%; p<0.01) and extended ICU stay (>2d) (47.47% vs 31.19%; p<0.01) were fewer for treated. HAR did not increase early morbidity and mortality. Related savings varied from 581 to 2741.94 $/patient, depending on if direct or global expenses were considered. Discussion: By reducing the gaseous and crystalloid emboli during CPB initiation, HAR seem to have a beneficial impact in recovery and reduces the overall transfusion until discharge, leading to significant cost savings per process. Due to the preliminary and retrospective nature of the research and limitations, our findings should be validated by future prospective and randomized studies.
... In Belgium and the Netherlands, the basic cost for a one day stay in the ICU is approximately between € 1545 and € 3221 (median €2160) and the nursing cost between €496 and €1229 (median €789) making daily costs approximately €3000 [13]. In the United States daily ICU-costs were greatest on the first day ($7728 -$8509), decreased on day 2 ($3872 -$4223) and became stable from day 3 forward ($3436 -$3550) [14]. In Australia the mean cost per patient bed-day was $4375 [15]. ...
In a thought-provoking article – or how she herself named it, ‘a thought experiment’ – the philosopher-medical ethicist Anna Smajdor analyzed in this journal the idea of whole-body gestational donation (WBGD) in brain-dead female patients, as an alternative means of gestation for prospective women who cannot or prefer not to become pregnant themselves. We have serious legal, economical, medical and ethical concerns about this proposal. First, consent for eight months of ICU treatment can never be assumed to be derived from consent for post-mortem organ donation; these two are of an incomparable and entirely different medical and ethical order. Moreover, the brain-dead woman is very likely to be medically unfit for high-tech surrogacy and the brain-dead state poses a high risk for deficient embryo/fetal development. Second, from a scarcity perspective, occupying an ICU bed for eight months appears to be unjust. The costs for eight months of ICU treatment are far too high compared to the costs of surrogacy for a living, selected, and healthy woman. Neither insurance companies nor prospective parents will want to pay these exceptionally high costs for a dead woman if a living surrogate mother can be hired for a considerably lower amount. Third, there is an increased risk for harm of the child to be in WBGD. And finally, WBGD risks violating the brain-dead woman’s dignity and harming the interests of her loved ones. In short, there is simply no need for brain-dead women as surrogates.
... hcup-us.ahrq.gov), and cost per ICU day ($9,347) was sourced from Dasta et al. [27]. Medication costs were obtained from RED BOOK TM (www.ibm.com/products/micromedexred-book) using wholesale acquisition costs, and were uniformly applied across sites of care. ...
Introduction:
Patients with triple-class exposed relapsed/refractory multiple myeloma (RRMM) have poor outcomes with substantial healthcare costs. Idecabtagene vicleucel (ide-cel), a B-cell maturation antigen (BCMA)-directed chimeric antigen receptor (CAR) T cell therapy, showed deep, durable responses in patients with RRMM in the pivotal phase 2 KarMMa trial (NCT03361748). Healthcare resource utilization (HCRU) and costs were estimated for ide-cel-treated patients in the KarMMa trial.
Methods:
Post-infusion costs were estimated based on HCRU data, including facility care, diagnostics, medications, and procedures. Length of stay (LOS) was extracted for inpatient and intensive care unit (ICU) care. All patients had a 14-day post-infusion inpatient stay per trial protocol. Analyses were conducted for patients treated in the United States (US), who received the ide-cel target dose of 450 × 106 CAR + T cells and assuming a 7-day inpatient stay.
Results:
Overall, 128 patients received ide-cel and were included in this analysis. Mean age was 60 years, 59% were men, and 81% were white. Mean total LOS was 23.9 days. Total estimated costs over 24 months post-infusion were US$115,614 per patient, driven by facility costs (75%; $86,385). Most costs were incurred in the first month (58%; $67,259). The scenario analysis assuming a 7-day inpatient stay showed estimated 24-month costs of $92,294. For the 54 (42%) patients who received ide-cel high dose, total costs over 24 months were $113,298 per patient.
Conclusions:
Extrapolation of costs based on HCRU data from patients receiving single-infusion of ide-cel in the KarMMa trial showed substantially reduced HCRU and costs over 2 years after initial treatment. Most costs were incurred during the first month after ide-cel infusion, likely attributable to the 14-day inpatient stay required by the trial protocol. These findings suggest a nominal, incremental monthly cost of care immediately after treatment, which may be lower in routine clinical practice.
... Studies showed that the medical costs of patients with COVID-19 were significantly higher than those of other infectious diseases due to the higher likelihood of hospitalization and mortality [10]. These circumstances are also right about the need for COVID-19 patients for special care services and the related costs [11][12][13]. As with any new disease, cost data related to the burden of COVID-19 has been scarce. ...
The impact of the coronavirus disease 2019 (COVID-19) pandemic on the global economy is far-reaching and difficult to assess accurately. We aimed to systematically determine the magnitude of the costs and the economic burden of intensive care for hospitalized COVID-19 patients since the onset of the pandemic by means of a systematic review. We conducted a PRISMA 2020-compliant (protocol: PROSPERO CRD42022348741) systematic review by searching PubMed, EMBASE, and Web of Science for relevant literature. We included studies that presented costs based on a primary partial economic evaluation. Using the Consolidated Health Economic Evaluation Reporting Standards checklist and the population, intervention, control, and outcome criteria, we established the risk of bias in studies at the individual level. Daily cost per ICU admission and total cost per ICU patient of the original studies extracted. A random effect model was adopted for meta-analysis whenever possible. Of the 1,635 unique records identified, 14 studies related to ICU-hospitalized costs due to COVID-19 were eligible for inclusion. Included studies represented 93,721 hospitalized COVID-19 patients. Regarding total direct medical costs, the lowest cost per patient at ICU was observed in Turkey ($2,984.78 ± 2,395.93), while the highest was in Portugal ($51,358.52 ± 30,150.38). The Republic of Korea reported the highest length of stay of 29.4 days (±17.80), and the lowest is observed in India for nine days (±5.98). Our findings emphasize COVID-19's significance on health-economic outcomes. Limited research exists on the economic burden of COVID-19 in the ICU. Further studies on cost estimates can enhance data clarity, enabling informed analysis of healthcare costs and aiding efficient patient care organization by care providers and policymakers.
... In particular, critical metrics, such as recruitment volume retained as pressures change, peak volume and pressures, lung elastances, and work of breathing. These metrics offer more accurate insight not previously available to optimise MV, where MV doubles the cost per day (Dasta et al., 2005). They are currently entering first clinical trials (Kim et al., 2020b), and have been tested in neonatal cohorts (Kim et al., 2019, Kim et al., 2020a. ...
... Future studies should consider the cost implications of EP. Cost and resource use are higher in ICU patients than non-ICU patients [33][34][35] and a cost-benefit analysis of the contributions made using the respective systems would be beneficial. Reasons for prescribers' behavioural changes with EP also need to be better understood. ...
Background:
Despite the strong face validity of electronic prescribing (EP), the empiric data in support of improved patient safety is sparse. The objective of this study was to compare the clinical significance of pharmacist contributions between an established EP and paper-based prescribing (PBP) system in the intensive care unit (ICU) to understand the EP impact on the quality of patient care.
Materials and methods:
We conducted a prospective longitudinal study in two 18-bed ICUs; one with EP and the other, PBP. Pharmacist contributions were analysed over three months. Demographic, clinical and adjunctive intervention data were also collected. A multilevel ordinal logistic regression model was used and patients were followed up for 28 days. The primary outcome was the distribution of clinical significance levels of pharmacist contributions.
Results:
There were 303 patients admitted to the ICU between April 1st and June 30th 2018. EP was used in 171 patients and PBP in 132 patients. 1658 contributions were analysed. There were 14.9% highly clinically significant contributions with EP compared to 44.6% with PBP. The EP group had lower odds (OR 0.05, 95% CI 0.02-0.12) for a higher clinical significance contribution compared to the PBP group, but this changed over the admission and differed between groups, with decreasing odds of a higher-level clinical contribution for each additional admission day with PBP (OR 0.57, 95%CI 0.42-0.78).
Conclusion:
This study showed a significant difference in the distribution of pharmacist contributions made over time, with clinical significance levels remaining stable in the EP group at low severity, as opposed to PBP which were initially high and then gradually decreased in severity over time. This contemporaneous controlled study found that the EP system required less significant input both in the severity and frequency of pharmacist contributions to maintain patient safety.
... Based on data from the Kaiser Family Foundation [52] Additional parameters that infuence costs associated with ICU patients and the daily cost of an ICU day were considered through evaluation of the additional expense of mechanical ventilation. We used the 2003 cost fgures shown by Dasta et al. [53] for the third and subsequent ICU days, with 1/3 of patients mechanically ventilated and 2/3 not ventilated (blended average cost per day of $3,443), and infated those costs to 2021 for an average cost of $6,083 per day or $253 extra per hour. If more than the typical 1/3 of patients, such as 50-80%, were ventilated, the average cost per hour would be closer to $300. ...
Neuroimaging in conjunction with a neurologic examination has become a valuable resource for today’s intensive care unit (ICU) physicians. Imaging provides critical information during the assessment and ongoing neuromonitoring of patients for toxic-metabolic or structural injury of the brain. A patient’s condition can change rapidly, and interventions may require imaging. When making this determination, the benefit must be weighed against possible risks associated with intrahospital transport. The patient’s condition is assessed to decide if they are stable enough to leave the ICU for an extended period. Intrahospital transport risks include adverse events related to the physical nature of the transport, the change in the environment, or relocating equipment used to monitor the patient. Adverse events can be categorized as minor (e.g., clinical decompensation) or major (e.g., requiring immediate intervention) and may occur in preparation or during transport. Regardless of the type of event experienced, any intervention during transport impacts the patient and may lead to delayed treatment and disruption of critical care. This review summarizes the commentary on the current literature on the associated risks and provides insight into the costs as well as provider experiences. Approximately, one-third of patients who are transported from the ICU to an imaging suite may experience an adverse event. This creates an additional risk for extending a patient’s stay in the ICU. The delay in obtaining imaging can negatively impact the patient’s treatment plan and affect long-term outcomes as increased disability or mortality. Disruption of ICU therapy can decrease respiratory function after the patient returns from transport. Because of the complex care team needed for patient transport, the staff time alone can cost $200 or more. New technologies and advancements are needed to reduce patient risk and improve safety.
... Resource utilization were first quantified by RRT duration, ICU LoS, and hospital LoS. All resources were then costed by applying a daily cost to RRT and LoS (26,(32)(33)(34)(35). Daily cost estimates were derived from published literature from the years 2003-2022 and expressed in 2021 $ (U.S. dollars) using the Consumer Price Index for Medical Care Services from the U.S. Bureau of Labor Statistics (36). ...
OBJECTIVES:. Acute kidney injury (AKI) and fluid overload (FO) are among the top reasons to initiate intermittent hemodialysis (IHD) or continuous renal replacement therapy (CRRT). Prior research suggests CRRT provides more precise volume control, but whether CRRT is cost-effective remains unclear. We assessed the cost-effectiveness of CRRT for volume control compared with IHD from a U.S. healthcare payer perspective.
DESIGN:. Decision analytical model comparing health outcomes and healthcare costs of CRRT versus IHD initiation for AKI patients with FO. The model had an inpatient phase (over 90-d) followed by post-discharge phase (over lifetime). The 90-day phase had three health states: FO, fluid control, and death. After 90 days, surviving patients entered the lifetime phase with four health states: dialysis independent (DI), dialysis dependent (DD), renal transplantation, and death. Model parameters were informed by current literature. Sensitivity analyses were performed to evaluate results robustness to parametric uncertainty.
SETTING:. ICU.
PATIENTS OR SUBJECTS:. AKI patients with FO.
INTERVENTIONS:. IHD or CRRT.
MEASUREMENTS AND MAIN RESULTS:. The 90-day horizon revealed better outcomes for patients initiated on CRRT (survival: CRRT 59.2% vs IHD 57.5% and DD rate among survivors: CRRT 5.5% vs IHD 6.9%). Healthcare cost was 2.7% (+$2,836) higher for CRRT. Over lifetime, initial CRRT was associated with +0.313 life years (LYs) and +0.187 quality-adjusted life years (QALYs) compared with initial IHD. Even though important savings were observed for initial CRRT with a lower rate of DD among survivors (–$13,437), it did not fully offset the incremental cost of CRRT (+$1,956) and DI survival (+$12,830). The incremental cost-per-QALY gained with CRRT over IRRT was +$10,429/QALY. Results were robust to sensitivity analyses.
CONCLUSIONS:. Our analysis provides an economic rationale for CRRT as the initial modality of choice in AKI patients with FO who require renal replacement therapy. Our finding needs to be confirmed in future research.
... [4,5] The causes for mechanical ventilation include ARF, acute lung injury, head injuries, critical illness and support to respiratory system after surgery. [6,7] Critical ill patients with lung pathologies need special attention to be adjusted with the ventilator setting because wrong setting may lead to certain adverse effects and complications that could be life threatening. [8,9] Patient management in intensive care units is an essential part of nursing care. ...
Respiratory problems and ailments are becoming the major concerns around the world in terms of its relevance, morbidity and mortality. Managing such problems is challenging task however improvements could be brought with the immediate interventions. Many of the patients require special attention in this regard to be managed with adequate mechanical ventilation. Statistics shows that approximately 80% of the admitted patients with acute respiratory illnesses required mechanical ventilation in critical and intensive care units. Therefore health care professionals specifically nurses who spends more time on floor with patients must have to be skilled and well equipped to fulfill the needs of patients receiving oxygen therapy on ventilator machines. Quasi experimental (pre and post study design) study was used to carry out the study in Ayub Teaching Hospital Abbottabad. A universal sample (30) critical care nurses were selected from Intensive Care Units. Data was collected by a self-administered questionnaire that was validated and found reliable after the pilot study. Questionnaires consist of two parts the first one demographic information and second parts is knowledge of mechanical ventilation. SPSS version 20 was used for the analysis of information. Descriptive statistical analysis method (frequency, mean and standard deviation) inferential statistics the Fisher exact test value was used. Findings were portrayed in the form of graphs, figures and tables. The results showed that 56.66% of the nurses had poor knowledge on the framed parameters in the initial phase of the study which was reduced to 10% in the later on stage of the study. Further the analysis reported that the mean score knowledge was (52.03±12.24) in the pre phase assessment of knowledge through multiple choice questions while the results were significantly found better with the mean score knowledge of (70.133±13.35) in the post intervention phase with a p value (0.011). The findings of the study showed that nurses were having inadequate knowledge regarding mechanical ventilation that may affect the care of critical ill patients. Therefore nurses may be updated with the latest guidelines, session, manuals and study modules that may improve the level of knowledge among nurse towards the provision of best possible care.
... Earlier intervention on the part of the clinician can help mitigate and altogether prevent complications that have been predicted to occur. The prevention of a VAC improves patient outcomes by shortening duration of ICU stay, reducing hospital costs, and preventing further mechanical injury (Dasta et al., 2005). ...
Introduction: Mechanical ventilation is a life-saving treatment in the Intensive Care Unit (ICU), but often causes patients to be at risk of further respiratory complication. We created a statistical model utilizing electronic health record and physiologic vitals data to predict the Center for Disease Control and Prevention (CDC) defined Ventilator Associated Complications (VACs). Further, we evaluated the effect of data temporal resolution and feature generation method choice on the accuracy of such a constructed model.
Methods: We constructed a random forest model to predict occurrence of VACs using health records and chart events from adult patients in the Medical Information Mart for Intensive Care III (MIMIC-III) database. We trained the machine learning models on two patient populations of 1921 and 464 based on low and high frequency data availability. Model features were generated using both basic statistical summaries and tsfresh, a python library that generates a large number of derived time-series features. Classification to determine whether a patient will experience VAC one hour after 35 h of ventilation was performed using a random forest classifier. Two different sample spaces conditioned on five varying feature extraction techniques were evaluated to identify the most optimal selection of features resulting in the best VAC discrimination. Each dataset was assessed using K-folds cross-validation (k = 10), giving average area under the receiver operating characteristic curves (AUROCs) and accuracies.
Results: After feature selection, hyperparameter tuning, and feature extraction, the best performing model used automatically generated features on high frequency data and achieved an average AUROC of 0.83 ± 0.11 and an average accuracy of 0.69 ± 0.10.
Discussion: Results show the potential viability of predicting VACs using machine learning, and indicate that higher-resolution data and the larger feature set generated by tsfresh yield better AUROCs compared to lower-resolution data and manual statistical features.
... Further, RATS diaphragm plication has similar improvement of symptoms and extremely low rates of morbidity and mortality that are similar to the open approach. These outcomes have important implications for overall costs, as it has been estimated that daily ICU care costs up to five times more than general recovery floor care, with the first postoperative day being the most expensive [18]. Therefore, a RATS approach may help to reduce overall healthcare costs through both shorter hospital stays and decreased ICU utilization. ...
Diaphragm paralysis and eventration are rare conditions in adults. Symptomatic patients may benefit from surgical plication of the elevated hemidiaphragm. The objective of this study was to compare short-term outcomes and length of stay following robotic-assisted vs. open diaphragm plication. A multicenter retrospective study was conducted that identified patients undergoing unilateral hemidiaphragm plication from 5/2008 to 12/2020. The first RATS plication was performed in 11/2018. Electronic medical records were reviewed, and outcomes were compared between RATS and open approach. One hundred patients underwent diaphragm plication, including thirty-nine (39.0%) RATS and sixty-one (61.0%) open cases. Patients undergoing RATS diaphragm plication were older (64 years vs. 55 years, p = 0.01) and carried a higher burden of comorbidities (Charlson Comorbidity Index: 2.0 vs. 1.0, p = 0.02). The RATS group had longer median operative times (146 min vs. 99 min, p < 0.01), but shorter median hospital length of stays (3.0 days vs. 6.0 days, p < 0.01). There was a non-significant trend toward a decreased rate of 30-day postoperative complications (20.5% RATS vs. 32.8% open, p = 0.18) and 30-day unplanned readmissions (7.7% RATS vs. 9.8% open, p > 0.99). RATS is a technically feasible and safe option for performing diaphragm plications. This approach increases the surgical candidacy of older patients with a higher burden of comorbid disease without increasing complication rates, while reducing length of hospital stay.
... Beyond tracheostomy, MV in critical trauma patients had a daily mean incremental cost of $ 1522.00 per patient per day. 62 the median in-hospital expenditures for severe tBi patients receiving MV treatment were estimated to be $ 55,267.00 per patient. ...
Introduction:
Tracheostomy is the most frequent bedside surgical procedure performed on patients with traumatic brain injury who require mechanical ventilation. To compare the effects of early tracheostomy vs late tracheostomy on the duration of mechanical ventilation in patients with traumatic brain injury, we carried out a systematic review and meta-analysis.
Evidence acquisition:
MEDLINE, Scopus, Web of Science, and Cochrane were searched from inception to 17th October 2022. Eligible clinical trials and observational studies reporting early versus late tracheostomy in TBI were searched. Two reviewers extracted data and independently assessed the risk of bias. The duration of mechanical ventilation was the primary outcome.
Evidence synthesis:
We pooled standardized mean differences and risk differences for random effects model. A total of 368 studies were retrieved and screened. Nineteen studies were selected, including 6253 patients. Mean time for early tracheostomy and late tracheostomy procedures was 6±2.9 days and 17±10.7 days, respectively. Early tracheostomy was associated with shorter mechanical ventilation duration (SMD=-1.79, 95% CI -2.71; -0.88) and fewer ventilator associated pneumonia (RD=-0.11, 95% CI -0.16; -0.06) when compared with late tracheostomy. Moreover, intensive care unit (ICU) (SMD=-1.64, 95% CI -2.44; -0.84) and hospital (SMD=-1.26, 95% CI -1.97; -0.56) length of stay were shorter when compared with late tracheostomy.
Conclusions:
The findings from this meta-analysis suggest that early tracheostomy in severe TBI patients contributes to a lower exposure to secondary insults and nosocomial adverse events, increasing the opportunity of patient's early rehabilitation and discharge.
... Future studies should consider the cost implications of EP. Cost and resource use are higher in ICU patients than non-ICU patients [33][34][35] and a cost-benefit analysis of the contributions made using the respective systems would be beneficial. Reasons for prescribers' behavioural changes with EP also need to be better understood. ...
... Approximately 40% of ICU patients require mechanical ventilation at any given hour [1], and thus mechanical ventilators can be in short supply when the number of critically ill patients increases, such as during the COVID-19 pandemic [2]. Although a ventilator can save lives, prolonged use of mechanical ventilation has risks including severe comorbidities, ventilator dependency, wastage of ICU resources, and additional costs [3]. Additionally, extubation failure is significantly associated with higher mortality, a longer length of stay in the ICU, and a higher likelihood of developing ventilator-associated complications [4]. ...
This retrospective study aimed to derive the clinical phenotypes of ventilated ICU patients to predict the outcomes on the first day of ventilation. Clinical phenotypes were derived from the eICU Collaborative Research Database (eICU) cohort via cluster analysis and were validated in the Medical Information Mart for Intensive Care (MIMIC-IV) cohort. Four clinical phenotypes were identified and compared in the eICU cohort (n = 15,256). Phenotype A (n = 3112) was associated with respiratory disease, had the lowest 28-day mortality (16%), and had a high extubation success rate (~80%). Phenotype B (n = 3335) was correlated with cardiovascular disease, had the second-highest 28-day mortality (28%), and had the lowest extubation success rate (69%). Phenotype C (n = 3868) was correlated with renal dysfunction, had the highest 28-day mortality (28%), and had the second-lowest extubation success rate (74%). Phenotype D (n = 4941) was associated with neurological and traumatic diseases, had the second-lowest 28-day mortality (22%), and had the highest extubation success rate (>80%). These findings were validated in the validation cohort (n = 10,813). Additionally, these phenotypes responded differently to ventilation strategies in terms of duration of treatment, but had no difference in mortality. The four clinical phenotypes unveiled the heterogeneity of ICU patients and helped to predict the 28-day mortality and the extubation success rate.
... 26 Similarly, depending on country, the cost of one-day hospitalization in the intensive care unit can be considerably high; and the cumulative costs of the medical procedures that become futile in cases of brain death are a burden on national health systems that can be clinically and socially justified only when organ donation has been intended, as well as the individual costs are expenses in private health insurance that companies are reluctant to cover. 27,28 Unless there is at least justification based on the necessity that organs must be kept alive with LS and other interventions until their procurement for transplantation, these consumptions and costs are characterized by the medical ethical phenomena of "defensive medicine" and "futile care" and are inconsistent with the fundamental medical ethical principle of "justice." This is so simply because the resources unduly allocated to these deceased individuals can instead be effectively used in the critical/intensive care of salvageable patients. ...
... Mechanical ventilation has a number of adverse effects such as ventilator-associated pneumonia [4], lung injuries [5,6], and a recently widely studied issue known as ventilator-induced diaphragmatic dysfunction (VIDD) [7,8]. The time required to wean patients from MV is directly proportional to ICU length of stay (LOS) which increases morbidity, mortality, and healthcare costs [9,10,11]. Almost half of ventilated patients have di cult or prolonged weaning [12]. General muscle weakness is a common problem in patients hospitalized in the ICU [13,14]. ...
Background: Diaphragm atrophy and dysfunction is a major problem among critically ill patients on mechanical ventilation. Ventilator-induced diaphragmatic dysfunction is thought to play a major role, resulting in a failure of weaning. Stimulation of the phrenic nerves and resulting diaphragm contraction could potentially prevent or treat this atrophy. The subject of this study is to determine the effectiveness of diaphragm stimulation in preventing atrophy by measuring changes in its thickness.
Methods: A total of 12 patients in the intervention group and 10 patients in the control group were enrolled. Diaphragm thickness was measured by ultrasound in both groups at the beginning of study enrollment (hour 0), after 24 hours, and at study completion (hour 48). The obtained data were then statistically analyzed and both groups were compared.
Results: The results showed that the baseline diaphragm thickness in the interventional group was (1.98 ± 0.52) mm and after 48 hours of phrenic nerve stimulation increased to (2.20 ± 0.45) mm (p=0.001). The baseline diaphragm thickness of (2.00 ± 0.33) mm decreased in the control group after 48 hours of mechanical ventilation to (1.72 ± 0.20) mm (p<0.001).
Conclusions: Our study demonstrates that induced contraction of the diaphragm by pacing the phrenic nerve not only reduces the rate of its atrophy during mechanical ventilation but also leads to an increase in its thickness – the main determinant of the muscle strength required for spontaneous ventilation and successful ventilator weaning.
... As previously described, in-hospital LOS (ICU and general ward) was captured in RESTORE-IMI 2 (stratified by ventilation status and health status at the end of hospitalization). Dasta et al. report ICU costs for non-ventilated and ventilated patients at days 1, 2 and 3 or more [18]. The inpatient general ward cost was sourced from the Kaiser Family Foundation database 2018 [19]. ...
Aim: This study evaluates the cost–effectiveness of imipenem/cilastatin/relebactam (IMI/REL) for treating
hospital-acquired bacterial pneumonia and ventilator-associated bacterial pneumonia (HABP/VABP) in an
‘early adjustment prescribing scenario’. Methods: An economic model was constructed to compare two
strategies: continuation of empiric piperacillin/tazobactam (PIP/TAZ) versus early adjustment to IMI/REL.
A decision tree was used to depict the hospitalization period, and a Markov model used to capture longterm
outcomes. Results: IMI/REL generated more quality-adjusted life years than PIP/TAZ, at an increased
cost per patient. The incremental cost–effectiveness ratio of $17,529 per QALY is below the typical US
willingness-to-pay threshold. Conclusion: IMI/RELmay represent a cost-effective treatment for payers and
a valuable option for clinicians, when considered alongside patient risk factors, local epidemiology, and
susceptibility data.
... On the other hand, delay in weaning from mechanical ventilation could contribute to complications such as nosocomial infections, ventilator-induced lung injury, and delirium (31,32). In addition, prolonged mechanical ventilation imposes a heavy financial burden in the intensive care unit setting (33). Laryngeal edema, which often manifests with stridor after tracheal extubation, is one of the most important contributors to extubation failure in the critical care setting (34). ...
Background
This meta-analysis aimed at assessing the diagnostic accuracy of ultrasound-measured laryngeal air column width difference (ACWD) in predicting post-extubation stridor (PES) in intubated adult patients.
Methods
We searched the Medline, Cochrane Library, EMBASE, and Google scholar databases from inception to October, 2022 to identify studies that examined the diagnostic accuracy of ACWD for PES. The primary outcome was the diagnostic performance by calculating the pooled sensitivity, specificity, and area under the curve (AUC). The secondary outcomes were the differences in ACWD and duration of intubation between patients with and without PES.
Results
Following literature search, 11 prospective studies (intensive care setting, n = 10; operating room setting, n = 1) involving 1,322 extubations were included. The incidence of PES among the studies was 4–25%. All studies were mixed-gender (females: 24.1–68.5%) with sample sizes ranging between 41 and 432. The cut-off values of ACWD for prediction of PES varied from 0.45 to 1.6 mm. The pooled sensitivity and specificity of ACWD for PES were 0.8 (95% CI = 0.69–0.88, I ² : 37.26%, eight studies) and 0.81 (95% CI = 0.72–0.88, I ² : 89.51%, eight studies), respectively. The pooled AUC was 0.87 (95% CI = 0.84–0.90). Patients with PES had a smaller ACWD compared to those without PES (mean difference = −0.54, 95% CI = −0.79 to −0.28, I ² : 97%, eight studies). Moreover, patients with PES had a longer duration of tracheal intubation than that in those without (mean difference = 2.75 days, 95% CI = 0.92, 4.57, I ² : 90%, seven studies).
Conclusion
Ultrasound-measured laryngeal ACWD showed satisfactory sensitivity and specificity for predicting PES. Because of the limited number of studies available, further investigations are needed to support our findings.
Systematic review registration
https://www.crd.york.ac.uk/prospero/ , identifier CRD42022375772.
... In North America and Europe, previous literature reports a range of US $1000-3500 per day in ICU costs, a decrease of 10 days in the ICU duration of stay per patient administered an extended infusion of cefepime would benefit health care institutions approximately US $10,000-35,000 per patient. 84,85 In addition, modification on ceftazidime infusion type has also demonstrated a cost-benefit ratio. CI versus II differed on costs because of the reduced amount of ceftazidime needed per day (3g with CI and 6g with II), which had an impact on the mean benefit of US $350.00 per patient. ...
Purpose:
Antimicrobial stewardship programs are important for reducing antimicrobial resistance because they can readjust antibiotic prescriptions to local guidelines, switch intravenous to oral administration, and reduce hospitalization times. Pharmacokinetics-pharmacodynamics (PK-PD) empirically based prescriptions and therapeutic drug monitoring (TDM) programs are essential for antimicrobial stewardship, but there is a need to fit protocols according to cost benefits. The cost benefits can be demonstrated by reducing toxicity and hospital stay, decreasing the amount of drug used per day, and preventing relapses in infection. Our aim was to review the data available on whether PK-PD empirically based prescriptions and TDM could improve the cost benefits of an antimicrobial stewardship program to decrease global hospital expenditures.
Methods:
A narrative review based on PubMed search with the relevant studies of vancomycin, aminoglycosides, beta-lactams, and voriconazole.
Results:
TDM protocols demonstrated important cost benefit for patients treated with vancomycin, aminoglycosides, and voriconazole mainly due to reduce toxicities and decreasing the hospital length of stay. In addition, PK-PD strategies that used infusion modifications to meropenem, piperacillin-tazobactam, ceftazidime, and cefepime, such as extended or continuous infusion, demonstrated important cost benefits, mainly due to reducing daily drug needs and lengths of hospital stays.
Conclusions:
TDM protocols and PK-PD empirically based prescriptions improve the cost-benefits and decrease the global hospital expenditures.
... For our cohort, this is likely in part driven by increased total LOS and increased interventions seen in the patients admitted to ICU. Previous studies have described the impact of LOS and interventions such as invasive mechanical ventilation in prolonging LOS for patients in critical care (33)(34)(35)(36). ...
Background: Dementia is a neurological syndrome affecting the growing elderly population. While patients with dementia are known to require significant hospital resources, little is known regarding the outcomes and costs of patients admitted to the intensive care unit (ICU) with dementia.
Methods: We conducted a population-based retrospective cohort study of patients with dementia admitted to the ICU in Ontario, Canada from 2016-2019. We compared the characteristics and outcomes of these patients to those with dementia admitted to non-ICU hospital settings. The primary outcome was hospital mortality but we also assessed length of stay (LOS), discharge disposition, and costs.
Results: Among 114,844 patients with dementia, 11,341 (9.9%) were admitted to the ICU. ICU patients were younger, more comorbid, and had less cognitive impairment (81.8 years, 22.8% had ≥3 comorbidities, 47.5% with moderate-severe dementia), compared to those in non-ICU settings (84.2 years, 15.0% had ≥3 comorbidities, 54.1% with moderate-severe dementia). Total mean LOS for patients in the ICU group was nearly 20 days, compared to nearly 14 days for the acute care group. Mortality in hospital was nearly three-fold greater in the ICU group compared to non-ICU group (22.2% vs. 8.8%). Total healthcare costs were increased for patients admitted to ICU vs. those in the non-ICU group ($67,201 vs. $54,080).
Conclusions: Patients with dementia admitted to the ICU have longer length of stay, higher in-hospital mortality, and higher total healthcare costs. Future studies should investigate preventable costs and while optimizing quality of life in this high risk and vulnerable population.
... This study describes the case mix and outcomes of 256 adult medical patients admitted to the ICU of a tertiary hospital in a contemporary SA population. The study cohort was young (42.1 years) compared with the ICU patients in HICs [19][20][21] and demonstrated a high HIV seroprevalence rate. Infectious diseases were major contributors to ICU admission. ...
Background:
The characteristics and mortality outcomes of patients admitted to South African intensive care units (ICUs) owing to medical conditions are unknown. Available literature is derived from studies based on data from high-income countries.
Objectives:
To determine ICU utilisation by medical patients and evaluate the scope of admissions and clinical associations with hospital mortality in ICU patients 12 years and older admitted to an Eastern Cape tertiary ICU, particularly in the subset with HIV disease.
Methods:
A retrospective descriptive one-year cohort study. Data were obtained from the LivAKI study database and demographic data, comorbidities, diagnosis, and mortality outcomes and associations were determined.
Results:
There were 261 (29.8%) medical ICU admissions. The mean age of the cohort was 40.2 years; 51.7% were female. When compared with the surgical emergencies, the medical subgroup had higher sequential organ failure assessment (SOFA) scores (median score 5 v. 4, respectively) and simplified acute physiology score III (SAPS 3) scores (median 52.7 v. 48.5), a higher incidence of acute respiratory distress syndrome (ARDS) (7.7% v. 2.9%) and required more frequent dialysis (20.3% v. 5.5%). Of the medical admissions, sepsis accounted for 32.4% of admission diagnoses. The HIV seroprevalence rate was 34.0%, of whom 57.4% were on antiretroviral therapy. ICU and hospital mortality rates were 11.1% and 21.5% respectively, while only acute kidney injury (AKI) and sepsis were independently associated with mortality. The HIV-positive subgroup had a higher burden of tuberculosis (TB), higher admission SOFA and SAPS 3 scores and required more organ support.
Conclusion:
Among medical patients admitted to ICU, there was a high HIV seroprevalence with low uptake of antiretroviral therapy. Sepsis was the most frequently identified ICU admission diagnosis. Sepsis and AKI (not HIV) were independent predictors of mortality. Co-infection with HIV and TB was associated with increased mortality.
Contributions of the study:
The epidemiology and outcomes of adults who are critically ill from medical conditions in South African intensive care units was previously unknown but has been described in this study. The association of sepsis, TB, HIV and acute kidney injury with mortality is discussed.
... Previous studies have suggested that prolonged MV is significantly associated with ICU mortality risk, 26À28 ICU readmission risk, 29 high ICU hospitalization costs, 7,24,30 and decreased long-term quality of life. 26 Accurate MV duration predictions can therefore allow better risk stratification of patients, assist clinical decisionmaking, and optimize ICU resource allocation, which is of great significance for improving both cost-effectiveness and patient outcomes. ...
Background
Acute respiratory distress syndrome (ARDS) is common in intensive care units with high mortality rate and mechanical ventilation (MV) is the most important related treatment. Early prediction of MV duration has benefit for patients risk stratification and care strategies support.
Objective
To develop an explainable model for predicting mechanical ventilation (MV) duration in patients with ARDS using the machine learning (ML) approach.
Method
The number of 1,148, 1,697, and 29 ARDS patients admitted to intensive care units (ICU) in the MIMIC-IV, eICU-CRD, and AmsterdamUMCdb databases were included in the study. Features at MV initiation from the MIMIC-IV dataset were used to train prediction models based on seven supervised machine learning algorithms. After 5-fold cross-validation for hyperparameters tuning, the hyperparameters- optimized model of different algorithms was tested by external datasets extracted from eICU-CRD and Amsterdamumcdb. Finally, three descriptive machine learning explanation methods were conducted for the model explanation.
Result
The XGBoosting model showed the most stable and accurate performance among two testing datasets (RMSE= 5.57 and 5.46 days in eICU-CRD and AmsterdamUMCdb) and was selected as the optimal model. The model explanation based on SHAP, LIME, and DALEX results showed a consistent result, vasopressor, PH, and SOFA score had the highest effect on MV duration prediction.
Conclusion
ML models with features at MV initiation can accurate predict MV duration in patients with ARDS in ICUs. Among seven algorithms, XGB models showed the best performance (RMSE= 5.57 and 5.46 in two external datasets). LIME, SHAP, and Breakdown methods showed good performance as AXI methods.
... 4 As the time spent on MV increases morbidity, mortality, and healthcare costs increase proportionally. 5,6 It is well known that like any other muscle in the body, the diaphragm atrophies when not in active use. ...
Background:
Prolonged mechanical ventilation caused by ventilator-induced diaphragm dysfunction (VIDD) is a serious problem in critically ill patients. Identification of patients who will have difficulty weaning from ventilation along with attempts to reduce total time on mechanical ventilation is some of the aims of intensive care medicine.
Observations:
This article briefly summarizes current options for temporary phrenic nerve stimulation therapy in an effort to keep the diaphragm active as direct prevention and treatment of ventilator-associated diaphragmatic dysfunction in patients on mechanical ventilation. The results of feasibility studies using different approaches are promising but so far, the clinical relevance is low. One important question is which tool would reliably identify early signs of diaphragmatic dysfunction and also be useful in guiding therapy. The authors present a brief overview of the current options considering the advantages and disadvantages of the available examination modalities. Despite the fact that current data point out some limitations of ultrasound examination, we believe that it still has a unique position in the bedside examination of critically ill patients on mechanical ventilation.
Conclusion:
Temporary phrenic nerve stimulation, regardless of the specific approach used, has the potential to directly treat or reverse VIDD, and ultrasound examination plays an important role in the comprehensive care of critically ill patients.
... CICUs (also called cardiac care units, acute coronary care units, or critical coronary care units) provide special, systematic, team-based critical care to patients recovering from cardiac surgeries and patients with severe cardiovascular diseases (CVDs-serious or life-threatening heart conditions such as heart attacks, acute coronary syndrome, cardiac arrhythmias, heart failure) and complications such as renal failure and respiratory issues (Loughran et al. 2017). Like CVDs, health conditions treated in ICUs are often the leading causes of deaths as well as elevated healthcare costs in the United States and other countries (e.g., Bowry et al. 2015;Dasta et al. 2005). ...
... Nevertheless, a general muscle affectation of critical patients was presented as a consequence of the greater use of IMV, named deconditioning syndrome, which was typically characterized by skeletal and respiratory muscle weakness [1,2]. To date, diaphragm dysfunction as a progressive reduction in muscle strength was induced immediately after IMV application, being a relevant clinical problem in intensive care units (ICUs) [3][4][5], as well as worsening the prognosis and mortality of pathological patients in ICUs [6][7][8][9][10]. ...
Worldwide, healthcare systems had to respond to an exponential increase in COVID-19 patients with a noteworthy increment in intensive care units (ICU) admissions and invasive mechanical ventilation (IMV). The aim was to determine low intensity respiratory muscle training (RMT) effects in COVID-19 patients upon medical discharge and after an ICU stay with IMV. A retrospective case-series study was performed. Forty COVID-19 patients were enrolled and divided into twenty participants who received IMV during ICU stay (IMV group) and 20 participants who did not receive IMV nor an ICU stay (non-IMV group). Maximal expiratory pressure (PEmax), maximal inspiratory pressure (PImax), COPD assessment test (CAT) and Medical Research Council (MRC) dyspnea scale were collected at baseline and after 12 weeks of low intensity RMT. A greater MRC dyspnea score and lower PImax were shown at baseline in the IMV group versus the non-IMV group (p < 0.01). RMT effects on the total sample improved all outcome measurements (p < 0.05; d = 0.38–0.98). Intragroup comparisons after RMT improved PImax, CAT and MRC scores in the IMV group (p = 0.001; d = 0.94–1.09), but not for PImax in the non-IMV group (p > 0.05). Between-groups comparison after RMT only showed MRC dyspnea improvements (p = 0.020; d = 0.74) in the IMV group versus non-IMV group. Furthermore, PImax decrease was only predicted by the IMV presence (R2 = 0.378). Low intensity RMT may improve respiratory muscle strength, health related quality of life and dyspnea in COVID-19 patients. Especially, low intensity RMT could improve dyspnea level and maybe PImax in COVID-19 patients who received IMV in ICU.
... Interventions that minimize the length of stay in the critical care unit and the duration of mechanical ventilation could result in significant savings in total inpatient costs. 13 However, the patient in our case was unable to afford to stay in an intensive care unit with mechanical ventilation and had to rely on the bag and mask ventilation until he lost his precious life on the way to the referral center. ...
Intermediate syndrome with respiratory failure is a serious complication that can be fatal as in our case of a 24‐year‐old‐man who developed intermediate syndrome requiring intubation and respiratory support. Furthermore, the patient's socio‐economic situation significantly impacts the illness's progress and prognosis. With this case report, we want to stress how a patient's socio‐economic background affects the course and outcome of a particular disease condition.
Background
Two prefusion F protein-based vaccines, Arexvy and Abrysvo, have been authorized by the US Food and Drug Administration for protecting older adults against Respiratory Syncytial Virus (RSV)-associated lower respiratory tract illness. We evaluated the health benefits and cost-effectiveness of these vaccines.
Methods
We developed a discrete-event simulation model, parameterized with the burden of RSV disease including outpatient care, hospitalization, and death for adults aged 60 years or older in the US. Taking into account the costs associated with these RSV-related outcomes, we calculated the net monetary benefit using quality-adjusted life-years (QALY) gained as a measure of effectiveness, and determined the range of price-per-dose (PPD) for Arexvy and Abrysvo vaccination programs to be cost-effective from a societal perspective.
Results
Using a willingness-to-pay of $95,000 per QALY gained, we found that vaccination programs could be cost-effective for a PPD under $120 with Arexvy and $111 with Abrysvo over the first RSV season. Achieving an influenza-like vaccination coverage of 66% for the population of older adults in the US, the budget impact of these programs at the maximum PPD ranged from $5.74 to $6.10 billion. If the benefits of vaccination extend to a second RSV season as reported in clinical trials, we estimated a maximum PPD of $250 for Arexvy and $233 for Abrysvo, with two-year budget impacts of $11.59 and $10.89 billion, respectively.
Conclusions
Vaccination of older adults would provide substantial direct health benefits by reducing outcomes associated with RSV-related illness in this population.
Aims: It is aimed to evaluate the effectiveness of the consultations and response times requested from the Intensive Care Unit on the cost. Methods: This study was conducted retrospectively in a 16-bed anesthesia intensive care unit (ICU) between 02.01.2019 and 30.12.2019. Patient information from the hospital data system was analyzed. Accordingly, demographic data, hospitalization diagnoses, departments for which consultation was requested, times of request, response times, and the average cost per day of a patient were investigated. Results: It was determined that consultation was requested from a total of 522 patients, 223 (43%) of the patients were female, 299 (57%) were male, and the age range was 18-98 (mean age 57). It was found that the average consultation response time in all departments was 4.09 hours outside of working hours and 3.54 hours during working hours. There was no significant difference in the response time of consultations between internal and surgical departments. The daily cost of one patient in the ICU was found to be 2380.39 ₺. Conclusion: Failure to promptly respond to the requested consultations in the intensive care unit may cause delays in patients' treatment and their discharge to the service. This situation increases the patient's length of stay and causes the intensive care units not to be used effectively and correctly. However, it can also increase morbidity and cost.
It is important to consider the total cost of care (TCOC) associated with a therapy and clinical benefit for relapsed or refractory (R/R) large B cell lymphoma (LBCL). We estimated the 1-year TCOC and cost per clinical outcome for patients with R/R LBCL treated with second-line lisocabtagene maraleucel (liso-cel) versus autologous stem cell transplantation (ASCT) using data from the TRANSFORM study (NCT03575351). A cost per clinical outcome analysis using a Monte Carlo simulation approach was conducted. Cost inputs were generated from a retrospective microcosting analysis of healthcare resource utilization (HCRU). Patient-level data from an interim analysis (March 2021) were used to derive HCRU and clinical inputs. Clinical inputs included median event-free survival (EFS), median progression-free survival (PFS), objective response rate, and complete response (CR) rate. In the intention-to-treat analysis, the mean (standard deviation) TCOC per patient was $550,864 ($173,087) for liso-cel and $413,200 ($290,802) for ASCT. The cost per clinical outcome model estimated a mean cost for liso-cel versus ASCT, respectively, per EFS month of $57,295 versus $186,369, per PFS month of $40,949 versus $78,797, per overall responder of $653,965 versus $881,804, and per complete responder of $828,045 versus $1,063,822. This economic model shows reductions in mean estimated TCOC per EFS month, PFS month, overall responder, and CR with liso-cel versus ASCT because of the superior efficacy of liso-cel. While liso-cel-treated patients incurred greater up-front costs, fewer required subsequent therapy and accumulated less downstream costs. These results underscore the importance of considering durability of response and clinical benefit when assessing total costs.
Aim:
To establish the burden of respiratory illness in cerebral palsy (CP) on the Western Australian health care system by quantifying the costs of respiratory hospitalizations in children with CP, compared with non-respiratory hospitalizations.
Method:
A 2-year (2014-2015) retrospective study using linked hospital data (excluding emergency department visits), in a population of children with CP in Western Australia aged 18 years and under (median age at hospitalization 7 years; interquartile range 5-12 years).
Results:
In 671 individuals (57% male) there were 726 emergency hospitalizations, and 1631 elective hospitalizations. Although there were more elective hospitalizations, emergency hospitalizations were associated with longer stays in hospital, and more days in an intensive care unit, resulting in a higher total cost of emergency hospitalizations than elective hospitalizations (total costs: emergency AU$7 748 718 vs elective AU$6 738 187). 'Respiratory' was the leading cause of emergency hospitalizations, contributing to 36% of all emergency admission costs. For a group of high-cost inpatient users (top 5% of individuals with the highest total inpatient costs) the most common reason for hospitalization was 'respiratory'. Where non-respiratory admissions were complicated by an additional respiratory diagnosis, length of stay was greater.
Interpretation:
Respiratory hospitalizations in CP are a significant driver of health care costs. In the paediatric group, they are a burden for a subgroup of children with CP.
Global neurosurgery is the clinical and public health practice of neurosurgery with the primary purpose of ensuring safe, timely, and affordable neurosurgical care to all who need it. Guided by the principles of global health equity, global neurosurgery embraces the ideals of the global surgery movement and seeks to fill the unmet need for neurosurgical care worldwide as a component of national health systems committed to universal health coverage (Park KB, Johnson WD, Dempsey RJ, World Neurosurg. 88:32-35, 2016). This chapter introduces some of the fundamental clinical entities constituting the burden of neurosurgical disease worldwide and management strategies for those entities from the vantage point of neurosurgeons with specific experience caring and advocating for neurosurgical care in resource-limited settings. Covering diagnostic and therapeutic principles of neurotrauma and related entities of acute care neurosurgery, the chapter is designed as an introductory reference that can support surgeons in resource-limited settings in optimizing care for patients suffering from these neurosurgical diseases.KeywordsGlobal neurosurgeryGlobal healthLow- and middle-income countriesNeurotraumaPublic health
Objectives:
The primary objective was to determine the financial resources allocated to docusate at a representative U.S. tertiary care center. Secondary objectives included comparing docusate utilization between two tertiary care centers, and exploring alternative uses for the funds spent on docusate.
Methods:
The study population included all patients 18 years and older admitted to University Hospital in Newark, New Jersey. Every scheduled docusate prescription for the study population between NaN Invalid Date NaN and NaN Invalid Date NaN was collected. The annual total cost associated with docusate use per year was calculated. The 2015 data from this study and a 2015 McGill University Health Centre study were compared. Also, alternative uses for the money utilized on docusate were assessed.
Results:
Over the study period, 37034 docusate prescriptions and 265,123 docusate doses were recorded. The average cost of prescribing docusate was $25,624.14 per year and $49.37 per hospital bed per year. A comparison between the 2015 data of University Hospital and McGill showed that McGill prescribed 107 doses and spent $10.09 more per hospital bed than University Hospital. Finally, alternative uses for the average yearly spending on docusate equated to 0.35 the salary of a nurse, 0.51 the salary of a secretary, 20.66 colonoscopies, 27.00 upper endoscopies, 186.71 mammograms, 1,399.37 doses of polyethylene glycol 3350, 3,826.57 doses of lactulose, or 4,583.80 doses of psyllium.
Conclusion:
A single average size tertiary care hospital spent about $25,000 yearly on docusate despite its lack of clinical effectiveness. While this amount is small compared to an overall hospital budget, when considering likely comparable docusate use at the U.S's 6,090 hospitals, the economic burden of docusate becomes significant. The funds currently being used on docusate could be redirected to alternative, more cost-effective purposes.
Objective:
To evaluate survival and direct medical costs of patients admitted in private hospitals with COVID-19 during the first wave.
Methods:
A retrospective, observational study analyzing survival and the economic data retrieved on hospitalized patients with COVID-19. Data from March 2020 to December 2020. The direct cost of hospitalization was estimated using the microcosting method with each individual hospitalization.
Results:
342 cases were evaluated. Median age of 61.0 (95% CI 57.0‒65.0). 194 (56.7%) were men. The mortality rate was higher in the female sex (p = 0.0037), ICU (p < 0.001), mechanical ventilation (p<0.001) and elderly groups. 143 (41.8%) patients were admitted to the ICU (95% CI 36.6%-47.1%), of which 60 (41.9%) required MV (95% CI 34.0%-50.0%). Global LOS presented median of 6.7 days (95% CI 6.0-7.2). Mean costs were US$ 7,060,00 (95% CI 5,300.94-8,819,00) for each patient. Mean cost for patients discharged alive and patients deceased was US$ 5,475.53 (95% CI 3,692.91-7,258.14) and US$ 12,955.19 (95% CI 8,106.61-17,803.76), respectively (p < 0.001).
Conclusions:
Patients admitted with COVID-19 in these private hospitals point to great economic impact, mainly in the elderly and high-risk patients. It is key to better understand such costs in order to be prepared to make wise decisions during the current and future global health emergencies.
Background:
Intercostal nerve cryoablation is an adjunctive measure that has demonstrated pain control, decrease in opioid consumption, and decrease in hospital length of stay (LOS) in patients who undergo surgical stabilization of rib fractures (SSRF).
Methods:
SSRF patients from January 2015 to September 2021 were retrospectively compared. All patients received multimodal pain regimens post-operatively and the independent variable was intraoperative cryoablation.
Results:
241 patients met inclusion criteria. 51 (21%) underwent intra-operative cryoablation during SSRF and 191 (79%) did not. Patients with standard treatment consumed 9.4 more daily MME (p = 0.035), consumed 73 percent more post-operative total MME (p = 0.001), spent 1.55 times as many days in the intensive care unit (p = 0.013), and spent 3.8 times as many days on the ventilator than patients treated with cryoablation, respectively. Overall hospital LOS, operative case time, pulmonary complications, MME at discharge, and numeric pain scores at discharge were no different (all p>0.05).
Conclusion:
Intercostal nerve cryoablation during SSRF is associated with fewer ventilator days, ICU LOS, total post-operative, and daily opioid use without increasing time in the operating room or perioperative pulmonary complications.
Background:
Weaning rate is an important quality indicator of care for patients with prolonged mechanical ventilation (PMV). However, diverse clinical characteristics often affect the measured rate. A risk-adjusted control chart may be beneficial for assessing the quality of care.
Methods:
We analyzed patients with PMV who were discharged between 2018 and 2020 from a dedicated weaning unit at a medical center. We generated a formula to estimate monthly weaning rates using multivariate logistic regression for the clinical, laboratory, and physiologic characteristics upon weaning unit admission in the first two years (Phase I). We then applied both multiplicative and additive models for adjusted p-charts, displayed in both non-segmented and segmented formats, to assess whether special cause variation existed.
Results:
A total of 737 patients were analyzed, including 503 in Phase I and 234 in Phase II, with average weaning rates of 59.4% and 60.3%, respectively. The p-chart of crude weaning rates did not show special cause variation. Ten variables from the regression analysis were selected for the formula to predict individual weaning probability and generate estimated weaning rates in Phases I and II. For risk-adjusted p-charts, both multiplicative and additive models showed similar findings and no special cause variation.
Conclusion:
Risk-adjusted control charts generated using a combination of multivariate logistic regression and control chart-adjustment models may provide a feasible method to assess the quality of care in the setting of PMV with standard care protocols.
A flail chest is one of the possible medical conditions suffered by individuals who were injured in traffic accidents, caused by multiple fractures of the ribs and sternum. Which often results in paradoxical chest movements. The consequence may be respiratory failure and need for long-term mechanical ventilation. Such treatment require Intensive Care Unit and may be associated with the possibility of numerous complications.
Modified Nuss procedure was performed in 79-year-old man, a victim of a car crash to obtain stabilization of the flail chest. After compensation of paradoxical movements on the third day it was possible to end mechanical ventilation. A quick procedure dedicated to the congenital deformation of the chest made it possible to avoid long, expensive intensive therapy with possible respiratory complications.
The NUSS procedure enables the effective and safe treatment of a flail chest in a selected group of patients.
We aimed to evaluate the characteristics, resource use and outcomes of critically ill patients with cancer according to appropriateness of ICU admission. This was a retrospective cohort study of patients with cancer admitted to ICU from January 2017 to December 2018. Patients were classified as appropriate, potentially inappropriate, or inappropriate for ICU admission according to the Society of Critical Care Medicine guidelines. The primary outcome was ICU length of stay (LOS). Secondary outcomes were one-year, ICU, and hospital mortality, hospital LOS and utilization of ICU organ support. We used logistic regression and competing risk models accounting for relevant confounders in primary outcome analyses. From 6700 admitted patients, 5803 (86.6%) were classified as appropriate, 683 (10.2%) as potentially inappropriate and 214 (3.2%) as inappropriate for ICU admission. Potentially inappropriate and inappropriate ICU admissions had lower likelihood of being discharged from the ICU than patients with appropriate ICU admission (sHR 0.55, 95% CI 0.49-0.61 and sHR 0.65, 95% CI 0.53-0.81, respectively), and were associated with higher 1-year mortality (OR 6.39, 95% CI 5.60-7.29 and OR 11.12, 95% CI 8.33-14.83, respectively). Among patients with appropriate, potentially inappropriate, and inappropriate ICU admissions, ICU mortality was 4.8%, 32.6% and 35.0%, and in-hospital mortality was 12.2%, 71.6% and 81.3%, respectively (p < 0.01). Use of organ support was more common and longer among patients with potentially inappropriate ICU admission. The findings of our study suggest that inappropriateness for ICU admission among patients with cancer was associated with higher resource use in ICU and higher one-year mortality among ICU survivors.
Spirulina is a functional food with antioxidant and anti-inflammatory effects. This study aimed to investigate the effects of Spirulina supplementation in critically ill patients with COVID-19. This study was a double-blind clinical trial that randomized patients, admitted to an intensive care unit (ICU), to Spirulina platensis supplementation (5g/d,N = 97) or control groups (n = 95). Acute Physiology and Chronic Health Evaluation (APACHE), National Early Warning Score (NEWS) 2, and Sequential Organ Failure Assessment Score (SOFA) were scoring systems to assess COVID-19 severity. Hospital and ICU length of stay, respiratory support at discharge, and 28-day mortality were assessed as well. In survival analysis, 126 participants (58 in control and 68 in Spirulina groups) were evaluated, and results showed no between-group difference in 28-day mortality (HR = 1.07, 95% CI 0.57–1.97) and NEWS2 (P-value = 0.14) but the SOFA score had a significant decrease in the Spirulina group compared to control (β=-0.48, P-value = 0.04). Spirulina resulted a shorter ICU length of stay (6 days,4.75–9.25) compared to the control group (10 days, 6–15), P-value = 0.007). The hospital length of stay was lower in Spirulina compared to the control group (P-value = 0.001). Spirulina supplementation was effective in reducing SOFA score and hospital and ICU length of stay in critically ill patients with COVID-19.
Introduction:
Despite the significant clinical consequences and socioeconomic costs of gun-shot wounds to the head (GSWH), studies examining pre-hospital risk factors, geo-spatial patterns, and economic cost are lacking.
Methods:
A retrospective analysis was performed for GSWH patients (single or multiple injuries) presenting to the level one Ryder Trauma Center (hospital patients) as well as the Miami Dade County Medical Examiner (ME) Department, from October 2013 to October 2015. Additionally, ME data was queried from the previous decade (2008-2017) to analyze longitudinal trends.
Results:
402 consecutive cases met inclusion criteria: 297 (74%) presented to the ME and 105 (26%) presented to the hospital. GSWH in our cohort had a case fatality rate of 89%, predominantly afflicting males, Caucasians, and victims of suicide, with a mean age of 41.9 ± 20.6 years. Hospital patients were more likely to be Black males from low socioeconomic (SES) regions involved in assault. Older, Caucasian males were overrepresented in patients attempting and completing suicide, thus comprised a higher percentage of ME cases. Geo-spatial analysis of hospital patient injury zip-codes illustrates GSWH are significantly clustered in low-income urban centers with greater poverty rates. In Miami-Dade County, the economic burden of GSWH, as measured by total healthcare costs and lifetime productivity losses, was estimated to be $11,867,415 and $246,179,498 respectively.
Conclusion:
In the first analysis of GSWH with the inclusion of both hospital and ME data in a representative urban setting, our findings demonstrate pre-hospital risk factors and the unequal distribution of the significant economic costs of GSWH.
Mechanical ventilation is widely used in intensive care units, especially for the treatment of acute respiratory distress syndrome and acute lung injury. Physiological parameters of critically ill patients change rapidly, which poses a challenge to the strategy development of mechanical ventilation. Despite the existence of multiple clinical guidelines, a personalized ventilation strategy is still lacking. With the rapid development of machine learning, many studies have applied machine learning methods to ventilator strategy optimization, but there is currently a lack of research on predicting the situation of reintubation after weaning. This study proposes a deep learning algorithm including an attention mechanism to predict the situation of reintubation after weaning, and achieved better performance than the basic algorithm.KeywordsMechanical ventilationDeep learningAttention mechanismReintubation
Purpose
The purpose of our study is to analyze what factors influence the cost of orthognathic surgery performed within the US.
Study Design
This retrospective cohort study was completed using the Kids’ Inpatient Database (KID) from 2000 to 2012 on all patients aged 14-20 years who had undergone orthognathic surgery. There predictor variables included patient and hospitalization characteristics. The primary outcome variable was hospital charge (US dollars). Multivariate linear regression was conducted to determine independent predictors for increased/decreased hospital charge.
Results
The final sample consisted of 14,191 patients (mean age, 17.4 ± 1.6 years; females, 59.2%). Each additional day in the hospital added $8,123 in hospital charges (p < 0.01). Relative to mandibular osteotomy, maxillary osteotomy (+$5,703, p < 0.01) and bi-maxillary osteotomy (+$9,419, p < 0.01) were each associated with increased hospital charges. Genioplasty (+$3,499, p < 0.01), transfusion of packed cells (TPC) (+$11,719, p < 0.01), continuous invasive mechanical ventilation (CIMV) < 96 hours (+$23,502, p < 0.01), CIMV ≥ 96 hours (+$30,901, p < 0.01) were each associated with significantly increased hospital charges. OSA added $6,560 in hospital charges (p < 0.01).
Conclusions
Maxillary osteotomy and bi-maxillary surgery were each associated with significantly increased charges relative to mandibular osteotomy. Concomitant genioplasty, TPC, CIMV, and OSA each significantly increased charges. Each additional day to the length of stay (LOS) significantly increased charges.
Background
Hospitalization costs for treatment of hemodialysis (HD) catheter-associated blood stream infections (CA-BSI) in adults are high. No studies have evaluated hospitalization costs for HD CA-BSI in children or identified factors associated with high-cost hospitalizations.Methods
We analyzed 160 HD CA-BSIs from the Standardizing Care to Improve Outcomes in Pediatric End-stage Kidney Disease (SCOPE) collaborative database linked to hospitalization encounters in the Pediatric Health Information System (PHIS) database. Charge-to-cost ratios were used to convert hospitalization charges reported in PHIS database to estimated hospital costs. Generalized linear mixed modeling was used to assess the relationship between higher-cost hospitalization (cost above 50th percentile) and patient and clinical characteristics. Generalized linear regression models were used to assess differences in mean service line costs between higher- and lower-cost hospitalizations.ResultsThe median (IQR) length of stay for HD CA-BSI hospitalization was 5 (3–10) days. The median (IQR) cost for HD CA-BSI hospitalization was $18,375 ($11,584–$36,266). ICU stay (aOR 5.44, 95% CI 1.62–18.26, p = 0.01) and need for a catheter procedure (aOR = 6.08, 95% CI 2.45–15.07, p < 0.001) were associated with higher-cost hospitalization.Conclusions
Hospitalizations for HD CA-BSIs in children are often multiple days and are associated with substantial costs. Interventions to reduce CA-BSI may reduce hospitalization costs for children who receive chronic HD.Graphical abstract
A higher resolution version of the Graphical abstract is available as Supplementary information
Purpose:
Recent studies of polatuzumab vedotin and CD19 chimeric antigen receptor T-cell therapy (CAR-T) have shown significant improvements in progression-free survival over standard of care (SOC) for patients with diffuse large B-cell lymphoma. However, they are costly, and it is unclear whether these strategies, alone or combined, are cost-effective over SOC.
Methods:
A Markov model was constructed to compare four strategies for patients with newly diagnosed intermediate- to high-risk diffuse large B-cell lymphoma: strategy 1: polatuzumab-rituximab, cyclophosphamide, doxorubicin, and prednisone (R-CHP) plus second-line CAR-T for early relapse (< 12 months); strategy 2: polatuzumab-R-CHP plus second-line salvage therapy ± autologous stem-cell transplant; strategy 3: rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone plus second-line CAR-T for early relapse; strategy 4: SOC (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone plus second-line salvage therapy ± autologous stem-cell transplant). Transition probabilities were estimated from trial data. Lifetime costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs) were calculated from US and Canadian payer perspectives. Willingness-to-pay (WTP) thresholds of $150,000 US dollars (USD) or Canadian dollars (CAD)/QALY were used.
Results:
In probabilistic analyses (10,000 simulations), each strategy was incrementally more effective than the previous strategy, but also more costly. Adding polatuzumab-R-CHP to the SOC had an ICER of $546,956 (338,797-1,199,923) USD/QALY and $245,381 (151,671-573,250) CAD/QALY. Adding second-line CAR-T to the SOC had an ICER of $309,813 (190,197-694,200) USD/QALY and $303,163 (221,300-1,063,864) CAD/QALY. Simultaneously adding both polatuzumab-R-CHP and second-line CAR-T to the SOC had an ICER of $488,284 (326,765-840,157) USD/QALY and $267,050 (182,832-520,922) CAD/QALY.
Conclusion:
Given uncertain incremental benefits in long-term survival and high costs, neither polatuzumab-R-CHP frontline, CAR-T second-line, nor a combination are likely to be cost-effective in the United States or Canada at current pricing compared with the SOC.
The objective of this study was to refine the APACHE (Acute Physiology, Age, Chronic Health Evaluation) methodology in order to more accurately predict hospital mortality risk for critically ill hospitalized adults. We prospectively collected data on 17,440 unselected adult medical/surgical intensive care unit (ICU) admissions at 40 US hospitals (14 volunteer tertiary-care institutions and 26 hospitals randomly chosen to represent intensive care services nationwide). We analyzed the relationship between the patient's likelihood of surviving to hospital discharge and the following predictive variables: major medical and surgical disease categories, acute physiologic abnormalities, age, preexisting functional limitations, major comorbidities, and treatment location immediately prior to ICU admission. The APACHE III prognostic system consists of two options: (1) an APACHE III score, which can provide initial risk stratification for severely ill hospitalized patients within independently defined patient groups; and (2) an APACHE III predictive equation, which uses APACHE III score and reference data on major disease categories and treatment location immediately prior to ICU admission to provide risk estimates for hospital mortality for individual ICU patients. A five-point increase in APACHE III score (range, 0 to 299) is independently associated with a statistically significant increase in the relative risk of hospital death (odds ratio, 1.10 to 1.78) within each of 78 major medical and surgical disease categories. The overall predictive accuracy of the first-day APACHE III equation was such that, within 24 h of ICU admission, 95 percent of ICU admissions could be given a risk estimate for hospital death that was within 3 percent of that actually observed (r2 = 0.41; receiver operating characteristic = 0.90). Recording changes in the APACHE III score on each subsequent day of ICU therapy provided daily updates in these risk estimates. When applied across the individual ICUs, the first-day APACHE III equation accounted for the majority of variation in observed death rates (r2 = 0.90, p less than 0.0001).
This study evaluates the accuracy of costs derived from the ratio of costs to charges (RCCs), using costs based on relative value units (RVUs) as the "gold standard." We found that RCC-calculated costs were not a good basis for determining the costs of individual patients. However, when examining average costs per diagnosis-related group (DRG), RCCs performed better. For almost 70% of the DRGs, average RCC-calculated costs were within 10% of average RVU-calculated costs. RCCs were even more reliable for comparing the relative cost of patients in a DRG in one hospital to the average cost of patients in that DRG in a group of hospitals. Charges, or an overall hospital RCC (as opposed to the departmental RCCs we used in most of our analyses), were not a good basis for determining relative hospital costs.
The outcome of patients receiving mechanical ventilation for particular indications has been studied, but the outcome in a large number of unselected, heterogeneous patients has not been reported.
To determine the survival of patients receiving mechanical ventilation and the relative importance of factors influencing survival.
Prospective cohort of consecutive adult patients admitted to 361 intensive care units who received mechanical ventilation for more than 12 hours between March 1, 1998, and March 31, 1998. Data were collected on each patient at initiation of mechanical ventilation and daily throughout the course of mechanical ventilation for up to 28 days.
All-cause mortality during intensive care unit stay.
Of the 15 757 patients admitted, a total of 5183 (33%) received mechanical ventilation for a mean (SD) duration of 5.9 (7.2) days. The mean (SD) length of stay in the intensive care unit was 11.2 (13.7) days. Overall mortality rate in the intensive care unit was 30.7% (1590 patients) for the entire population, 52% (120) in patients who received ventilation because of acute respiratory distress syndrome, and 22% (115) in patients who received ventilation for an exacerbation of chronic obstructive pulmonary disease. Survival of unselected patients receiving mechanical ventilation for more than 12 hours was 69%. The main conditions independently associated with increased mortality were (1) factors present at the start of mechanical ventilation (odds ratio [OR], 2.98; 95% confidence interval [CI], 2.44-3.63; P<.001 for coma), (2) factors related to patient management (OR, 3.67; 95% CI, 2.02-6.66; P<.001 for plateau airway pressure >35 cm H(2)O), and (3) developments occurring over the course of mechanical ventilation (OR, 8.71; 95% CI, 5.44-13.94; P<.001 for ratio of PaO(2) to fraction of inspired oxygen <100).
Survival among mechanically ventilated patients depends not only on the factors present at the start of mechanical ventilation, but also on the development of complications and patient management in the intensive care unit.
We forecast a slowdown in national health spending growth in 2002 and 2003, reflecting slower projected Medicare and private personal health spending growth. These factors outweigh higher projected Medicaid spending growth, caused by weak labor markets, and an expectation of continued high private health insurance premium inflation related to the underwriting cycle. Over the entire projection period, national health spending growth is still expected to outpace economic growth. The result is that the health share of gross domestic product is projected to increase from 14.1 percent in 2001 to 17.7 percent in 2012.
Critical care resources in the United States are being rationed, that is, not all critical care expected to be beneficial is being provided to all patients who desire it. Although the extent of rationing is uncertain, it is an everyday occurrence in some hospitals and is likely to occur at least some of the time in many hospitals. Substantial evidence suggests that current rationing practices are highly subjective and perhaps inequitable. Critical care is widely believed to be beneficial to many patients, despite a striking dearth of supportive data. Since this type of care is being inequitably denied to some patients, hospitals should either adopt formal rationing guidelines or, alternatively, they should take clear steps to avoid rationing by altering the supply of or the demand for critical care. Reasonable arguments are presented in support of both approaches, as are suggestions for their implementation.(JAMA. 1989;261:2389-2395)
The smearing estimate is proposed as a nonparametric estimate of the expected response on the untransformed scale after fitting a linear regression model on a transformed scale. The estimate is consistent under mild regularity conditions, and usually attains high efficiency relative to parametric estimates. It can be viewed as a low-premium insurance policy against departures from parametric distributional assumptions. A real-world example of predicting medical expenditures shows that the smearing estimate can outperform parametric estimates even when the parametric assumption is nearly satisfied.
To estimate the incidence of acute respiratory failure (ARF) in the United States and to analyze 31-day hospital mortality among a cohort of patients with ARF. Design and setting: Retrospective cohort drawn from the Nationwide Inpatient Sample of 6. 4 million discharges from 904 representative nonfederal hospitals during 1994.
All 61,223 patients in the sample whose discharge records indicated all of the following: acute respiratory distress or failure, mechanical ventilation, > or = 24 h of hospitalization, and age > or = 5 years.
An estimated 329,766 patients discharged from nonfederal hospitals nationwide in 1994 met study criteria for ARF. The incidence of ARF was 137.1 hospitalizations per 100,000 US residents age > or = 5 years. Incidence increased nearly exponentially each decade until age 85 years. Overall, 35.9% of patients with ARF did not survive to hospital discharge. At 31 days, hospital mortality was 31.4%. According to the proportional hazards model, significant mortality hazards included age (> or = 80 years and > or = 30 years), multiorgan system failure (MOSF), HIV, chronic liver disease, and cancer. Hospital admission for coronary artery bypass, drug overdose, or trauma other than head injury or burns was associated with a reduced mortality hazard. Interaction was present between age and MOSF, trauma, and cancer. A point system derived from the hazard model classified patients into seven groups with distinct 31-day survival probabilities ranging from 24 to 99%.
The incidence of ARF increases markedly with age and is especially high among persons > or = 65 years of age. Nonpulmonary hazards explain short-term (31-day) survival.
Objective.
—To determine the prevalence of intensive care unit (ICU)—acquired infections and the risk factors for these infections, identify the predominant infecting organisms, and evaluate the relationship between ICU-acquired infection and mortality.
: Critical care services consume a large share of health-care resources, many of which are devoted to the care of ventilator-dependent patients who often require prolonged support. The precise determination of costs of mechanical ventilation is quite complex and may even be elusive. This results from several factors, including the difficulty inherent in separating the "technology" of mechanical ventilation from the reason for its use, variable cost accounting methodologies used by different institutions, and the overlap between direct and indirect costs that accrue. Furthermore, cost determinations of ventilator dependency must be distinguished from cost effectiveness, the latter linking clinical outcome and utility to the amount of resources expended. In view of the heightened concern for cost containment, impending health care reform, and changes in health care reimbursement, the pulmonary and critical care physician must become familiar with the economics of mechanical ventilation. Doing so will facilitate financial savings without sacrificing clinical quality.
(C) Williams & Wilkins 1994. All Rights Reserved.
Critical care resources in the United States are being rationed, that is, not all critical care expected to be beneficial is being provided to all patients who desire it. Although the extent of rationing is uncertain, it is an everyday occurrence in some hospitals and is likely to occur at least some of the time in many hospitals. Substantial evidence suggests that current rationing practices are highly subjective and perhaps inequitable. Critical care is widely believed to be beneficial to many patients, despite a striking dearth of supportive data. Since this type of care is being inequitably denied to some patients, hospitals should either adopt formal rationing guidelines or, alternatively, they should take clear steps to avoid rationing by altering the supply of or the demand for critical care. Reasonable arguments are presented in support of both approaches, as are suggestions for their implementation.
KIE
Considerable evidence supports the contention that U.S. hospitals ration critical care resources in an informal, often irrational and unfair manner. The value, efficacy, and cost of intensive care units are discussed and two options are proposed to tackle the problem of rationing. Hospitals should either establish formal, specific, and equitable rationing guidelines or, alternatively, develop plans to avoid rationing by increasing the supply of resources or by decreasing the demand for them. It is suggested that demand be decreased by more aggressive discharge or by a system of graded care rather than by denying admission. Arguments in favor of and against rationing are presented. It is concluded that, whichever option is chosen, plans should be developed openly, approved by appropriate supervisory bodies, and brought to the attention of hospital staff and patients.
To determine the prevalence of intensive care unit (ICU)-acquired infections and the risk factors for these infections, identify the predominant infecting organisms, and evaluate the relationship between ICU-acquired infection and mortality.
A 1-day point-prevalence study.
Intensive care units in 17 countries in Western Europe, excluding coronary care units and pediatric and special care infant units.
All patients (> 10 years of age) occupying an ICU bed over a 24-hour period. A total of 1417 ICUs provided 10 038 patient case reports.
Rates of ICU-acquired infection, prescription of antimicrobials, resistance patterns of microbiological isolates, and potential risk factors for ICU-acquired infection and death.
A total of 4501 patients (44.8%) were infected, and 2064 (20.6%) had ICU-acquired infection. Pneumonia (46.9%), lower respiratory tract infection (17.8%), urinary tract infection (17.6%), and bloodstream infection (12%) were the most frequent types of ICU infection reported. Most frequently reported micro-organisms were Enterobacteriaceae (34.4%), Staphylococcus aureus (30.1%;[60% resistant to methicillin], Pseudomonas aeruginosa (28.7%), coagulase-negative staphylococci (19.1%), and fungi (17.1%). Seven risk factors for ICU-acquired infection were identified: increasing length of ICU stay (> 48 hours), mechanical ventilation, diagnosis of trauma, central venous, pulmonary artery, and urinary catheterization, and stress ulcer prophylaxis. ICU-acquired pneumonia (odds ratio [OR], 1.91; 95% confidence interval[Cl], 1.6 to 2.29), clinical sepsis (OR, 3.50; 95% Cl, 1.71 to 7.18), and bloodstream infection (OR, 1.73; 95% Cl, 1.25 to 2.41) increased the risk of ICU death.
ICU-acquired infection is common and often associated with microbiological isolates of resistant organisms. The potential effects on outcome emphasize the importance of specific measures for infection control in critically ill patients.
To study methods for costing hospital services, specifically in relation to multi-unit studies of activity, case mix, severity of illness, outcome, and resource use in adult intensive care units (ICUs).
Twenty published cost studies of adult ICUs. The studies are all published in English and are both European and American.
Cost studies of adult ICUs published in international journals (English language).
Literature survey, where the articles were obtained through MEDLINE and other database searches.
Cost of intensive care therapy was compared across the 20 studies. However, as stressed in the article, to compare costs of intensive care therapy across units is not possible for a number of reasons. One of the reasons for this limitation is that the studies employed different approaches to costing and thereby introduced a methodologic bias. In addition, the costing methodology applied in the majority of the studies was wrongly specified in relation to the purpose and viewpoint of the studies.
The methodologies for costing ICU therapy are flawed and fail to provide correct answers. In most studies, the study question is not adequately specified and the cost concept used in the studies is not tailored to the purposes of the study. Standardizing the cost model would lead to better, faster, and more reliable costing. This standardized cost model should not be rigid, but adaptable to different decision situations. A decision tree or taxonomy is proposed as a way toward better costing of ICU activity.
Cleveland Health Quality Choice (CHQC) is a unique community-based program designed to provide more efficient delivery of healthcare services through routine collection and dissemination of selected patient interventions and outcomes. This effort, coordinated by a consortium of business, hospital, and medical leaders, provides comparative public data on hospital performance. In the ICU, this effort involves collection of Acute Physiology and Chronic Health Evaluation (APACHE) III, as well as severity and prognostic data. To date, results suggest that a higher percentage of patients admitted to the ICU are at low risk of death or adverse outcome when compared with a national benchmark using APACHE III. Risk-adjusted mortality rates are lower and length of stay is shorter than predicted. CHQC demonstrates that cooperative public efforts, undertaken by groups with often divergent interests and using objective risk estimates, can provide useful data for hospital quality improvement activities and market-based health reform efforts.
In many ICUs, admission and discharge hinge on the need for intubation and ventilatory support. As few as 5% to 10% of ICU patients require prolonged mechanical ventilation, and this patient group consumes > or = 50% of ICU patient days and ICU resources. Prolonged ventilatory support and chronic ventilator dependency, both in the ICU and non-ICU settings, have a significant and growing impact on healthcare economics. In the United States, the need for prolonged mechanical ventilation is increasingly recognized as separate and distinct from the initial diagnosis and/or procedure that leads to hospitalization. This distinction has led to improved reimbursement under the prospective diagnosis-related group (DRG) system, and demands more precise accounting from healthcare providers responsible for these patients. Using both published and theoretical examples, mechanical ventilation in the United States is discussed, with a focus on cost containment. Included in the discussion are ventilator teams, standards of care, management protocols, stepdown units, rehabilitation units, and home care. The expanding role of total quality management (TQM) is also presented.
This paper explains practical approaches for collecting inpatient cost data for cost-of-illness and cost-effectiveness analyses. The economic definition of cost of an item is the value of the resources that are consumed in its production. Cost analysis should collect the resources hypothesized to be affected by the illness or intervention. The dollar value of these resources can also be estimated. Diagnosis-related group (DRG) reimbursements are not helpful when all study patients have the same DRG or when no DRG exists (e.g., nosocomial infection). Hospital charges are not a good surrogate for costs. Hence, data needed include resources used, charges, and cost-to-charge ratios, so that cost can be estimated. Resources used can be obtained from hospital information systems. For some resource use (e.g., physician services, pharmacy, and intravenous fluids), charges or cost-to-charge ratios may not be available, and an external standard may be needed to estimate the dollar value. For many types of resources, hospital financial systems provide both charges and cost-to-charge ratios. This yields an estimate of average cost (total cost divided by patient days) when marginal cost (change in variable cost per day of patient stay) is a better estimate of the value of the resources consumed. However, cost-to-charge ratios remain the only practical way of estimating cost in many circumstances and are commonly used in economic studies. Cost-of-illness estimates vary among the various nonrandomized study designs used. "Real-world" randomized trials are potentially useful to obtain advantages of randomization but avoid the protocol-induced biases of traditional double-blind controlled trials.
Correcting the decrease in oxygen delivery from anemia using allogeneic RBC transfusions has been hypothesized to help with increased oxygen demands during weaning from mechanical ventilation. However, it is also possible that transfusions hinder the process because RBCs may not be able to adequately increase oxygen delivery. In this study, we determined whether a liberal RBC transfusion strategy improved outcomes related to mechanical ventilation.
Seven hundred thirteen patients receiving mechanical ventilation, representing a subgroup of patients from a larger trial, were randomized to either a restrictive transfusion strategy, receiving allogeneic RBC transfusions at a hemoglobin concentration of 7.0 g/dL (and maintained between 7.0 g/dL and to 9.0 g/dL), or to a liberal transfusion strategy, receiving RBCs at 10.0 g/dL (and maintained between 10.0 g/dL and 12.0 g/dL). The larger trial was designed to evaluate transfusion practice rather than weaning per se.
Baseline characteristics in the restrictive-strategy group (n = 357) and the liberal-strategy group (n = 356) were comparable. The average durations of mechanical ventilation were 8.3 +/- 8.1 days and 8.3 +/- 8.1 days (95% confidence interval [CI] around difference, - 0.79 to 1.68; p = 0.48), while ventilator-free days were 17.5 +/- 10.9 days and 16.1 +/- 11.4 days (95% CI around difference, - 3.07 to 0.21; p = 0.09) in the restrictive-strategy group vs the liberal-strategy group, respectively. Eighty-two percent of the patients in the restrictive-strategy group were considered successfully weaned and extubated for at least 24 h, compared to 78% for the liberal-strategy group (p = 0.19). The relative risk (RR) of extubation success in the restrictive-strategy group compared to the liberal-strategy group, adjusted for the confounding effects of age, APACHE (acute physiology and chronic health evaluation) II score, and comorbid illness, was 1.07 (95% CI, 0.96 to 1.26; p = 0.43). The adjusted RR of extubation success associated with restrictive transfusion in the 219 patients who received mechanical ventilation for > 7 days was 1.1 (95% CI, 0.84 to 1.45; p = 0.47).
In this study, there was no evidence that a liberal RBC transfusion strategy decreased the duration of mechanical ventilation in a heterogeneous population of critically ill patients.
Intensive care patients require therapy that can vary considerably in type, duration and cost, so making it extremely difficult to predict patient resource use. Few studies measure actual costs; usually average daily costs are calculated and these do not reflect the variation in resource use between individual patients. The aim of this study was to analyse a data set of 193 critically ill adult patients to look for associations between routinely collected descriptive data and patient-specific costs. Regression analysis was used to explore any relationships between average daily patient-specific costs and the following variables: duration of intensive care unit stay, Acute Physiology and Chronic Health Evaluation II scores in the first 24 h, gender, age, mechanical ventilation at any point during the stay, postoperative status, emergency admission and mortality. Overall, this analysis explained 33.6% of the variation in average daily costs. The additional costs of an extra day of care, mechanical ventilation, an extra point on the Acute Physiology and Chronic Health Evaluation II score, and survival were obtained.
In patients undergoing open-heart surgery, allogeneic blood transfusion (ABT) may be related to an enhanced inflammatory response and impaired pulmonary function, resulting in a need for prolonged mechanical ventilation. Transfused red blood cell (RBC) supernatant, platelet supernatant or plasma components, may exercise varying effects on pulmonary function, because these fluids differ in their content of soluble biological-response modifiers.
The records of 416 patients undergoing coronary artery bypass graft operations at the Massachusetts General Hospital were reviewed. Possible predictors and the number of days of postoperative ventilation, as well as the number of all transfused blood components, were recorded. The association between mechanical ventilation past the day of operation and the volume of transfused RBC supernatant, platelet supernatant, or plasma components, was calculated by logistic regression analyses.
The volume of each transfused fluid differed (P < 0.0001) among patients ventilated for 0, 1, 2, 3, or > or = 4 days after the day of the operation. After adjusting for the effects of confounding factors, the volume of administered RBC supernatant was associated (P = 0.0312) with the likelihood of postoperative ventilation past the day of operation, but the volume of platelet supernatant, plasma components, or total transfused fluid was not (P = 0.1528, P = 0.1847, and P = 0.0504, respectively).
These results are congruent with the hypotheses that ABT may impair postoperative pulmonary function and that any such adverse effect of ABT is probably mediated by the supernatant fluid of stored RBCs. Both hypotheses should be examined further, in future studies of the outcomes of ABT.
Critical care providers are under increasing pressure to be attentive to cost concerns. The ICU consumes a significant amount of resources and, as such, is a frequently identified target of efforts to limit escalating healthcare costs. Attempts to reduce costs need not progress in a haphazard fashion. Rather, they can proceed in a logical, systematic manner with the assistance of formal economic studies. Cost-effectiveness analysis is one tool for these projects-it allows physicians to compare the financial consequences of different approaches to resource allocation. ICU physicians, therefore, must become familiar with the basic concepts that underlie cost-effectiveness analysis. Cost-effectiveness analyses that address many different aspects of critical care delivery are now commonly found in the critical care literature. With a framework for evaluating these studies, clinicians can better apply their findings to their own institutions.
Length of stay data are increasingly used to monitor ICU economic performance. How such material is presented greatly affects its utility.
To develop a weighted length of stay index and to estimate expected length of stay. To assess alternative ways to summarize weighted length of stay to evaluate ICU economic performance.
Retrospective database study.
Data for 751 ICU patients in 1998 at two hospitals used to develop weighted length of stay index. Data on 42,237 patients from 72 ICUs used as the basis of economic performance evaluation.
Difference between actual and expected weighted length of stay, where expected weighted length of stay is based on patient clinical characteristics.
Length of stay statistically explains approximately 85 to 90% of interpatient variation in hospital costs. The first ICU day is approximately four times as expensive, and other ICU days approximately 2.5 times as expensive, as non-ICU hospital days. In a regression model for weighted length of stay, patient clinical characteristics explain 26% of variation. ICU economic performance can be measured by excess weighted length of stay of a "typical" patient or by occurrence of long excess weighted lengths of stay. Although different summary measures of performance are highly correlated, choice of measure affects relative ranking of some ICUs' performance.
Providers of statistical data on ICU economic performance should adjust length of stay for patient characteristics and provide multiple summary measures of the statistical distribution, including measures that address both the typical patient and outliers.
To determine the attributable cost of ventilator-associated pneumonia from a hospital-based cost perspective, after adjusting for potential confounders.
Patients admitted between January 19, 1998, and December 31, 1999, were followed prospectively for the occurrence of ventilator-associated pneumonia. Hospital costs were defined by using the hospital cost accounting database.
The medical and surgical intensive care units at a suburban, tertiary care hospital.
Patients requiring >24 hrs of mechanical ventilation.
None.
We measured occurrence of ventilator-associated pneumonia, in-hospital mortality rate, total intensive care unit (ICU) and hospital lengths of stay (LOS), and total hospital cost per patient. Ventilator-associated pneumonia occurred in 127 of 819 patients (15.5%). Compared with uninfected, ventilated patients, patients with ventilator-associated pneumonia had a higher Acute Physiology and Chronic Health Evaluation II score on admission (p <.001) and were more likely to require multiple intubations (p <.001), hemodialysis (p <.001), tracheostomy (p <.001), central venous catheters (p <.001), and corticosteroids (p <.001). Patients with ventilator-associated pneumonia were more likely to be bacteremic during their ICU stay (36 [28%] vs. 22 [3%]; p <.001). Patients with ventilator-associated pneumonia had significantly higher unadjusted ICU LOS (26 vs. 4 days; p <.001), hospital LOS (38 vs. 13 days; p <.001), mortality rate (64 [50%] vs. 237 [34%]; p <.001), and hospital costs (70,568 dollars vs. 21,620 dollars, p <.001). Multiple linear regression, controlling for other factors that may affect costs, estimated the attributable cost of ventilator-associated pneumonia to be 11,897 dollars (95% confidence interval = 5,265 dollars-26,214 dollars; p <.001).
Patients with ventilator-associated pneumonia had significantly longer ICU and hospital LOS, with higher crude hospital cost and mortality rate compared with uninfected patients. After we adjusted for underlying severity of illness, the attributable cost of ventilator-associated pneumonia was approximately 11,897 dollars.
A life-threatening attack of asthma that leads to intensive care unit (ICU) admission, intubation, or both identifies patients at high risk of subsequent morbidity and mortality and represents a major cost burden.
To assess the rates, characteristics, and costs of ICU admissions and intubations among asthma-related hospitalizations.
This analysis was performed using a database of 215 hospitals representing more than 3 million annual inpatient visits. Asthma-related hospital admissions were identified by a primary diagnosis code for asthma during 2000. Logistic regression was used to estimate the odds ratios (ORs) for predictors of ICU admission, intubation, and in-hospital mortality. Ordinary least squares regression was used to estimate adjusted mean costs and length of stay.
Of 29,430 admissions with a primary diagnosis of asthma, 10.1% were admitted to the ICU and 2.1% were intubated. The risk of in-hospital death was significantly greater in patients who were intubated but not admitted to the ICU (OR, 96.20; 95% confidence interval [CI], 50.24-184.20), those who were admitted to the ICU and intubated (OR, 62.69; 95% CI, 38.17-102.96), and patients with more severe comorbidities (OR, 1.53; 95% CI, 1.38-1.70). On average, intubated patients stayed in the hospital 4.5 days longer and incurred more than $11,000 in additional costs; patients admitted to the ICU stayed 1 day longer and accounted for $3,000 in additional costs vs standard admissions.
The inpatient mortality, morbidity, and cost burden of life-threatening asthma in the United States is considerable. This study characterizes patients with asthma at risk of ICU admissions and intubations. Appropriate recognition and treatment are needed to prevent these severe and potentially life-threatening events.
- Duan