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American Journal of Critical Care. 2002;11: 467-473
Copyright © 2002 by the American Association of Critical-Care Nurses.
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Outcomes of and Resource Consumption by High-Cost Patients in the Intensive Care Unit

By John M. Welton, RN, PhD, Anthony A. Meyer, MD, PhD, Larry Mandelkehr, MBA, Samir M. Fakhry, MD and Sandra Jarr, RN, MSN. From the Medical University of South Carolina, Charleston, College of Nursing (JMW), the University of North Carolina, School of Medicine, Chapel Hill, NC (AAM), Inova Health Systems, Fairfax, VA (SF), and University of North Carolina Hospitals, Chapel Hill, NC (LM, SJ).


   Abstract
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• Background Care of patients in an intensive care unit is among the most costly in hospitals. Little is known about high-cost patients within the intensive care unit or their outcomes of care.

• Objectives To examine outcomes of and resource consumption by high-cost adult patients who received care in an intensive care unit at an academic medical center.

• Methods Data on patients admitted during the period January 1, 1995, through June 30, 1999, were analyzed retrospectively. An intensive care unit database, the hospital discharge data set, and a cost-accounting data set were used to determine the total intensive care unit cost for the hospitalization. Patients were then stratified into cost deciles. Hospital and intensive care unit outcomes for patients in the top decile were compared with those of patients in the other deciles.

• Results Cost data were available on 10606 of the 11244 patients who received care in an intensive care unit. Patients in the top decile accounted for 48.7% of all intensive care unit costs, and 67.6% of this group survived to discharge despite prolonged care. Patients transferred from an outside hospital were more likely to be in the top decile, have a longer stay in the intensive care unit, or die than were the other patients.

• Conclusions A small group of patients accounts for a disproportionately higher amount of intensive care unit resources but has a relatively high survival rate. This cohort should be treated as an intact group that is not amenable to traditional cost-cutting measures.

Healthcare providers face an ever-growing dilemma in attempts to improve patients’ outcomes from severe illness and injury. The United States has 32 850 beds in intensive care units (ICUs) in 4233 hospitals.1 Survivors of extended ICU stays have associated high expenses, both in dollars and in resources used, such as nursing care, and internal and external pressure to reduce the spiraling costs of healthcare is increasing. ICU care is an identifiable target for cost-cutting measures. It has been assumed that high-cost users of ICUs have poor outcomes and that most die. Little research has been done on the actual use of ICUs and hospital resources and the outcomes of these patients. Ultimately, the main issue is whether costs of care can be reduced by addressing the unique needs of high-cost ICU patients by using methods other than the rationing of ICU use.

One question is whether extended ICU care is futile.2–10 In certain populations, such as patients with advanced cancers or elderly patients who require prolonged mechanical ventilation, use of an ICU may be questionable because of the patients’ high mortality rate.11,12 Age alone should not influence decisions to withhold or withdraw life support in the ICU setting, because in some studies,13–25 elderly patients fared as well as younger patients with prolonged ICU stays. Patients treated initially at a tertiary care facility also appear to have better outcomes than do patients transferred to the facility from outlying hospitals, with lower costs and increased survival.26–28

A secondary issue is recognizing patients for whom ICU care is futile. Predictions based on the results of currently available tools such as the Acute Physiology and Chronic Health Evaluation are fraught with problems, and no method is clearly superior in distinguishing patients who will die in an ICU from those who will not.29–32

In several studies,33–39 patients had relatively good outcomes after prolonged ICU care. These results are a challenge to healthcare providers and others who advocate rationing or in some way limiting the use of expensive ICU resources. Overall, because of the confounding findings, evaluating the efficacy of caring for the sickest of the sick is difficult.

We retrospectively analyzed the costs of care and use of ICU resources for adult patients at a single academic medical center during a 4 1/2-year period. By identifying the patients whose costs of care were highest, we hoped to understand the unique needs of this population and to propose changes in practice that might reduce costs without having an adverse effect on their care. Our results suggest that these patients should be regarded as a special group with care needs distinctly different from those of most ICU patients.


   Methods
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We retrospectively analyzed data on patients admitted to any of 6 adult critical care units at the University of North Carolina Hospitals during the period January 1, 1995, through June 30, 1999. Data from 3 data sources were matched by patients’ medical record numbers and hospital admission dates: the hospital discharge abstract UB92 data set; cost data from HBOC Trendstar (McKessonHBOC, Atlanta, Ga); and an ICU database program developed at the University of North Carolina Hospitals.40 The ICU data were collected for each patient’s ICU admission during a hospitalization, and summary data were generated for ICU days and first Acute Physiologic Score component of the Acute Physiology and Chronic Health Evaluation II instrument41 and merged with the other data sets that summarized each patient’s hospitalization, including demographics, total hospital days, ICU and hospital costs, admission source, discharge disposition, and diagnostic-related group (DRG).

Excluded were data on patients who did not receive care in an adult ICU or whose primary DRG was for burns. Cost data were available for 10 606 of a total of 11 244 patients. ICU costs were calculated by using standard cost-accounting procedures, which included determining the direct operating costs for each ICU, such as nurses’ salaries, supplies, and so forth, and a prorated part of the indirect costs associated with delivering care. This variable reflects a reasonable estimate of the costs to the institution associated with delivering care in the various ICUs; the actual charges billed for services are an inaccurate indicator of economic performance of an institution.42,43

The University of North Carolina Hospitals have a total 53 adult ICU beds: 2 primary medical/respiratory ICUs (16 beds); 3 surgical units: surgical/trauma, neurosurgical, and cardiothoracic (24 beds); and 1 cardiac care unit (13 beds). All patients who were admitted to an ICU during their hospital stay during the study period were included. The Acute Physiologic Score component of the Acute Physiology and Chronic Health Evaluation II instrument was collected by 1 of 2 data collection research assistants for each ICU admission. The Acute Physiologic Score from the first admission to an ICU was used for patients who had more than one ICU admission.

The calculated total ICU costs were used to stratify patients by ranking ICU costs into deciles. Patients in the 90th percentile were designated high-cost patients; they were the 10% of patients admitted to an ICU who had the highest ICU costs. Data were collected in a relational database (Microsoft Access, Version 2000, Microsoft Corp, Redmond, Wash) and were analyzed by using the SPSS statistical software package (Version 10, SPSS, Chicago, Ill).


   Results
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Patients’ characteristics, outcome, and resource variables are given in Table 1Go. We found significant differences across groups for financial class, physician service, admission source, age, Acute Physiologic Scores, hospital and ICU lengths of stay, and hospital and ICU costs. Resource consumption varied between the high-cost patients and the other patients. The high-cost group accounted for 47.8% of all ICU days and 50% of ICU expenditures (Table 2Go).


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  		Table 1 Demographics

 

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  		Table 2 Resource consumption in the intensive care unit*

 
The disposition of patients after discharge from the hospital also differed for the 2 groups. High-cost patients were more likely than the other patients to die or be transferred to another facility such as rehabilitation or skilled nursing centers (Table 3Go). Among the high-cost patients, 67.6% survived to discharge, 24.6% died in the ICU, and 7.7% died outside the ICU, either in a medical or surgical unit or in intermediate care units of the hospital.


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  		Table 3 Distribution by hospital discharge category*

 
The top 10 discharge DRGs are presented in Table 4Go. The findings indicate a marked difference between the high-cost patients and the other patients. Two DRGs alone (483 and 475) accounted for 41.4% of all hospital discharges for the high-cost group.


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  		Table 4 Distribution of top-ranked discharge diagnosis-related groups*

 

   Discussion
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Our first major finding is that patients in the high-cost group used a disproportionately higher amount of resources and accounted for 48.7% of days of ICU care and 50% of total ICU costs even though they made up only 10% of patients admitted to an ICU. The second major finding is that most of the patients (67.6%) in this group survived to discharge. Our findings are consistent with those of Fakhry et al34; despite maximum care, high use of resources, and high costs, most high-cost patients survived to discharge. The higher tendency of this group to be discharged to other facilities or health-care at home indicates their continuing care and dependency needs after hospitalization. These findings help discount the common notion that the majority of very sick patients who receive extended ICU care die and the even more dangerous notion that removing these patients from the ICU will decrease the cost of care.

The issue of ICU costs is vexing. Several investigators44–52 reported that ICU consumption of resources and costs decreased when clinical pathways for specific disease management were used. Although those findings are encouraging, the patients who accounted for the highest ICU costs in our study were the outlier patients, those who were admitted for various reasons but ultimately had prolonged stays.

One weakness of our study is that we did not differentiate between patients who required a prolonged ICU stay and patients who were electively admitted to an ICU for a short period for closer monitoring or supportive care. For example, several surgical procedures may predispose patients to serious complications such as airway compromise or hemorrhage. The higher nurse-to-patient ratio in the ICU is needed to ensure more rapid response to changes in patients’ conditions. The circumstances of the high-cost patients in our study are distinctly different from those of electively admitted ICU patients, who are predicted to have short ICU stays. Our findings are difficult to generalize to other hospitals because of differences in demographics, ICU use, and populations of patients.

An interesting question raised by this study is, What are the underlying costs associated with ICU care? In several studies,53–56 most of these costs, more than 50%, were for nursing labor. The relationship between cost of patients’ care and hours of nursing care provided in the ICU is also significant.57 This finding is reasonable because ICUs are generally organized to allow lower nurse-to-patient ratios and specialization of nurses.58,59 The variable most likely to affect underlying direct costs of care is the nurse-to-patient ratio. As the ratio increases, that is, a single nurse is taking care of more patients for a given shift, individual patients receive fewer hours of care, and direct cost per patient decreases if all other variables are unchanged.60

Within the past several years, some hospitals have created step-down or intermediate care units to provide patients with more nursing care than they may receive in a general nursing ward but less than that received in an ICU. Use of intermediate care units has shown some early promise, especially in reducing mortality of patients on the general nursing ward who do not warrant ICU care.61–66 The efficacy of these special care units should be evaluated cautiously, because previous studies67,68 indicated that fewer hours of nursing care were associated with increases in the prevalence of nosocomial infections and adverse effects on length of stay and mortality.

Use of specialty care units organized around a comprehensive management team and involvement of patients’ families may be an alternative to ICU care.65,69,70 Unlike conventional intermediate care units, specialty units focus on patients with prolonged high-dependency needs, such as ventilator-dependent patients.

Another potential method of reducing costs is through better unit coordination and collaboration between nurses and physicians.71,72 Knaus et al73 and Shortell et al74 found that better coordinated ICUs can lead to a reduction in mortality. We hypothesize that when adjustments are made for differences in the severity of illness, better performing units can have better outcomes, such as reduction in deaths and use of ICU resources. The relationship between units with better coordination and communication and direct costs of care has not been reported.

Last, the issue of hospital transfers of very sick patients must be addressed. In our sample, as in the study by Flabouris,26 patients who were transferred to the ICU from another hospital had increased costs, lengths of stay, and mortality rates. Our results also indicate that these patients are also more likely to be in the high-cost group than are patients initially admitted to the facility with an ICU. This finding puts academic medical centers and other tertiary care facilities at risk, because they may receive a disproportionately higher number of patients who, because of the underlying severity of illness, use more ICU resources than other patients do. This situation increases the overall costs of care and skews the statistical interpretation of studies that include many hospitals. It may be inappropriate to use unadjusted mean costs, lengths of stay, or mortality rates as the sole basis for comparison of outcomes of care without using an instrument to adjust for differences in severity of illness or injury.75,76

The issue of how best to deal with patients who become sick in community hospitals is unresolved. Should these patients be moved to larger centers at an earlier point in their care? The assumption is that earlier care at hospitals better equipped and staffed to meet the needs of critically ill patients may produce better outcomes. Further study is needed to assess the overall effect of such a policy.


   Conclusions
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 Abstract
 Methods
 Results
 Discussion
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References
 
A small group of patients admitted to an adult ICU at a single university hospital accounted for a disproportionately higher utilization of ICU resources. This group accounted for 10% of patients admitted but ranked in the 90th percentile for ICU costs. Survival for this high-cost group was reasonable, although patients transferred from outlying hospitals had poorer outcomes and used proportionally more resources than did patients not transferred from other hospitals.

This high-cost cohort should be treated differently than the "typical" ICU patient. Current cost-cutting methods such as use of clinical pathways may not be appropriate for this group. Other alternative methods of reducing consumption of ICU resources should address the nursing care needs of these patients, because these needs account for the highest proportion of direct ICU costs.

The effect of these high-cost patients and their long lengths of stay on statistical analysis is also noteworthy. Hospitals may change the DRG code to maximize reimbursement for care, but by doing so, they hide the initial diagnosis or procedure. Therefore, studies that compare patients’ outcomes across DRGs may not be representative of the true costs or lengths of stay for a particular population of patients. In addition, a small group of outlier patients may influence the distribution of mean costs and ICU length of stay. Academic medical centers that receive patients from outlying hospitals are more at risk than are other facilities for this statistical anomaly.

To purchase reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints{at}aacn.org.


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