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Daily cost of an intensive care unit day: The contribution of mechanical ventilation

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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.

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... It is documented in the literature that MV is associated with significantly higher daily costs for patients in the ICU and interventions related to the reduction in MV duration lead to significant reductions in the total patient cost. 22 In addition, it is proven that prolonged LOS in combination with MV predisposes a patient to greater risk of infections and death which also increase costs. 23 The average total direct-variable cost per patient with multi- factors that cannot easily be determined. ...
... 8.47% (from22,233.1€ in the first to 203,409.9€ in the second study-period) can be attributed mostly to the shorter treatment duration since the calculation of these costs was proportional to the patient's LOS and less to the reduction in actual costs. In a similar study in India over the same period, indirect costs accounted for 19.4% of total costs (compared to 19.5% in the present study).31 ...
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Background: During the last decades the combination of international economic and healthcare crisis has led to pressure on healthcare systems and has made financial evaluations particularly important. Aim: To measure the total cost in ICUs, to analyze its components, and their changes during the study period. Method and Material: All cost components in four cost categories (direct-variable, direct-fixed, indirect-variable, and indirect-fixed) of all patients admitted in a 6-bed mixed type adult ICU in a general (non-university) hospital of northern Greece in two consecutive periods, with total duration 2 years was measured. The direct-variable cost (medications, consumables, and diagnostic tests) was assessed with bottom-up (micro-costing) method while for the cost components of rest three categories the top-down (attributable costing) was used. Results: In a 331 patients’ sample with 2823 total patient days, the sum cost was 2,417,788€ (1,370,420€ and 1,047,368€ in 1st and 2nd period respectively). The direct variable cost was 897,866.07€ (37.14%), the direct-fixed 1,049,068.6€ (43.39%), the indirect-variable 45,210.6€ (1.87%), and the indirect-fixed 425,643.0€ (17.60%). The mean daily cost per patient was 835.62€ and 885.35€, and the total cost per patient was 7,967.6€ and 6,587.2€ in the two periods of study respectively. The total cost of all non-survivors’ patients (N=85, 25.7%) was 595,009.1€ and the efficiency cost per survivor 9,828.4€. The mean daily cost and the total cost per survivor was 840.8€ and 7,409.7€ while for non-survivors was και 908.4€ and 7,000.1€ respectively. During the second study period, a reduction in total costs was observed and especially in direct-variable category attributed mainly to the prices of medicines consumables, and staff gradual costs reductions. Conclusions: Changes in cost categories vary over time due to social and financial factors while the variables as the ICU environment or patient’s characteristics as severity of disease are the main cost drivers. Monitoring and recording of cost components variance would help with valuable information to healthcare managers, doctors, or nursing leaders. Extending this study with a multicenter to more ICUs could provide clearer conclusions about cost variability.
... The monthly hospitalization costs were estimated based on the unit costs of stays in intensive care unit (ICU) and non-ICU settings, and the length of stay (LOS) in each setting. Unit cost inputs of ICU and non-ICU inpatient stays were derived from Medeiros et al. 33 and Dasta et al. 34 . LOS inputs were based on the ADMIRAL trial data and published literature 16,35 . ...
... The cost of HSCT was based on Medeiros et al. 33 . Post-progression costs included those associated with outpatient visits, emergency room visits, inpatient stays, diagnostic procedures, and lab tests, and were estimated for the post-EFS period following disease progression 15,33,34,51 . Since the target population was R/R FLT3 mut+ AML, all patients were assumed to incur the cost of one FLT3 testing of $249 regardless of the treatment received 46 . ...
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Aims To estimate the economic impact of the introduction of gilteritinib for the treatment of relapsed/refractory (R/R) FLT3 mutation-positive (FLT3 mut+) acute myeloid leukemia (AML) from a U.S. payer’s perspective. Methods A budget impact model (BIM) was developed to evaluate the 3-year total budgetary impact of treating adults with R/R FLT3 mut+ AML eligible for gilteritinib in a hypothetical U.S. health plan. Total costs (drugs/administration, hospitalization, monitoring, adverse events, transfusions, subsequent hematopoietic stem cell transplantation, post-progression, and FLT3 testing) were estimated before and after gilteritinib entry. The budget impact was the total cost difference between the two scenarios. The target population size and cost inputs were based on public data or published literature, drug market share was informed by market research data, and the model included recommended treatments for R/R FLT3 mut+ AML per clinical guidelines. Deterministic sensitivity analyses (DSAs) and scenario analyses varying key model inputs and asusmptions were conducted to test for robustness. Results In a hypothetical health plan with 1 million members, 20.9 adults with R/R FLT3 mut+ AML were estimated to be eligible for gilteritinib. Of these, it was assumed 30.0% would be treated with gilteritinib in Year 1 following gilteritinib entry, increasing the total plan budget by $663,795 and the per-member-per-month (PMPM) cost by $0.055. In Years 2 to 3, the market share of gilteritinib increased to 45.0%, increasing the total plan budget impact by $1,078,371 and $1,087,230, and the PMPM cost by $0.090 and $0.091, respectively. The model results remained robust in DSAs and scenario analyses, with the largest impact observed when the projected uptake of gilteritinib was changed. Limitations The results of this BIM are contingent upon the model’s assumptions and inputs. Conclusions Adding gilteritinib to the formulary for the treatment of adults with R/R FLT3 mut+ AML had a minimal budget impact from a U.S. payer's perspective.
... There were no studies or calculations done on ventilated patients in Bahrain, therefore, we reviewed the literature on costs of ventilated patients per day (Table 3) and adopted the pricing of the United States, which is 1522 USD per day. [18][19][20] Adopting this cost, we calculated a median total cost per patient of 10 731 USD in the early mortality group and 49 056 USD in the late mortality group, with a difference that was highly significant statistically (P<.001). ...
... Compared to our cohort, their lower in-hospital mortality rate is paired with lower APACHE II scores. Lieberman et al reported a mortality rate of 68.3% with a mean APACHE II score of 22.0 (27.8-16.2). 11 Pintado et al looked at patients aged 75 years and above and reported a mortality rate of 55.6% with mean APACHE II scores of 17 (11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24). 22 Although we did not follow these patients or assess their function upon discharge, the literature suggests that elderly patients who survive MV are more likely to suffer from disabilities compared to survivors without PMV; this disability is usually larger than would be predicted from the premorbid functional status. ...
Article
Background: Globally, the percentage of elderly patients has been increasing, leading to a higher demand for healthcare resources and intensive care. Bahrain has a majority Muslim population and Islam governs most policies, including end-of-life care. All patients at our institute receive full resuscitative measures regardless of the prognosis, leading to a high number of mechanically ventilated patients. Objectives: Assess characteristics, outcomes, theoretical costs, and use of antibiotics in critically ill elderly patients requiring mechanical ventilation. Design: Retrospective. Setting: Intensive care unit and general ward of a tertiary medical care center. Patients and methods: We studied all elderly patients (≥60 years old) admitted under general medicine in the period of January to June 2018 who needed intensive care and were intubated. Main outcome measures: The duration of mechanical ventilation, theoretical costs, antibiotic usage. Sample size: 140 patients. Results: Of 140 patients, 136 died (97%) and half of the deaths (n=69, 50.7%) occurred within the first 24 hours of intubation. Sixty-nine (79.3%) of the patients on short-term ventilation (≤96 hours) died within 24 hours of intubation, while the four survivors were on long-term ventilation (>96 hours) (P<.001). All the nonsurviving patients (n=136) were on antimicrobial therapy, mostly for hospital-acquired infections. The median (interquartile range) APACHE II score was relatively high at 28.0 (8.0) with significantly higher scores in the early mortality group compared to the late mortality group (30 [10] vs 26 [7], P=.013) and higher scores in the short-term vs long-term ventilation group (29 [10] vs 26 [7], P=.029). The median theoretical cost per patient in the early and late mortality groups was USD 10 731 and USD 30 660, respectively (P<.001). Conclusions: Given that less than 3% of patients had a favorable outcome, 50% of the cases died within 24 hours after intubation, hospital costs and antimicrobial use were high, the current policy of "full resuscitative measures for all" should be revised. We suggest implementing an end-of-life care policy, since the goal of resuscitation is to reverse premature death, not prolong the dying process. Limitations: Small sample size and absence of long-term follow-up. Theoretical costs were used as no direct calculated costs were available in our hospital. Conflict of interest: None.
... Previous studies suggest that faster recovery from lung injury and earlier freedom from mechanical ventilation leads to reductions in hospital and intensive care stays, improved long-term health, better quality of life and reduced healthcare costs. [14][15][16][17][18][19] It is anticipated that treating lung injury with nebulised heparin could save as much as $100 million dollars annually in intensive care costs alone. ...
... Previous studies suggest that faster recovery from lung injury and earlier freedom from mechanical ventilation leads to reductions in hospital and intensive care stays, improved long-term health, better quality of life and reduced healthcare costs. [14][15][16][17][18][19] Treating lung injury with nebulised heparin could potentially save as much as $100 million dollars annually in intensive care costs alone. ...
Method
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Nebulised Heparin fro lung Injury protocol
... We break down other health-care utilization costs according to how many hospitalized patients require an ICU stay and how many require mechanical ventilation. We use estimates from Dasta et al. on average costs for ICU patients and for patients needing mechanical ventilation [27]. We source estimates of median ICU length of stays and median number of days of mechanical ventilation for COVID-19 patients from CDC [21], which presents estimates of the median number of days of hospitalization for patients admitted to the ICU by the same three adult age groups-10 days for those 18 to 49, 14 days for those 50 to 64, and 13 days for those 65 and older. ...
... Dasta For the 13.5 percent of hospitalized COVID-19 patients that we estimate will require mechanical ventilation, they are expected to require 5 days of mechanical ventilation [21]. Dasta et al. estimate that the first day of mechanical ventilation costs about $11,000, the second day about $5,000, and $4,000 thereafter, again in 2002 dollars [27]. We estimate costs for five days of mechanical ventilation during a stay that lasts 12 days. ...
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This paper estimates the benefits and costs of state suppression policies to “bend the curve” during the initial outbreak of COVID-19 in the United States. We employ an approach that values benefits and costs in terms of additions or subtractions to total production. Relative to a baseline in which only the infected and at-risk populations mitigate the spread of coronavirus, we estimate that total benefits of suppression policies to economic output are between $632.5 billion and $765.0 billion from early March 2020 to August 1, 2020. Relative to private mitigation, output lost due to suppression policies is estimated to be between $214.2 billion and $331.5 billion. The cost estimate is based on the duration of nonessential business closures and stay-at-home orders, which were enforced between 42 and 65 days. Our results indicate that the net benefits of suppression policies to slow the spread of COVID-19 are positive and may be substantial. We discuss uncertainty surrounding several parameters and employ alternative methods for valuing mortality benefits, which also suggest that suppression measures had positive net benefits.
... By the alarming sound produced, it is easily noticed that the patient has irregular breathing and must be notified to the doctor. The main advantage of this proposed method is no care taker and physical attention is required [3] [9]; it implements the automatic monitoring procedure very easily and effectively [10][11] using hardwares. This project considers the performance metrics such as temperature of the body, pulse rate of heart, moisture in the air and baby's movement for evaluation [2] [13]. ...
Article
: This research work aims to create awareness and monitor the breath rate of a neonate using the air flow sensors and to reduce the number of infants' death. It is designed based on the Arduino which is open-source electronics platform for hardware and software use. This prototype is developed for reliable and efficient baby monitoring system and play as infant care and monitoring system.A cardio respiratory system is used to monitor the infant's heart rate, rhythm, breathing rate and other relevant and useful medical information using Electro Cardio Graph (ECG) and other IoT (Internet of Things) devices.This research work proved that the respiration monitoring system for infants can be implemented at low cost and also can prevent the respiration failure deaths.
... 7 In the United States, the estimated daily cost for an ICU bed without mechanical ventilation is $6,667 in US dollars (USD), whereas mechanical ventilation costs $10,794 USD per day. 8 Comparatively, in our institution, the cost per day of a regular hospital bed is $950 USD, whereas the cost per day of an ICU bed is $2,100 USD with the cost of mechanical ventilation reaching $3,200 USD per day. ...
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Purpose: Patients with terminal diseases frequently undergo interventions that are futile and may be detrimental to their quality of life. We conducted a quality improvement project aimed to reduce the utilization of futile acute care services (ACSs) for patients with cancer treated with a palliative intent. Methods: A multidisciplinary team reviewed the records of terminally ill patients with cancer who died between November 2017 and May 2018, during their admission at our institution. The review aimed to assess the magnitude of improper utilization of ACSs and admission to the intensive care unit (ICU). Lack of timely documentation of the goals of care (GOCs) was the main reason for this problem. We defined timely documentation as the availability of electronic documentation of patients' GOC before the need for ACSs. Interventions were implemented to improve the process; postintervention data were captured and compared with the baseline data. Results: After the delivery of staff education and the implementation of mandatory documentation of the GOCs in the healthcare electronic record system, the timely documentation of the GOCs for patients with a palliative intent increased significantly from 59% at baseline to 83% in the postintervention phase. The impact of this intervention led to a decrease in admissions to the ICU from 26% to 12% and an estimated annual cost saving of $777,600 in US dollars. Conclusion: Our interventions resulted in improved documentation of the GOCs and decrease in the utilization of ACSs including ICU admissions and the associated cost.
... 251,170.14). A study conducted by Dasta et al. [25] reported a mean cost of $31,574 (Rs. 2205,507.05). ...
... Because of the high cost of ICU care, healthcare providers and hospital administration often face the dilemma of meeting an increased demand for healthcare services within financial constraints of the institute (28). Medications contribute significantly to the cost of ICU care (29). ...
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Objectives:. The recent conflicting data on the mortality benefit of neuromuscular blocking agents in acute respiratory distress syndrome and the potential adverse effects of continuous neuromuscular blocking agent necessitates that these medications should be used judiciously with dose reduction in mind. The aims of the study were to improve the process of care by provider education of neuromuscular blocking agent titration and monitoring and to determine the impact of clinical endpoint based neuromuscular blocking agent titration protocol. Design:. We conducted a proof-of-concept historically controlled study of protocol-based intervention standardizing paralytic monitoring and titration using clinical variables. Education of the protocol was provided to ICU staff via bedside teaching and workshops. The primary outcomes were the time to reach goal paralysis and cumulative neuromuscular blocking agent dose. Secondary outcomes included maintenance of deeper sedation (Richmond Agitation and Sedation Scale –5) prior to neuromuscular blocking agent initiation, total time on mechanical ventilation, length of stay, and mortality. Setting:. Medical ICU at a quaternary academic hospital between March 2019 and June 2020. Patients:. Adult severe acute respiratory distress syndrome (Pao2/Fio2
... 24 When necessary, unit costs were obtained from peer-reviewed literature and inflated to 2019 US dollars using the US Bureau of Labor Statistics consumer price index for medical care. 25,26 Given that reimbursement rates do not reflect actual costs, a payment/cost ratio was applied to Medicare payment rates to estimate the true cost of HCRU incurred by the health care system. 27 Furthermore, we used cost ratios from the literature for cost adjustments to reflect the site of care where the health services occurred or were administered. ...
Article
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Chimeric antigen receptor (CAR) T-cell therapies have demonstrated high response rates in patients with relapsed/refractory large B-cell lymphoma (LBCL); however, these therapies are associated with 2 CAR T cell–specific potentially severe adverse events (AEs): cytokine release syndrome (CRS) and neurological events (NEs). This study estimated the management costs associated with CRS/NEs among patients with relapsed/refractory LBCL using data from the pivotal TRANSCEND NHL 001 trial of lisocabtagene maraleucel, an investigational CD19-directed defined composition CAR T-cell product with a 4-1BB costimulation domain administered at equal target doses of CD8+ and CD4+ CAR+ T cells. This retrospective analysis of patients from TRANSCEND with prospectively identified CRS and/or NE episodes examined relevant trial-observed health care resource utilization (HCRU) associated with toxicity management based on the severity of the event from the health care system perspective. Cost estimates for this analysis were taken from publicly available databases and published literature. Of 268 treated patients as of April 2019, 127 (47.4%) experienced all-grade CRS and/or NEs, which were predominantly grade ≤2 (77.2%). Median total AE management costs ranged from $1930 (grade 1 NE) to $177 343 (concurrent grade ≥3 CRS and NE). Key drivers of cost were facility expenses, including intensive care unit and other inpatient hospitalization lengths of stay. HCRU and costs were significantly greater among patients with grade ≥3 AEs (22.8%). Therefore, CAR T-cell therapies with a low incidence of severe CRS/NEs will likely reduce HCRU and costs associated with managing patients receiving CAR T-cell therapy. This clinical trial was registered at www.clinicaltrials.gov as #NCT02631044.
... Moreover, ICU resources are scarce and the daily cost of the ICU is roughly at least three times greater than a day on neurosurgical ward [3]. ...
Article
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Background Postoperative admission to intensive care unit (ICU) after craniotomy for brain tumor was the routine in the past years. However, there is little evidence supporting this dogma and doubts have been casted by many authors in the last years. Our aim was to identify risk factors for ICU admission after elective brain tumor surgery in order to propose an individualized admission to ICU tailored on patient needs. Methods We conducted a retrospective cohort study including all patients undergoing elective surgery for brain tumor in a neurosurgical post anesthesia care unit of a university hospital over a period of 6 years. In order to identify and validate risk factors for ICU admission, we split the final cohort of patients in a training cohort (two/third of the cohort) and the validation cohort (one/third of the cohort) using a random sequence. Using univariate and multivariate logistic regression, we created a scoring system in the training cohort and tested it with the validation cohort. Moreover, we perform a sensitivity analysis on the overall population. Results A total of 420 patients were eligible for this study. ASA-PS, tumor volume, and surgery length entered the scoring system. Sensitivity analysis on the overall population for the scoring system had an AUC of 0.774 (95% CI 0.668–0.880, the best threshold at 12.5) Conclusions We created a tool based on ASA-PS, length of surgery, and tumor volume to evaluate the risk for ICU admission after supratentorial tumor resection. Prospective studies are deemed necessary to validate our tool.
... As far as the economic burden of direct medical costs is concerned, although the costs vary with the number of the infected people, the severity of the disease, mean length of stay in the hospital, mean length of stay in the ICU, and other factors [13,14], international studies showed that medical costs of the patients with COVID-19 were significantly higher than those of other infectious diseases due to the higher probability of hospitalization and mortality [15]. These circumstances are also right about the need for COVID-19 patients for special care services and the related costs [16][17][18]. Statistics have shown that 3% of the people with COVID-19 in the world are in critical condition and need special care services [5]. The results of a study on 138 individuals with COVID-19 in Wuhan, China, indicated that 26.1% of the patients used special care services, of whom 41.6 and 47.2% received non-invasive and invasive ventilation, respectively [19]. ...
Article
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This study aimed to estimate both direct medical and indirect costs of treating the Coronavirus disease 2019 (COVID-19) from a societal perspective in the patients at a referral hospital in Fars province as well as the economic burden of COVID-19 in Iran in 2020. Methods This study is a partial economic evaluation and a cross-sectional cost-description study conducted based on the data of the COVID-19 patients referred to a referral university hospital in Fars province between March and July 2020. The data were collected by examining the patients’ records and accounting information systems. The subjects included all the inpatients with COVID-19 (477 individuals) who admitted to the medical centre during the 4 months. Bottom-up costing (also called micro-costing approach), incidence-based and income-based human capital approaches were used as the main methodological features of this study. Results The direct medical costs were estimated to be 28,240,025,968 Rials ($ 1,791,172) in total with mean cost of 59,203,409 Rials ($ 3755) per person (SD = 4684 $/ 73,855,161 Rials) in which significant part (41%) was that of intensive and general care beds (11,596,217,487 Rials equal to $ 735,510 (M = 24,310,728 Rials or $ 1542, SD = 34,184,949 Rials or $ 2168(. The second to which were the costs of medicines and medical consumables (28%). The mean indirect costs, including income loss due to premature death, economic production loss due to hospitalization and job absenteeism during recovery course were estimated to be 129,870,974 Rials ($ 11,634) per person. Furthermore, the economic burden of the disease in the country for inpatient cases with the definitive diagnosis was 22,688,925,933,095 Rials equal to $ 1,439,083,784. Conclusion The results of this study showed that the severe status of the disease would bring about the extremely high cost of illness in this case. It is estimated that the high prevalence rate of COVID-19 has been imposing a heavy economic burden on the country and health system directly that may result in rationing or painful cost-control approaches.
... Length of ICU stay was treated as a proportion of overall stay [26] and costs per day of ICU stay were the additional aggregated daily costs of a mechanically ventilated patient added to the daily hospitalization amount. [27] All costs were inflated to 2019 dollars using the ...
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Aims: Potentially life-threatening diagnosis of non-convulsive status epilepticus (NCSE) can only be confirmed with electroencephalography (EEG). When access to EEG is limited, physicians may empirically treat, risking unnecessary sedation and intubation, or not treat, increasing risk of refractory seizures. Either may prolong hospital length of stay (LOS). The current study aimed to examine the effect of a new EEG system (Ceribell Rapid Response EEG, Rapid-EEG) on hospital costs by enabling easy access to EEG and expedited seizure diagnosis and treatment. Materials and methods: We built a two-armed decision-analytic cost-benefit model comparing Rapid-EEG with clinical suspicion alone for NCSE. Diagnostic parameters were informed by a multicenter clinical trial (DECIDE, NCT03534258), while LOS and cost parameters were from public US inpatient data, published literature, and Center for Medicare and Medicaid Services fee schedules. We calculated reference case estimates from mean values, while uncertainty was assessed using 95% prediction intervals (PI) generated by probabilistic sensitivity analysis (PSA) and ANCOVA sum of squares. All costs were indexed to 2019 US$. Results: Each use case of Rapid-EEG saved $3,971 to $17,290 as it led to reduction in the hospital LOS by 1.2 days (6.1 vs. 7.4 days) and ICU LOS by 0.4 days (1.5 vs. 1.9 days). Using PSA, Rapid-EEG saving was $5,633 per use case (95% PI: $($4,649 to $6,617), as it led to diminished hospital LOS by 1.1 days (95% PI: 0.9-1.4 days) and reduced ICU LOS by 0.5 days (95% PI: 0.4-0.6 days). Cost-savings were demonstrated in 75% of replications. Sixty-four percent of variance in total costs was attributable to LOS for persons incorrectly diagnosed with seizures. Limitations: Results were obtained from the analysis of existing data and not a prospective outcome trial. Conclusions: Rapid-EEG alters the treatment course for patients with suspected seizures and will result in cost savings per patient.
... Patient care for delirium in the ICU often involves frequent monitoring, extended hospitalization, and increased interventions, including diagnostic testing, pharmacological agents, restraints, and prolonged mechanical ventilation [10][11][12][13][14][15][16][17]. ...
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Purpose: Delirium frequently affects critically ill patients in the intensive care unit (ICU). The purpose of this study is to evaluate the impact of delirium on ICU and hospital length of stay (LOS) and perform a cost analysis. Materials and methods: Prospective studies and randomized controlled trials of patients in the ICU with delirium published between January 1, 2015, and December 31, 2020, were evaluated. Outcome variables including ICU and hospital LOS were obtained, and ICU and hospital costs were derived from the respective LOS. Results: Forty-one studies met inclusion criteria. The mean difference of ICU LOS between patients with and without delirium was significant at 4.77 days (p < 0.001); for hospital LOS, this was significant at 6.67 days (p < 0.001). Cost data were extractable for 27 studies in which both ICU and hospital LOS were available. The mean difference of ICU costs between patients with and without delirium was significant at $3,921 (p < 0.001); for hospital costs, the mean difference was $5,936 (p < 0.001). Conclusion: ICU and hospital LOS and associated costs were significantly higher for patients with delirium, compared to those without delirium. Further research is necessary to elucidate other determinants of increased costs and cost-reducing strategies for critically ill patients with delirium. This can provide insight into the required resources for the prevention of delirium, which may contribute to decreasing healthcare expenditure while optimizing the quality of care.
... We used a cost of $1779 for H1N1 influenza infection and $167 for A or B type influenza. Based on methods from previous cost-effectiveness analyses looking at influenza, we derived these costs from combined costs of care in the intensive care unit, hospital, and home [12,14,[33][34][35][36]. We multiplied the cost of H1N1 to the 0.57% of vaccinated individuals predicted to be infected with influenza and 7.4% of unvaccinated individuals. ...
Article
Objective To assess the cost-effectiveness of influenza vaccination for all pregnant patients in the United States. Methods We designed a cost-effectiveness model to compare outcomes and costs in pregnant patients who received the inactivated, trivalent influenza vaccine to those who did not. We used a theoretical cohort of 4 million patients, the number of individuals giving birth in the United States per year. We assumed that H1N1 and A or B type influenza were of equal incidence based on seasonal variation from the past ten years. Our outcomes include acquiring H1N1, acquiring A or B type influenza, maternal death, stillbirth, infant death, preterm birth, and cerebral palsy in addition to cost and quality-adjusted life years (QALYs). Probabilities were derived from the literature and QALYs generated at a discount rate of 3%. Sensitivity analyses were performed to assess the robustness of our model. Results In our theoretical cohort of 4 million pregnant patients, the influenza vaccination strategy was associated with 1632 fewer stillbirths (24,332 in the vaccine strategy vs. 25,964 in the no vaccine strategy), 120 fewer maternal deaths (284 vs. 404), 340 fewer infant deaths (5608 vs. 5948), 32,856 fewer preterm births (403,896 vs. 436,752), and 641 fewer cases of moderate cerebral palsy (12,388 vs. 13,029). Additionally, the vaccination strategy corresponded to savings of $3.7 billion ($63.3 billion vs. $67.0 billion) and increased QALYs of 81,696 (226,852,076 vs 226,770,380). Therefore, it was considered a dominant strategy. Univariate sensitivity analysis demonstrated that the vaccine is cost saving until vaccine cost passes $900, far above the current cost of $12.16. In addition, we used sensitivity analysis to vary seasonal proportions of H1N1 to A or B type influenza. The vaccine was cost saving and increased QALYs for any proportion of H1N1 to A or B type influenza including when H1N1 was absent. Conclusion We demonstrate that in a cohort of 4 million patients, the influenza vaccine may save $3.7 billion per year, improve maternal and infant outcomes, and reduce morbidity and mortality. Our study provides further evidence that providers should strongly recommend that pregnant patients receive their annual influenza vaccine.
... Although the mean length of stay was decreased by 5.4 days, it was also found that the improvement of length of stay improved to 9 days with advanced age as shown in Fig 5. A 5.4 day ICU stay in the US for mechanically ventilated and non-ventilated patients has been to cost an estimated $37,258 and $28,852 per day respectively in 2020 [21]. There were 42,865 laboratory confirmed COVID-19 associated hospitalization reported by US sites between March 1, 2020 and August 1, 2020 [22]. ...
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Purpose COVID-19 pandemic has multifaceted presentations with rising evidence of immune-mediated mechanisms underplay. We sought to explore the outcomes of severe COVID-19 patients treated with a multi-mechanism approach (MMA) in addition to standard-of-care (SC) versus patients who only received SC treatment. Materials and methods Data were collected retrospectively for patients admitted to the intensive care unit (ICU). This observational cohort study was performed at five institutions, 3 in the United States and 2 in Honduras. Patients were stratified for MMA vs. SC treatment during ICU stay. MMA treatment consists of widely available medications started immediately upon hospitalization. These interventions target immunomodulation, anticoagulation, viral suppression, and oxygenation. Primary outcomes included in-hospital mortality and length of stay (LOS) for the index hospitalization and were measured using logistic regression. Results Of 86 patients admitted, 65 (76%) who had severe COVID-19 were included in the study; 30 (46%) patients were in SC group, compared with 35 (54%) patients treated with MMA group. Twelve (40%) patients in the SC group died, compared with 5 (14%) in the MMA group (p-value = 0.01, Chi squared test). After adjustment for gender, age, treatment group, Q-SOFA score, the MMA group had a mean length of stay 8.15 days, when compared with SC group with 13.55 days. ICU length of stay was reduced by a mean of 5.4 days (adjusted for a mean age of 54 years, p-value 0.03) and up to 9 days (unadjusted for mean age), with no significant reduction in overall adjusted mortality rate, where the strongest predictor of mortality was the use of mechanical ventilation. Conclusion The finding that MMA decreases the average ICU length of stay by 5.4 days and up to 9 days in older patients suggests that implementation of this treatment protocol could allow a healthcare system to manage 60% more COVID-19 patients with the same number of ICU beds.
... An accurate, predictive virtual patient or digital clone based on a mechanical model of patient-specific lung mechanics would augment clinical data, provide a more comprehensive picture of patient-specific state, and predict response to care [ 21 , 22 ]. Accurate prediction enables more personalised, confident, and efficient MV delivery, minimising the risk of VILI, and could potentially reduce the length of MV, which is clinically and economically important [23] . ...
Article
Background Mechanical ventilation (MV) is a core intensive care unit (ICU) therapy. Significant inter- and intra- patient variability in lung mechanics and condition makes managing MV difficult. Accurate prediction of patient-specific response to changes in MV settings would enable optimised, personalised, and more productive care, improving outcomes and reducing cost. This study develops a generalised digital clone model, or in-silico virtual patient, to accurately predict lung mechanics in response to changes in MV. Methods An identifiable, nonlinear hysteresis loop model (HLM) captures patient-specific lung dynamics identified from measured ventilator data. Identification and creation of the virtual patient model is fully automated using the hysteresis loop analysis (HLA) method to identify lung elastances from clinical data. Performance is evaluated using clinical data from 18 volume-control (VC) and 14 pressure-control (PC) ventilated patients who underwent step-wise recruitment maneuvers. Results Patient-specific virtual patient models accurately predict lung response for changes in PEEP up to 12 cmH2O for both volume and pressure control cohorts. R² values for predicting peak inspiration pressure (PIP) and additional retained lung volume, Vfrc in VC, are R²=0.86 and R²=0.90 for 106 predictions over 18 patients. For 14 PC patients and 84 predictions, predicting peak inspiratory volume (PIV) and Vfrc yield R²=0.86 and R²=0.83. Absolute PIP, PIV and Vfrc errors are relatively small. Conclusions Overall results validate the accuracy and versatility of the virtual patient model for capturing and predicting nonlinear changes in patient-specific lung mechanics. Accurate response prediction enables mechanically and physiologically relevant virtual patients to guide personalised and optimised MV therapy.
... Cost Eff Resour Alloc (2020) 18:57 (i.e. €5,695) and an important factor that contributes to these high daily costs is whether or not patients receive mechanical ventilation [2]. Therefore, better management of mechanically ventilated patients could be a worthwhile investment when it reduces length of stay and their time on ventilation support. ...
Article
Full-text available
Background Mechanical ventilation services are an important driver of the high costs of intensive care. An optimal interaction between a patient and a ventilator is therefore paramount. Suboptimal interaction is present when patients repeatedly demand, but do not receive, breathing support from a mechanical ventilator (> 30 times in 3 min), also known as an ineffective effort event (IEEV). IEEVs are associated with increased hospital mortality prolonged intensive care stay, and prolonged time on ventilation and thus development of real-time analytics that identify IEEVs is essential. To assist decision-making about further development we estimate the potential cost-effectiveness of real-time analytics that identify ineffective effort events. Methods We developed a cost-effectiveness model combining a decision tree and Markov model for long-term outcomes with data on current care from a Greek hospital and literature. A lifetime horizon and a healthcare payer perspective were used. Uncertainty about the results was assessed using sensitivity and scenario analyses to examine the impact of varying parameters like the intensive care costs per day and the effectiveness of treatment of IEEVs. Results Use of the analytics could lead to reduced mortality (3% absolute reduction), increased quality adjusted life years (0.21 per patient) and cost-savings (€264 per patient) compared to current care. Moreover, cost-savings for hospitals and health improvements can be incurred even if the treatment’s effectiveness is reduced from 30 to 10%. The estimated savings increase to €1,155 per patient in countries where costs of an intensive care day are high (e.g. the Netherlands). There is considerable headroom for development and the analytics generate savings when the price of the analytics per bed per year is below €7,307. Furthermore, even when the treatment’s effectiveness is 10%, the probability that the analytics are cost-effective exceeds 90%. Conclusions Implementing real-time analytics to identify ineffective effort events can lead to health and financial benefits. Therefore, it will be worthwhile to continue assessment of the effectiveness of the analytics in clinical practice and validate our findings. Eventually, their adoption in settings where costs of an intensive care day are high and ineffective efforts are frequent could yield a high return on investment.
... Hospitalized World Health Organization 11 Dasta et al 12 ...
Preprint
Introduction: A recent systematic review and meta-analysis by our group reported on thirteen published cohorts investigating 110,078 patients. Patients administered statins after their COVID-19 diagnosis and hospitalization were found to have a lower risk of mortality. Given this reported superiority, a logical next question would be whether statins are cost-effective treatment options for hospitalized COVID-19 patients. In this paper, we report on a cost-effectiveness analysis of statin-containing treatment regimens for hospitalized COVID-19 patients, from a United States healthcare perspective. Methods: A Markov model was used, to compare statin use and no statin use among hospitalized COVID-19 patients. The cycle length was one week, with a time horizon of 4 weeks. A Monte Carlo microsimulation, with 20,000 samples were used. All analyses were conducted using TreeAge Pro Healthcare Version 2021 R1.1. Results: Treatment of hospitalized COVID-19 patients with statins was both cheaper and more effective than treatment without statins; statin-containing therapy dominates over non-statin therapy. Conclusion: Statin for treatment of COVID-19 should be further investigated in RCTs, especially considering its cost-effective nature. Optimistically and pending the results of future RCTs, statins may also be used broadly for treatment of hospitalized COVID-19 patients.
... Transpulmoner indikatör dilüsyon tekniğinin klinik uygulamasında soğuk salin bolusunun sıcaklığı indikatör olarak rol oynar, santral dolaşıma enjekte edilir ve geçişi pulmoner arterde (transkardiyak termodilüsyon) veya distal aortta (transpulmoner termodilüsyon) saptanır. Stewart ve Hamilton tarafından geliştirilen prensiplere dayanarak indikatörün zamana bağlı değişimi hesaplanarak kardiyak output hesaplanır ve bir indikatör dilüsyon eğrisi (transit süresine karşı konsantrasyon) oluşturulur [31] . Bu eğriden yola çıkarak CO, intratorasik hacimler, EVLW ve pulmoner vasküler permeabilite indeks (PVPI) gibi hemodinamik veriler elde edilebilir. ...
Article
The incidence of postoperative pulmonary complications varies between 1-23 % and these complications can cause serious mortality. Measurement of extravascular lung water (EVLW) is beneficial not only for the prevention of complications but also in weaning, fluid management and monitorization of response to pharmacological interventions. EVLW consists of interstitial, intracellular, alveolar and lymphatic fluid in lungs except for pulmonary vasculature. Its normal range is 3-7 m/kg in healthy adults, values greater than 10 ml/kg point to pulmonary edema. Although the gold standard for measurement of EVLW is the gravimetric method, due to the fact it can only be applied postmortem, measurement methods by using ultrasonography and transpulmonary thermodilution have been developed. EVLW measurement can be affected by renal replacement therapy, extracorporeal membrane oxygenation (ECMO), pleural effusions and high PEEP. New research focusing on the effect of EVLW measurement on postoperative hemodynamic management is necessary in the future.
... These costs were derived from the medical literature and are the average national costs of ventilator, and dialysis management. [16,17] The cost of vasoconstrictors came from the pharmaceutical company that manufactures it. [18] Furthermore, the cost per day of the ICU and subsequent regular floor beds are added to the cost. ...
Article
Full-text available
Rationale: The purpose of this research is to determine and develop a valid analytical method that can be easily implemented by providers to evaluate whether they should join the bundled payments for care improvement (BPCI) advanced bundled payment program, and analyze the projected impacts of BPCI advanced payment on their margins. Methods: We have developed a decision tree model that incorporates the types of sepsis encountered and the resultant typical complications and associated costs. Results: The initial cost of a sepsis episode was $30,386. Since Medicare requires that there is a 3% cost reduction under BPCI, we applied the model with a 3% cost reduction across the board. Since the model considers probabilities of the complications and readmission, there was actually a 3.36% reduction in costs when the 3% reduction was added to the model. We applied 2-way sensitivity analysis to the intensive care unit (ICU) long and short costs. We used the unbundled cost at the high end, and a 10% reduction at the low end. Per patient episode cost varied between $28,117 and $29,658. This is a 5.2% difference between low and high end. Next, we looked at varying the hospital bed (non-ICU) costs. Here the resultant cost varied between $28,708 and $29,099. This is only a 1.34% difference between low and high ends. Finally, we applied a sensitivity analysis varying the attending physician and the intensivist reimbursement fees. The result was a cost that varied between $29,191 and $29,366 which is a difference of only 0.595%. Conclusion: This is the precise environment where decision tree analysis modeling is essential. This analysis can guide the hospital in just how to allocate resources in light of the new BPCI advanced payment model.
... Example 2 (Mechanical Ventilation on Intensive Care) Mechanical ventilation is an invasive, painful, and extremely unpleasant therapy that requires induction of artificial coma, and carries a high risk of mortality [88]. It is also expensive, with a typical ICU ventilator admission >$30,000 [89]. To the patient, the need for mechanical ventilation-due to evidence of respiratory/ventilatory failure-is by itself an adverse outcome, and is unacceptable to some, even if it means they will not survive. ...
Conference Paper
Full-text available
Time-series learning is the bread and butter of data-driven clinical decision support, and the recent explosion in ML research has demonstrated great potential in various healthcare settings. At the same time, medical time-series problems in the wild are challenging due to their highly composite nature: They entail design choices and interactions among components that preprocess data, impute missing values, select features, issue predictions, estimate uncertainty, and interpret models. Despite exponential growth in electronic patient data, there is a remarkable gap between the potential and realized utilization of ML for clinical research and decision support. In particular, orchestrating a real-world project lifecycle poses challenges in engineering (i.e. hard to build), evaluation (i.e. hard to assess), and efficiency (i.e. hard to optimize). Designed to address these issues simultaneously, Clairvoyance proposes a unified, end-to-end, autoML-friendly pipeline that serves as a (i) software toolkit, (ii) empirical standard, and (iii) interface for optimization. Our ultimate goal lies in facilitating transparent and reproducible experimentation with complex inference workflows, providing integrated pathways for (1) personalized prediction, (2) treatment-effect estimation, and (3) information acquisition. Through illustrative examples on real-world data in outpatient, general wards, and intensive-care settings, we illustrate the applicability of the pipeline paradigm on core tasks in the healthcare journey. To the best of our knowledge, Clairvoyance is the first to demonstrate viability of a comprehensive and automatable pipeline for clinical time-series ML.
... Dasta et al. analysed the daily costs of intensive care unit patients being the highest on day one with $6,667 (ventilated: $10,794) and the lowest from the third day ongoing at $3,184 per day (mechanical ventilation $3,184) in Ohio, United States of America. Therefore, the authors argue that reducing intensive care necessity means an overall decrease in the patients' expenses[7]. Health expanses vary among different countries and therefore data from Greece shall be mentioned as well. ...
... Another critical aspect associated with intensive care ventilation are costs. Recent years have been characterized by a signi cant increase of healthcare costs (6,7). Expenses of Intensive Care unit (ICU) usually cover up to 20% of overall hospital's costs (8) especially when considering those patients who require prolonged mechanical ventilation (9). ...
Preprint
Full-text available
Background The technological complexity and heterogeneity of intensive care ventilator models currently available on the market together with the heterogeneity in pediatric patients (0 to 18 years old), make the choice of the best machine for pediatric healthcare setting crucial.This paper is aimed at addressing all the critical aspects linked to the implementation of intensive care ventilators in a pediatric setting, highlighting the most relevant technical features and describing the methodology to conduct health technology assessment (HTA) for supporting the decision-making process.Four ventilators models were included in the assessment process. A decision-making support tool (DoHTA method) based on Analytic Hierarchy Process, was applied. 28 Key Performance Indicators (KPIs) were identified, defining the safety, clinical effectiveness, organizational, technical, and economic aspects. The Performance scores of each ventilator have been measured with respect to KPIs integrated with the total cost of ownership (TCO) analysis, leading to a final rank of the four possible technological solutions. ResultsThe final technologies’ performance scores reflected a deliver valued, contextualized, and shared outputs, detecting the most performant technological solution for the specific hospital context. HTA results had informed and supported the pediatric hospital decision-making process. Conclusions This study, identifying and discussing the pros and cons of innovative features of ventilators and all the evaluation criteria and aspects to be taken into account during the evaluation process, can be considered as a valuable proof of evidence as well as a reliable and transferable method for conducting a decision making process in a hospital context.
... 12 In reality there are intake costs associated with taking in new patients. As a result, the first day in the hospital is likely more costly than subsequent days (see, e.g., Dasta et al. 2005). Unfortunately, we cannot take this into account in our analysis, because we only have data on the number of patients for each day, and not on inflow and outflow. ...
Article
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We study the effectiveness of non-pharmaceutical interventions (NPIs) against COVID-19 on the allocation of scarce resources in the hospital sector in Scandinavia. Denmark and Norway imposed strict NPIs, but Sweden followed an extraordinarily lenient approach. We use an event study to compare COVID-19 hospitalizations, intensive-care (ICU) patients, and deaths in Sweden with Denmark and Norway. The outcome variables initially follow a common trend, but diverge 2–3 weeks after lockdown. Both the timing of the effect and the similarity in the trend between Denmark and Norway are highly consistent with a causal effect of the lockdown. We use our event study to build a counterfactual model that predicts the outcome variables for Denmark and Norway if they had followed Sweden’s approach. In the absence of strict NPIs, the peak number of hospitalizations would have been 2.5 (3.5) times as large in Denmark (Norway). Overall, Denmark (Norway) would have had 334 (671) percent more hospital-patient days, 277 (379) percent more ICU-patient days, and 402 (1015) percent more deaths. The benefit of lockdown in terms of healthcare and mortality costs amounts to between 1 and 4 (0.9 and 3.5) percent of GDP in Denmark (Norway).
Article
Background Chronic rhinosinusitis with nasal polyposis (CRSwNP) in the setting of aspirin-exacerbated respiratory disease (AERD) is a disease that is difficult to treat and prone to recurrence. Dupilumab is a promising treatment for these patients, but its cost-effectiveness has not yet been compared with aspirin (acetylsalicyclic acid, or ASA) desensitization, a known and effective treatment. We aimed to compare the cost-effectiveness of ASA desensitization with dupilumab therapy for the treatment of CRSwNP in AERD. Methods Analyses of cost-effectiveness, as measured in quality-adjusted life years (QALYs), and cost-utility, as measured in number of required revision endoscopic sinus surgeries (ESSs), were conducted. Results ASA desensitization after ESS was cost-effective and dominated appropriate medical management. Adding salvage dupilumab was also cost-effective (incremental cost-effectiveness ratio [ICER] $135,517.33), and upfront dupilumab therapy was not cost-effective in any scenario (ICER $273,181.32). The cost-utility analysis demonstrated that, over a 10-year period per patient, appropriate medical management after ESS cost $54,125.31 and resulted in 2.25 revision ESSs, ASA desensitization after ESS cost $53,775.15 and resulted in 2.02 revision ESSs, ASA desensitization with salvage dupilumab cost $121,176.25 and resulted in 1.68 revision ESSs, and upfront dupilumab cost $185,950.34 and resulted in 1.51 revision ESSs. Conclusion Dupilumab for the treatment of severe CRSwNP was found to be cost-effective as salvage therapy under the willingness-to-pay threshold of $150,000. Further analysis highlighted that the cost-effectiveness of dupilumab was most sensitive to drug price and expected gains in quality of life. This suggests that additional investigation into improving patient population selection and tailoring treatment algorithms may improve the cost-effectiveness of dupilumab in specific scenarios.
Article
Objectives Physiotherapy in an adult intensive care unit (ICU) affects health outcome. To justify the investment in ICU physical therapy, the cost savings associated with its benefits need to be established. The main objective of this study is to evaluate the potential cost savings of implementing 24-hour, 7-days-per-week physiotherapist (24/7-PT) in a Chilean public high-complex specialized ICU. Methods Using clinical data from a literature review and a micro-costing technique, we conducted a cost-benefit analysis in the National Institute of Thorax in Chile. Our example scenario involves 697 theoretical admissions of adult patients with cardiovascular or respiratory diseases, and the costs and benefits by reduction of length of stay in ICU, days of mechanical ventilation, and days with respiratory infections during the first year and 5 years of admissions. A sensitivity analysis was considered according to the variability in total costs, production income, and clinical benefits. Results Net cost savings generated in our example scenario demonstrate that the implementation of 24/7-PT produces a minimum saving for the institution of $16 242 during the first year and $69 351 over a 5-year interval considering individual income production. Out of the 30 scenarios included in the sensitivity analyses, 26 (87%) demonstrated net savings. Conclusions A financial model, based on literature review and actual cost data, projects that 24/7-PT intervention is a cost-benefit alternative in adult ICU patients with cardiovascular or respiratory diseases in Chile. It is necessary a scenario of at least 3 sessions per day with insurance payment for individual treatments to support the long-term implementation of a 24/7-PT program.
Article
Background Hospitals and other health care delivery organizations are sometimes resistant to implementing evidence‐based programs, citing unknown budgetary implications.Objective In this paper, I discuss challenges when estimating health care costs in implementation research.DesignA case study with intensive care units highlights how including fixed costs can cloud a short‐term analysis.ParticipantsNone.InterventionsNone.Main MeasuresHealth care costs, charges and payments.Key ResultsCost data should accurately reflect the opportunity costs for the organization(s) providing care. Opportunity costs are defined as the benefits foregone because the resources were not used in the next best alternative. Because there is no database of opportunity costs, cost studies rely on accounting data, charges, or payments as proxies. Unfortunately, these proxies may not reflect the organization’s opportunity costs, especially if the goal is to understand the budgetary impact in the next few years.Conclusions Implementation researchers should exclude costs that are fixed in the time period of observation because these assets (e.g., space) cannot be used in the next best alternative. In addition, it is common to use costs from accounting databases where we implicitly assume health care providers are uniformly efficient. If providers are not operating efficiently, especially if there is variation in their efficiency, then this can create further problems. Implementation scientists should be judicious in their use of cost estimates from accounting data, otherwise research results can misguide decision makers.
Article
Background Acute hypoxemic respiratory failure (ARF) is characterized by both lower arterial oxygen and carbon dioxide tensions in the blood. First line treatment for ARF includes oxygen therapy – intially admininstered non invasively using nasal prongs, high flow nasal cannulae (HFNC) or masks. Invasive mechancial ventilation (IMV) is usually reserved for patients who are unable to maintain their airway, those with worsening hypoxemia, or those who develop respiratory muscle fatigue and consequent hypercapnia. Inhaled nitric oxide (iNO) gas is known to improve oxygenation in patients with ARF by manipulating ventilation-perfusion matching. Addition of iNO may potentially alleviate the need for IMV in selected patients. Case summary In this article we report our preliminary experience of using HFNC to deliver oxygen and nitric oxide gas in patients with hypoxemic ARF as a strategy to potentially avoid IMV in selected patients. Conclusion This article demonstrates the feasibility of this technique based on our experience of patients with hypoxemic ARF and generates hypothesis for future studies.
Article
Purpose Aortic stenosis (AS) is the most common cause of adult valvular heart disease. In the past decade, minimally invasive surgery (MIS) to treat AS has gained popularity, especially if performed in combination with rapid deployment valves (RDVs), which shorten cross-clamp time (XCT). This study examines specific outcomes and related costs of aortic valve replacement (AVR) before and after the introduction of RDVs. Methods We used the AVR simulator, an economic model developed to correlate cost and resource utilization associated with the adoption of RDVs, to compare 2 scenarios: (1) a current scenario based on standard AVR practices and (2) a proposed scenario based on increasing use of RDVs and an MIS approach. Both scenarios involved 3 subgroups of patients treated with (1) conventional AVR, (2) MIS, and (3) AVR combined with a coronary artery bypass graft. The current scenario (status quo) involved patients treated with traditional biological valves, and the proposed scenario involved patients who underwent implantation with an RDV. The AVR simulator was fed with real-world input data to estimate complication rates and resource consumption in the proposed scenario. Real-world input data for this analysis were obtained from patients diagnosed with a symptomatic heart valve disease between 2015 and 2018, at Clinica-San-Gaudenzio, Novara, Italy. Lastly, the AVR simulator estimated hospital savings by comparing the 2 scenarios. Findings A total of 132 patients underwent implantation with a traditional biological valve, and 107 were treated with a commercial valve system. The RDV was associated with an increase of 52% of patients undergoing MIS, which generated a 6.1-h reduction of XCT and a total savings of €6695. RDVs also reduced intensive care unit (ICU) and hospital ward length of stay (LOS), leading to savings of €677 and €595 per patient, respectively. Mortality and blood transfusions also improved. The savings for the hospital (related to shorter XCT, hospital ward LOS, and ICU LOS) amounted to €144.111. Our findings were consistent with data gathered from our real-word setting, and results of a sensitivity analysis indicate that our findings were robust across different possible situations. Implications Switching to RDVs and MIS procedures for AVRs was associated with a reduction of costs related to XCT, hospital ward LOS, and ICU LOS. Hospitals can upload literature- and experience-based clinical and cost values to the AVR simulator to estimate a hospital's performance with the introduction of RDVs compared with standard biological valves. This study was not randomized, so more extensive studies could confirm our results in the future.
Article
Background The Pareto principle states that majority of the effect comes from minority of the causes. This property is widely utilized in quality improvement science. Research Question Among patients requiring mechanical ventilation (MV) are there subgroups by MV duration that may serve as potential nodes for high value interventions aimed at reducing costs without compromising quality? Study Design and Methods: We conducted a multicenter retrospective cohort study from ∼780 hospitals in the Premier database, 2014-2018. Using ICD-9-CM and ICD-10 codes we identified MV patients, and, dividing them into quintiles by MV duration, compared their hospital costs, post-MV onset LOS, ICU LOS, and cumulative post-MV onset hospital days per quintile. Results A total of 691,961 patients were included in the analysis. Median [interquartile range, IQR] duration of MV in days by quintile was as follows: quintile (Q) 1-1[1,1]; Q2-2[2,2]; Q3-3[3,3]; Q4-6[6,7]; Q5-13[10,19]. Median [IQR] post-MV onset LOS (Q1: 2 [0,5]; Q5: 17 [12,26]) and hospital costs (Q1: $15,671 [$9,180, $27,901]; Q5 $70,133 [$47,136, $108,032]) rose from Q1 through Q5. Patients in Q5 consumed 47.7% of all post-MV initiation hospital days among all patients requiring MV, and the mean per-patient hospital costs in Q5 exceeded the sum of costs incurred by Q1-Q3. Adjusted marginal mean (95% confidence interval) hospital costs rose exponentially from Q1 through Q5: Q2 vs. Q1 $3,976 ($3,354, $4,598); Q3 vs. Q2 $5,532 ($5,103, $5,961); Q4 vs. Q3 $11,705 ($11,071, $12,339); Q5 vs. Q4 $26,416 ($25,215, $27,616). Interpretation MV patients in the highest quintiles by MV duration utilize disproportionate amount of resources as evidenced by MV duration, hospital LOS, and costs, making them a potential target for streamlining MV care.
Article
Background A better understanding of the clinical features associated with prolonged hospitalization in acute respiratory failure may allow for better informed care planning. Research Question To assess the incidence, mortality, cost and clinical determinants of prolonged hospitalization among patients with acute respiratory failure (ARF). Study Design and Methods Using the National Inpatient Sample (NIS) data from 2004 to 2014, we identified adults 18 years and older with International Classification of Disease, 9th Edition (ICD-9), codes for ARF requiring mechanical ventilation for at least two days (ICD-9 518.81 or 518.82, 96.7 or 96.04, and 96.05). Outcomes studied included incidence, in-hospital mortality, cost of hospitalization, and associated patient-level and hospital-level characteristics. Trends were assessed by logistic regression, linear regression and general linear modeling with Poisson distribution. Results Of the 5,539,567 patients with ARF, 77,665 (1.4%) had a prolonged length of stay, defined as ≥60 days (pLOS). Among pLOS, 52,776 (68%) survived to discharge. Over the study period, incidence of pLOS decreased by 48%, in-patient mortality decreased by 18%, per patient cost-of-care rose, but percent of the total cost of ARF care consumed by patients with pLOS did not significantly decrease (p=0.06). PLOS was more likely to occur in urban teaching hospitals (OR 6.8, CI 4.6-10.2, p<0.001), hospitals located in the Northeastern US (OR 3.6, CI 3.0-4.3, p<0.001), and among patients with Medicaid insurance coverage (OR 2.1, CI 1.9-2.4, p<0.001). Interpretation From 2004-2014, incidence and mortality decreased among patients with ARF and pLOS, and while per patient costs rose, percent of total cost of care remained stable. There is substantial variation in length-of-stay for patients with ARF by US region, hospital teaching status and patient insurance coverage.
Article
Objectives: Mechanical ventilation increases the risk of hospital-acquired conditions (HACs) such as ventilator-associated pneumonia (VAP) and pressure injury (PrI). Beds with continuous lateral rotation therapy (CLRT) are shown to reduce HAC incidence, but the value of switching to CLRT beds is presently unknown. We compared the cost-effectiveness of CLRT beds with standard care in intensive care units. Methods: A cost-effectiveness analysis from the healthcare sector and societal perspectives was conducted. A Markov model was constructed to predict health state transitions from time of ventilation through 28 days for the healthcare sector perspective and 1 year for the U.S. societal perspective. Value of information was calculated to determine whether parameter uncertainty warranted further research. Results: Our analysis suggested that CLRT beds dominate standard care from both perspectives. From the healthcare sector perspective, expected cost for CLRT was U.S. $47,165/patient compared with a higher cost of U.S. $49,258/patient for standard care. The expected effectiveness of CLRT is 0.0418 quality-adjusted life years/patient compared with 0.0416 quality-adjusted life years/patient for standard care. Continuous lateral rotation therapy dominated standard care in approximately 93% of Monte Carlo simulations from both perspectives. Value of information analysis suggests that additional research is potentially cost-effective. Conclusions: Continuous lateral rotation therapy is highly cost-effective compared with standard care by preventing HACs that seriously harm patients in the intensive care unit.
Article
Background Over 90 million Americans suffer from advanced illness (AI) and spend their last days of life in critical care units receiving costly, unwanted, aggressive medical care. Objective Evaluate the impact of a specialized care model in medical/surgical units for hospitalized geriatric patients and patients with complex care requirements where designated AI beds align care with patient’s wishes/goals, minimize aggressive interventions, and influence efficient resource utilization. Design US based multi-facility retrospective, longitudinal descriptive study of screened positive AI patients in AI Beds (N = 1,237) from 3 facilities from 2015 to 2017. Results Patient outcomes included 60% referrals to AI beds from ICU, a decrease of 39-49% in average ICU LOS, a 23% reduction of AI bed patient expirations, 9.0% referrals to hospice, and projected cost savings of $4,361.66/patient, US dollars. Conclusion Allocating AI beds to deliver care to AI patients resulted in a decreased cost of care by reducing overall hospital LOS, mortality, and efficient use of both critical care and hospital resources.
Article
The rise of model-based and machine learning methods have created increasingly realistic opportunities to implement personalized, patient-specific mechanical ventilation (MV) in the ICU. These methods require monitoring of real-time patient ventilation waveform data (VWD) during MV treatment. However, there are relatively few non-invasive and/or non-proprietary systems to monitor and record patient-specific lung condition in real-time. In this paper, we present a CARE network data acquisition and monitoring system (CARENet) to automate data collection and to remotely monitor patient-specific lung condition and ventilation parameters. The automated system acquires VWD from a mechanical ventilator using a data acquisition device (DAQ), stores data in network-attached storage (NAS), and processes VWDs via a data management platform (DMP) web application. The web application enables real-time and retrospective model-based monitoring and analysis of clinical MV data. In particular, CARENet provides detailed breath-by-breath patient-specific respiratory mechanics, as well as the overall trends assessing changes in patient condition. Validation testing with a retrospective data set illustrated how breath-to-breath and time-varying patient-ventilator interaction during MV can be monitored, and, in turn, can be used to guide MV treatment. The network data acquisition system design presented is low-cost, open, and enables continuous, automated, scalable, real-time collection and analysis of waveform data, to help improve decision making, care, and outcomes in MV.
Article
Background Elderly rib fracture patients are generally admitted to an ICU which may result in overutilization of scarce resources. We hypothesized that this practice results in significant overtriage. Methods Retrospective study of patients over age 70 with acute rib fracture(s) as sole indication for ICU admission. Primary outcomes were adverse events (intubation, pneumonia, death), which we classified as meriting ICU admission. We utilized Cribari matrices to calculate triage rates. Results 101 patients met study criteria. 12% had adverse events occurring on average at day 5. Our undertriage rate was 6% and overtriage rate 87%. The 72 overtriaged patients utilized 295 total ICU days. Evaluating guideline modification, ≥3 fractures appears optimal. Changing to this would have liberated 50 ICU days with 3% undertriage. Conclusion Elderly patients with small numbers of rib fractures are overtriaged to ICUs. Modifying guidelines to ≥3 rib fractures will improve resource utilization and save ICU beds.
Article
This retrospective study estimated postinfusion health care resource utilization (HCRU) by site of care among 303 patients with relapsed/refractory large B-cell lymphoma who received third- or later-line treatment with lisocabtagene maraleucel (liso-cel) in the TRANSCEND NHL 001 and OUTREACH trials. Inpatients (n = 256) had higher rates of hospitalization versus outpatients (n = 47; >99% vs 62%), by definition, and higher rates of tocilizumab use for cytokine release syndrome and/or neurological events (22% vs 9%). Rates of intensive care unit admission, corticosteroid use, vasopressor use, hemodialysis, and intubation were generally low and similar between groups. Median (range) total hospital length of stay was 15 (0-88) days (inpatients) and 4 (0-77) days (outpatients). Over 6 months, estimated mean postinfusion cost of care was $89,535 (inpatients) and $36,702 (outpatients). Most costs were incurred in the first month postinfusion (inpatients, $50,369 [56%]; outpatients, $19,837 [54%]). Lower overall HCRU was observed with outpatient postinfusion monitoring.
Article
IntroductionWe evaluated the real-world healthcare resource utilization (HRU) and costs among patients with high-grade non-muscle invasive bladder cancer (HG-NMIBC) following Bacillus Calmette-Guérin (BCG) therapy.Methods Patients aged ≥ 65 years diagnosed with HG-NMIBC between 2008 and 2015 who received adequate BCG induction and were identified in the SEER-Medicare database. Those who received intravesical chemotherapy or radical cystectomy within 12 months of the last BCG induction dose, and had ≥ 6 months of data availability after treatment (index date), were included. Annualized HRU and mean medical costs (2020 United States dollars) were estimated and compared between patients with versus without progression. Inverse probability of treatment weighting was used to adjust for differences in baseline characteristics.ResultsOf 986 patients diagnosed with HG-NMIBC who met the inclusion criteria, 257 (26.1%) progressed; the mean ages were similar between patients who did and did not progress (77.6 vs. 77.0 years). The overall population had a mean of 0.96 [standard deviation (SD): 1.18] inpatient admissions, 6.47 (11.40) hospitalization days, 1.38 (2.19) emergency department (ED) visits, and 48.03 (44.97) outpatient visits per patient-year during the study period; total annualized costs per patient post-BCG were $39,102 ($44,244). Patients experiencing progression had significantly higher mean numbers of inpatient admissions [1.61 (SD 1.40) vs. 0.72 (0.99)], hospitalization days [11.77 (14.96) vs. 4.59 (9.29)], ED visits [2.34 (2.92) vs. 1.03 (1.76)], and outpatient visits [65.97 (44.72) vs. 41.63 (43.09)] per patient-year compared with patients without progression (all p < 0.05). Total mean annualized costs per patient after BCG among those who progressed [$65,668 (SD $53,943)] were more than double compared with patients who did not [$29,780 ($36,425)].Conclusions Existing treatments for HG-NMIBC after BCG therapy are associated with substantial HRU and medical costs, particularly after progression. Novel treatments and earlier detection are needed to reduce progression rates and associated costs in this difficult-to-treat population.
Article
Objective: Macroglossia is a characteristic feature of Beckwith-Wiedemann syndrome (BWS), commonly treated with reduction glossectomy to restore form and function. There exists no consensus on the perioperative management of these patients undergoing tongue reduction surgery, including anecdotal information regarding how long postoperative intubation should be maintained. The aim of this study is to evaluate the necessity of prolonged postoperative intubation in patients receiving tongue reduction surgery via the surgical and anesthetic management methods at our center. Design: Retrospective case series. Setting: Institutional care at Level I Children's Hospital. Participants: All children less than 18 years old with BWS and congenital macroglossia who underwent tongue reduction surgery over 5 consecutive years at our center (N = 24). Interventions: Tongue reduction surgery via the "W" technique. Main outcome measures: Success of immediate postoperative extubation and related surgical complications. Results: Immediate, uncomplicated postoperative extubation was successfully performed in all patients who received tongue reduction surgery for congenital macroglossia. Conclusions: Prolonged postoperative intubation for tongue reduction surgery may not be necessary as immediate, uncomplicated postoperative extubation was achieved in 100% of patients who received tongue reduction surgery at our center.
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Purpose Long term care facility (LTCF) residents are at high risk for severe COVID-19 symptoms, but those in rural and resource-limited areas, such as West Virginia (WV) and the larger Appalachian region, may experience delays in obtaining higher levels of medical care due to isolated geography and limited transportation. The study examined the outcomes between residents from 1 LCTF in WV who were moved to a hospital as compared to those remaining in the facility. Methods This cohort study compares mortality outcomes among severely symptomatic residents desiring hospitalization and those electing to stay at the facility receiving palliative opioids with supplemental oxygen. Findings Forty residents tested positive for COVID-19 with 11 developing severe respiratory symptoms. Eight residents elected to receive care at the LTCF while 3 desired hospitalization. Mortality was assessed at 4 time points and was not statistically different between those who were hospitalized versus those who received palliative opioids at the LTCF. Although not significant, the difference in mortality between those hospitalized (66.7%) and those receiving opioids at the LTCF (12.5%) in the acute phase trended toward significance ( P = .072). Overall mortality at the 6-month time point among all residents who developed severe respiratory symptoms at this LTCF was 54.5%. Conclusions LTCF residents choosing different levels of therapeutic intervention for severe COVID-19 symptoms had no mortality difference. Palliative opioids may be an effective treatment for LTCF residents with severe COVID-19 and also a bridge to care in rural areas with limited resources until more advanced treatments can be accessed.
Article
OBJECTIVE We sought to evaluate the short- and long-term resource utilization and costs associated with ICH, taken from an entire population. We additionally sought to evaluate the association of oral anticoagulation (OAC) and healthcare costs. METHODS Retrospective cohort study of adult patients (≥18 years) with ICH in the entire population of Ontario, Canada (2009-2017). We captured outcomes through linkage to health administrative databases. We used generalized linear models to identify factors associated with total cost. Analysis of OAC use was limited to patients ≥ 66 years. The primary outcome was total 1-year direct healthcare costs in 2020 US dollars. RESULTS Among 16,248 individuals with ICH (mean age: 71.2 years, male: 52.3%), 1-year mortality was 46.0%, and 24.2% required mechanical ventilation. The median total 1-year cost was $26,886 [(interquartile range [IQR]) 9,641-62,907] with costs for those who died in hospital of $7,268 (IQR 4,031-14,966) versus $44,969 (IQR 20,264-82,414, P < 0.001) for survivors to discharge. Oral anticoagulation (OAC) use (analysis limited to individuals ≥ 66 years old) was associated with higher total 1-year costs (cost ratio 1.06 [95% confidence interval: 1.01-1.11]). Total 1-year costs for the entire cohort exceeded $120 million per year over the study period. CONCLUSIONS ICH is associated with significant healthcare costs, and the median cost of an ICH patient is roughly 10-times the median inpatient cost in Ontario. Costs were higher among survivors than deceased patients. OAC use is independently associated with increased costs. In order to maximize cost-effectiveness, future therapies for ICH must aim to reduce disability, and not only improve mortality.
Chapter
Postoperative management of major surgical oncology patients is always challenging in view of patient status and complex surgical interventions. Preoperative clinical status may be affected due to chemotherapy, radiotherapy and impact due to cancer per se. This is compounded by complex, long duration, and extensive surgical interventions. Thus, patients require utmost care for an uneventful outcome after successful surgical interventions. Patients may require intensive monitoring in dedicated unit like intensive care unit (ICU) for optimization of various systems functions affected intraoperatively. Usually in cases of uneventful surgery and airway integrity being maintained, trachea is extubated soon after completion of surgery and requires routine postoperative observation in addition to optimal analgesia. However, a group of patients would require intensive monitoring or postoperative mechanical ventilation support in view of compromised systemic function including airway. Due to limited availability of beds in ICU and limited resources, triage should be done for making decision of shifting the patient to ICU. Although ICU constitutes less than 10% of total hospital beds but more than 20% of hospital expenditure is contributed by ICU. Usually ICU stay is 3–5 times more expensive than general surgical wards.
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ICU management depends on the level of occupation and the length of stay of the patients. Daily prediction of the days to discharge (DTD) of ICU patients is essential to that management. Previous studies showed a low predictive capability of internists and ML-generated models. Therefore, more elaborated combinations of ML technologies are required. Here, we present four approaches to the analysis of the DTDs of ICU patients from different perspectives: heterogeneity quantification, biomarker identification, phenotype recognition, and prediction. Several ML-based methods are proposed for each approach, which were tested with the data of 3,973 patients of a Spanish ICU. Results confirm the complexity of analyzing DTDs with intelligent data analysis methods.
Chapter
The social and financial costs for patients, caregivers, and family of a critical care admission are staggering. The enforced absence from the usual social and economic roles results in both financial toxicity and social isolation that can limit recovery. The process known as socio-economic reintegration after critical illness can be defined as:The resumption of relationships, roles, and financial income after a period of critical illness. This should include family, friends, nurturing and supportive roles, reclaiming interests, as well as returning to work (if of employment age). The resumption of relationships, roles, and financial income after a period of critical illness. This should include family, friends, nurturing and supportive roles, reclaiming interests, as well as returning to work (if of employment age). Solutions should start from the moment a patient is admitted to hospital. After hospital discharge, patients and caregivers need support and guidance on how to return to their previous lives. This process needs to be guided by patients and family while involving the wider multidisciplinary team including medical teams, financial experts, employers, and peers. Ultimately, champions are needed to raise awareness within governments and broader society in order to improve socio-economic reintegration after critical illness.
Objectives To review the studies, which calculated the total intensive care unit costs and indicated the main cost drivers in the intensive care by using either top-down, bottom-up approach or the combination of them. Research methodology/designs A systematic review of papers published until October 2020 was conducted. Search was performed on PubMed, Medline, Scopus and Science Direct databases. Setting This review i examined costs in adult intensive care units, in countries belonging to the Organisation for Economic Co-operation and Development (OECD) (medical, surgical or general adult , paediatric and neonatal were not included). Main outcome measures Eighteen articles were included in the review. Results Eight of the studies used the top-down costing methodology, six of them used the bottom-up approach and four of them used both of them. The mean total patient cost per day ranged from €200.75 to €4321.91 (all costs are presented in 2020 values for euro). Human resources were identified as the largest proportion of total costs. Length of stay, mechanical ventilation, continuous haemodialysis and severe illness are the main cost drivers of intensive care unit total costs. Conclusion There are a variety of methods and study designs used to calculate costs of an intensive care unit stay.t It is necessary to evolve standardised costing methods in order to make comparisons and succeed in cost-effective management.
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Amaç: Yoğun bakım hastalarının beklenilen ölüm oranlarının hesaplanması, mevcut tıbbi durumu acil teşhis ve tedavi gerektirecek hastaların hızlıca belirlenmesi, yoğun bakımların standardizasyonu, hizmet kalitesinin değerlendirilmesi ve sağlanması açısından önemlidir. Bu nedenle mortalite tahmininde geliştirilen ölçekler kullanılmaktadır. Bu çalışmada mortalite prediktörü olabilecek inflamasyon belirteçlerinden C-reaktif protein, prokalsitonin, albümin ve beyaz küre değerlerinin mortalite tahminindeki etkinliğinin araştırılması amaçlandı. Gereç ve Yöntemler: Çukurova Üniversitesi Tıp Fakültesi Reanimasyon Yoğun Bakım ünitesine Ağustos 2017 ve Ocak 2018 arasında kabul edilen, 18 yaş üstü hastalar prospektif ve gözlemsel olarak incelendi. Hastaların demografik, klinik ve laboratuvar verileri kaydedildi. Acute Physiology and Chronic Health Evaluation-II (APACHE-II) skoru hesaplandı. Skor sonuçları ve yatış anındaki laboratuvar verilerinin yoğun bakım yatış süresi ve yoğun bakım tedavisi sonlanımı ile ilişkisi değerlendirildi. Bulgular: C-reaktif protein, yoğun bakım yatış süresi (p=0.044) ve APACHE-II skoru (p=0.02) ile korelasyon gösterirken; prokalsitonin ise APACHE II skoru ile (p=0.001) korele bulundu. Tüm hastalar değerlendirildiğinde C-reaktif protein (p<0.001) ve prokalsitonin (p=0.004) düzeylerinin ölen hastalarda istatistiksel anlamlı daha yüksek olduğu görüldü. Cerrahi grubundaki hastalar acil ve elektif cerrahi hastaları olarak değerlendirildiğinde; acil cerrahi grubunda, ölen ve sağ kalan hastalardaki C-reaktif protein (p>0.05) ve prokalsitonin (p>0.05) düzeyleri arasında istatistiksel anlamlı fark bulunmazken, elektif cerrahi grubunda ölen hastalarda C-reaktif protein (p=0.011) ve prokalsitonin (p=0.017) değerleri istatistiksel anlamlı daha yüksek idi. Medikal hasta grubu incelendiğinde ise ölen hastalarda C-reaktif protein değeri (p=0.001) istatistiksel anlamlı daha yüksek iken, albümin (p<0.001) değeri istatistiksel anlamlı düşük idi. Sonuç: Bu çalışmada elde edilen verilere göre C-reaktif protein ve prokalsitonin değerlerinin mortalite tahmininde iyi bir belirteç olarak kullanabileceği düşünülmektedir. Elektif cerrahi sonrasında yoğun bakıma kabul edilen hastalarda C-reaktif protein ve prokalsitonin değerlerinin; medikal hasta grubunda ise C-reaktif protein, albümin ve APACHE-II skorunun birlikte değerlendirilmesiyle, daha yüksek olasılıkla mortalite tahmini yapılabileceğini düşünmekteyiz.
Article
Importance End-of-life care is costly, and decedents often experience overtreatment or low-quality care. Noninvasive ventilation (NIV) may be a palliative approach to avoid invasive mechanical ventilation (IMV) among select patients who are hospitalized at the end of life. Objective To examine the trends in NIV and IMV use among decedents with a hospitalization in the last 30 days of life. Design, Setting, and Participants This population-based cohort study used a 20% random sample of Medicare fee-for-service beneficiaries who had an acute care hospitalization in the last 30 days of life and died between January 1, 2000, and December 31, 2017. Sociodemographic, diagnosis, and comorbidity data were obtained from Medicare claims data. Data analysis was performed from September 2019 to July 2020. Exposures Use of NIV or IMV. Main Outcomes and Measures Validated International Classification of Diseases, Ninth Revision, Clinical Modification or International Statistical Classification of Diseases, Tenth Revision, Clinical Modification procedure codes were reviewed to identify use of NIV, IMV, both NIV and IMV, or none. Four subcohorts of Medicare beneficiaries were identified using primary admitting diagnosis codes (chronic obstructive pulmonary disease [COPD], congested heart failure [CHF], cancer, and dementia). Measures of end-of-life care included in-hospital death (acute care setting), hospice enrollment at death, and hospice enrollment in the last 3 days of life. Random-effects logistic regression examined NIV and IMV use adjusted for sociodemographic characteristics, admitting diagnosis, and comorbidities. Results A total of 2 470 435 Medicare beneficiaries (1 353 798 women [54.8%]; mean [SD] age, 82.2 [8.2] years) were hospitalized within 30 days of death. Compared with 2000, the adjusted odds ratio (AOR) for the increase in NIV use was 2.63 (95% CI, 2.46-2.82; % receipt: 0.8% vs 2.0%) for 2005 and 11.84 (95% CI, 11.11-12.61; % receipt: 0.8% vs 7.1%) for 2017. Compared with 2000, the AOR for the increase in IMV use was 1.04 (95% CI, 1.02-1.06; % receipt: 15.0% vs 15.2%) for 2005 and 1.63 (95% CI, 1.59-1.66; % receipt: 15.0% vs 18.2%) for 2017. In subanalyses comparing 2017 with 2000, similar trends found increased NIV among patients with CHF (% receipt: 1.4% vs 14.2%; AOR, 14.14 [95% CI, 11.77-16.98]) and COPD (% receipt: 2.7% vs 14.5%; AOR, 8.22 [95% CI, 6.42-10.52]), with reciprocal stabilization in IMV use among patients with CHF (% receipt: 11.1% vs 7.8%; AOR, 1.07 [95% CI, 0.95-1.19]) and COPD (% receipt: 17.4% vs 13.2%; AOR, 1.03 [95% CI, 0.88-1.21]). The AOR for increased NIV use was 10.82 (95% CI, 8.16-14.34; % receipt: 0.4% vs 3.5%) among decedents with cancer and 9.62 (95% CI, 7.61-12.15; % receipt: 0.6% vs 5.2%) among decedents with dementia. The AOR for increased IMV use was 1.40 (95% CI, 1.26-1.55; % receipt: 6.2% vs 7.6%) among decedents with cancer and 1.28 (95% CI, 1.17-1.41; % receipt: 5.7% vs 6.2%) among decedents with dementia. Among decedents with NIV vs IMV use, lower rates of in-hospital death (50.3% [95% CI, 49.3%-51.3%] vs 76.7% [95% CI, 75.9%-77.5%]) and hospice enrollment in the last 3 days of life (57.7% [95% CI, 56.2%-59.3%] vs 63.0% [95% CI, 60.9%-65.1%]) were observed along with higher rates of hospice enrollment (41.3% [95% CI, 40.4%-42.3%] vs 20.0% [95% CI, 19.2%-20.7%]). Conclusions and Relevance This study found that the use of NIV rapidly increased from 2000 through 2017 among Medicare beneficiaries at the end of life, especially among persons with cancer and dementia. The findings suggest that trials to evaluate the outcomes of NIV are warranted to inform discussions about the goals of this therapy between clinicians and patients and their health care proxies.
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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).
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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.
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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.
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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.
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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)
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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.
Article
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.
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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.
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: 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.
Article
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.
Article
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.
Article
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.
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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.
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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.
Article
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.
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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.
Article
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.
Article
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.
Article
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.
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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.
Article
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.
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