Large Variations in Cost Has No Effect on Length of Stay or Mortality

Although intensive care doctors are responsible for large cost variations in the medical management of critically ill patients in the intensive care unit (ICU), higher resource use has no effect on patient length of stay or possible mortality.

This research appears in the first issue for December 2006 of the American Journal of Respiratory and Critical Care Medicine, published by the American Thoracic Society.

Allan Garland, M.D., of the Division of Pulmonary and Critical Care Medicine at MetroHealth Medical Center in Cleveland, and three associates studied costs ordered by nine intensivists in a single medical ICU who provided care to 1,184 patients during 14-day rotating shifts over a 29-month period. Average daily discretionary costs varied by 43 percent or $1,003 per admission between the intensivists who spent the most and those who spent the least.

“In this single ICU, we demonstrated large differences in resource use that are attributable to differences in physicians’ practice styles,” said Dr. Garland. “Higher-spending intensivists did not generate better outcomes than their lower spending colleagues, so it may be possible to reduce ICU costs without worsening outcomes by altering these practice styles.”

In addition to accumulating higher total discretionary costs in the ICU, the highest-spending physicians spent more on pharmacy, radiology, laboratory, blood banking and echocardiography. During the study, the respiratory system was the organ system most frequently associated with ICU admission, comprising 27 percent of the patients. Seventy-five percent of those in the ICU were transferred from the hospital’s emergency department.

Slightly less than one-quarter of the patients required invasive mechanical ventilation. The ICU mortality rate was 7.3 percent, and another 5.3 percent survived the ICU, but died before hospital discharge.

Contrary to the researchers’ early expectations, survey data showed that intensivists had an accurate sense of the ICU costs they generated.

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“Perhaps the higher spenders believe their practice style produces better outcomes,” said Dr. Garland. “Alternatively, practice styles may derive from a complex interaction between training and personality traits, such as response to uncertainty. We are not aware of any prior studies that have compared physicians’ self-assessments with objective measurement of their practice patterns or outcomes.”

The authors acknowledged that the study’s major limitation is that it evaluated only one ICU. While this may raise “concern about the generalizability of [the] results,” Drs. Garland and colleagues noted that the nature, organization, operation, staffing and case mix in their ICU was similar to others in large academic medical centers.

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In an editorial on the research in the same issue of the journal, Jeremy Kahn, M.D., M.Sc., of the University of Pennsylvania, and Derek C. Angus, M.D., M.P.H., of the University of Pittsburgh School of Medicine, wrote: “Total per capita health care costs have increased 560 percent since 1980 and health care costs comprise over 16 percent of the United States gross domestic product. A large proportion of these costs are directly attributable to the ICU.”

They continued: “The ICU is a resource-intensive environment where new drugs, expensive technologies and specialized clinical care all contribute to dramatic health care expenditures. Reducing the costs of healthcare in general and intensive care in particular, is a priority for physicians, hospital administrators and policy makers.”

“Perhaps the greatest lesson of the Garland study is that cost control is not just the work of the health policy expert or hospital administrator—it is also the task of the individual ICU clinicians. It is now clearer than ever that accepting this task is a difficult but necessary part of critical care in the twenty-first century.”

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