Standardize ICU Admission Practices to Cut Costs

Diana Swift

August 10, 2016

Hospitals that admitted patients to intensive care units (ICUs) more often were more likely to routinely perform invasive procedures and incur higher costs with no commensurate improvement in mortality, according to a retrospective cohort study tracking ICU use for four common conditions.

Published online August 8 in JAMA Internal Medicine, the study looked at ICU use in 94 hospitals in the states of Maryland and Washington during 2010 to 2012. Using information from the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project State Inpatient Databases, the study followed 156,842 hospitalizations for diabetic ketoacidosis, pulmonary embolism, upper gastrointestinal hemorrhage, and congestive heart failure, representing 4.7% of admissions at these centers. Admissions for these four indications numbered 15,022, 20,778, 23,141, and 97,901, respectively.

The investigators found no difference in risk-adjusted 30-day mortality between high and low users of ICUs but noted a greater number of invasive procedures such as central venous catheterization, as well as higher costs compared with ward care.

Notably, most institutions had similar rates of ICU use (high or low) across all four conditions. That suggested that institutional culture and systemic factors such as patterns of patient triage for ward vs ICU care may influence clinicians' use the ICU. Among other factors, ICU beds, nurse-to-patient ratios, and individual practice styles may foster greater ICU use.

Such institutional parameters "should be explored as areas for interventions to improve the efficiency of ICU utilization, especially among higher-use institutions," write Dong W. Chang, MD, from the Los Angeles Biomedical Research Institute, Harbor-University of Los Angeles, California, Medical Center, Torrance, and Martin F. Shapiro, MD, PhD, from the University of California, Los Angeles.

In other findings, ICU use was elevated at opposite ends of the size spectrum and with different patient populations in smaller hospitals and teaching hospitals. “Our study wasn’t granular enough to sort out the reasons for this, but it may be that smaller hospitals have no intermediate-care beds, so it’s either the ward or the ICU,” Dr Chang told Medscape Medical News.

According to the authors, the broad variability in ICU use is likely as much a result of the conspicuous absence of clear-cut guidelines for admission as differences in hospital resources, policies, and culture. "These findings suggest that optimizing ICU utilization may improve quality and value of ICU care, but accomplishing that will require institutional assessments of factors that lead clinicians to admit patients to the ICU for cases in which that level of care may not be necessary," Dr Chang and Dr Shapiro write.

They concede that their administrative data-based study could not capture details surrounding ICU admission such as medical complexity.

Overall, median ICU admission rates for lower- vs higher-use centers were as follows: 43.6% and 67.2% for diabetic ketoacidosis, 12.2% and 26.5% for pulmonary embolism, 23.4% and 34.2% for upper gastrointestinal bleeding, and 9.6%, and 28.7% for congestive heart failure. But across different institutions, these rates ranged broadly from 16.3% to 81.2% for diabetic ketoacidosis, 5.0% to 44.2% for pulmonary embolism, 11.5% to 51.2% for upper gastrointestinal bleeding, and 3.9% to 48.8% for congestive heart failure.

The authors note that other studies have shown similar variations in ICU use for ketoacidosis, pulmonary embolism, and congestive heart failure, also with no significant mortality benefit. Mixed results, however, have emerged from other research about ICU use costs. ICU care has been associated with worse outcomes for elderly patients with pneumonia.

According the authors' estimates, savings could be substantial if higher-use centers altered their patterns to reflect those of their lower-use counterparts. They estimated that the savings for Washington and Maryland during the study period could have been about $8 million for diabetic ketoacidosis, $3.5 million for pulmonary embolism, $6 million for upper gastrointestinal bleeding, and $120 million for congestive heart failure.

"Overuse of ICUs among patients who can likely be treated in non-ICU settings may lead to inappropriately aggressive care and misallocation of resources away from patients who may truly need critical care services," write the authors. "These clinical concerns, as well as the high cost and resource utilization of critical care services, make it imperative to identify the clinical situations for which patients derive the most benefit when receiving ICU care."

In terms of additional expenditures for the four conditions, analyses between ICU use and costs were $33.85 per percent of predicted admission for diabetic ketoacidosis (P < .001), $30.18 for pulmonary embolism (P = .02), $29.89 for upper gastrointestinal hemorrhage (P = .01), and $97.83 for congestive heart failure (P < .001) The respective adjusted costs of hospitalization for institutions in lower- and higher-use groups for these conditions were, respectively, $7141 and $8204, $10,660 and $11,117, $10,164 and $10,851, and $10,175 and $13,587.

Lengths of hospital stay, however, were comparable among high and low users of ICUs.

In a related commentary, Neil A. Halpern, MD, MCCM, from Memorial Sloan Kettering Cancer Center, New York, City, observed that the four study illnesses could sometimes be classified as "in between" in terms of ward vs ICU care if they are not severe, and "patients with in-between conditions may appear to be in between to some but not to all hospitals."

He suggested that such in-between cases might be better served by another tier of ICU care without the automatic use of standardized protocols for all admissions and with greater recognition of the differences between patients.

Dr Halpern also observed that although many variables may affect ICU use, the study could not capture these parameters, given its reliance on a large administrative data set and absent any analysis of individual hospitals. He pointed to "the difficulty of defining and assigning values to intangible hospital and ICU parameters."

He advised ICU administrators to give more thought to new ICU admissions in the interest of more individualized treatment. "Although care bundles, standards, and protocols are all the rage today to improve patient care and outcomes and to avoid medical errors, the results of this study suggest that in their haste to apply standardized care pathways (eg, invasive procedures for ICU admissions), the high ICU utilizers forgot to individualize care," Dr Halpern writes.

He called for further studies of ICU triage and care pathways to improve patient outcomes and resource use.

This study was supported by the National Institutes of Health/National Center for Advancing Translational Science University of California, Los Angeles, Clinical and Translational Science Institute grant. The authors and the editorial commentator have disclosed no relevant financial relationships.

JAMA Intern Med. Published online August 8, 2016. Article abstract, Commentary extract

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