COST evaluation in the ICU – Helsinki 2010

1. COST evaluation in the ICU – Helsinki 2010 Jakob Steen Andersen, MD, EDIC; ICU, National University Hospital, Copenhagen

2. The future of critical care - Current trends Increasing demand for critical care services (due in part to an aging population, survivors of previously fatal illnesses) Focus on quality measurement Focus on the increasing cost of healthcare ”modern healthcare is expensive, and modern critical care is extremely expensive” “what these trends do not tell us is how we will meet these challenges”

3. ICU cost : Intensive care units (ICUs) currently represent the largest clinical cost centres in hospitals, with expenses estimated to reach up to 20% of a hospital's budget [1] Despite accounting for only 10% of all inpatient beds, intensive care units (ICU) accrue nearly one third of all inpatient costs [2] Studies have estimated that $4 to $5 billion dollars were spent in the United States directly related to the medical expenditures of mechanical ventilation Mechanical ventilation on average increases the length of ICU stay by 4.0 days and increases the average cost of care by $18,643 [3] (15.338 EUR). The total cost per ICU patient highly depends on the severity of illness and the length of the ICU stay 1. Chalfin DB: Cost-effectiveness analysis in health care. Hosp Cost Manag Account 1995, 7:10-14 2. Shorr, AF. An update on cost-effectiveness analysis in critical care. Curr Opin Crit Care 2002; 8:337-343. 3. Dasta J, McLaughlin T, Mody S, et al. Daily cost of an intensive care unit day: the contribution of mechanical ventilation. Crit Care Med 2005 Vol. 33: 1266-71

4. ICU cost : • Medical literature demonstrates that nearly 50% of critical care patients will be mechanically ventilated (MV) • and the average length of ICU stay for MV patients is 6.9 days and that the daily cost of care for a MV patient is • $3,500 (2.880 EUR) per day. • The most expensive patients were those needing mechanical ventilation, those patients having a high severity • of illness and / or severe sepsis as well as nonsurvivors. • Patients admitted for unscheduled surgical procedures (emergency cases) caused significantly increased cost. • The cost for staffing is the highest expenditure of intensive care treatment, with ~ 56 % on average overall . • Park J, Griffiths MJD. Recent Advances in Mechanical Ventilation. Clincal Medicine 2005, September/October 441-4 • Teres D, Rapoport J, Lemeshow S, Kim S, Akhras K: Effects of severity of illness on resource use by survivors and nonsurvivors of severe sepsis at intensive care unit admission. Crit Care Med 2002, 30:2413-2419.

5. ICU cost : 51 ICUs ( 2003 ) in hospitals all over Germany453 patients; LOS > 24 hours : Focus care hospitals (fcH) - (median ICU LOS, 12 days, hospital LOS, 29 days) Maximum care hospitals (mcH) - (median ICU LOS, 6 days; hospital LOS, 23 days) Primary care hospitals (pcH) - (median ICU LOS, 5 days; hospital LOS, 19 days) General care hospitals (gcH) - (median ICU LOS, 4 days; hospital LOS, 20 days) Prevalence Study on Variable cost : - Drug, blood and blood products and fluid therapy, - Invasive procedures, the usage of disposables (drainages, dressings, etc.)* and - Diagnostic procedures such as X-ray scan, computed tomography scan, - Laboratory testing and microbiological analysis. * Except procedures outside the ICU (for example, surgical interventions) Fixed cost*: - Mean local staff costs per day (Physicians for consultation were not included - Basic bed costs per day ('hotel costs') include overhead costs for nonclinical support services, maintenance, energy and hospital administration. *Equipment ( monitors, ventilator etc.) and other investment costs as well as depreciation were not included. Moerer et al.. A German national prevalence study on the cost of intensive care:an evaluation from 51 intensive care units Critical Care 2007; Vol 11 No 3.

6. ICU cost : 51 *ICUs ( 2003 ) in hospitals all over Germany453 patients; LOS > 24 hours : Cost calculations – result : The mean total costs per patient and day were € 791 ± 305. 19.4% of the patients costing more than €1,000 per day and a maximum of €2,815 per patient-day. Studies from previous studies from different European countries found mean daily costs ranging between €1.125 and €1.590 per day ( 8 studies 1996-2003 )   Staff costs comprise the largest proportion of total costs at around 50-60%, followed by medication costs (including blood products, fluids, nutrition, drugs) at 18.7%. The mean daily cost in various subgroups of patients differed considerably - the severity of illness has a huge impact on ICU cost The case mix and workload significantly differs between different levels of hospitalcare. * ICU Germany 1 /17 hosp.beds ; ICU Scandinavia 1 / 40 hosp.beds ; Moerer et al.. A German national prevalence study on the cost of intensive care:an evaluation from 51 intensive care units Critical Care 2007; Vol 11 No 3.

7. ICU cost calculation initiated by the Danish National Board of Health - 2005 ICU costs in Canada, England and Danmark ( RH; Kolding ) Ref.: SST / Valcon / RH Kolding 2005) * 117.1 mio DKK ~ 15.7 mill. EUR

8. Drg - registration in the ICU, National University Hospital, Copenhagen 2001-2005. In 2001 before we became master section / parent unit the ICU drg registration ~ 10 mio DKK (1.34 mill EUR) compared to the actual hospital ICU rate ~ 90 mio DKK (12.1 mill EUR) / year In 2003 after we became master section / parent unit the ICU drg registration increased to ~ 41 mio DKK ( 5,51 mill EUR) / year – an increase ~ 300 %. In 2004 implementation of new model for improvement of DRG registration in the ICU’s* increased the ICU drg registration to ~ 80 mio DKK ( 10.8 mill EUR ) / year In 2005 implementation of an ICU electronic patient journal system** lead to an increase of ~ > 120 mio DKK ( > 16.1 mill EUR) / year - an increase > 50 % * Developed an initiated by the Danish National Board of Health and the Danish Society of Anaesthesiology and Intensive Care * *CIS 3.04; Daintel.

9. ICU DRG Grading system – DK. The new (2004) ICU DRG-grading system consists of four groups reflecting progressive deterioration in organ failure

10. The new (2004) ICU DRG-grading system consists of four groups reflecting progressive deterioration in organ failure. Andersen JS, Drenck NE, Keiding H. Ugskr læger.2007. 727-730.

11. The DK ICU DRG-system consists of four groups reflecting progressive deterioration in organ failure. The rules for allocation according to ICU DRG-system underwent changes in 2006 and 2007.

14. Discharge other ICU other hospital : 2007: 3,7 % 2008: 5,6 % 2009: 2,0 %

15. Key Performance Indicators (KPIs) • Cost evaluation should not be used as an indicators for controlling people/healthcare organizations • The main reasons for measuring performance are: • To learn and improve • To report externally and demonstrate compliance/operational optimization • ( ex.: ICU-capacity maintenance /discharge policy) • To control and monitor “healtcare performance and quality” – is our organisation on track or not.

16. Key Performance Indicators : Costs Activity Productivity Efficiency Patient numbers ICU LOS Mechanical vent. RRT (renal) Tracheotomi ECMO Hemodyn. support Cooling …… Nursing professional activity …… Fixed cost Staff costs Equipment Basic bed costs/day Maintenance Administration Variable cost Drugs Invasive procedures Disposables Blood products, fluids.. Diagnostic procedures X-ray; CT; MR… Laboratory testing Micobiological analysis Physiotheraphy Resource use pr. treatment DRG Cost pr. day Cost pr. procedure …… Specific ressource use pr. CPR / diagnosis / outcomegroup Quality Survival (mortality) SMR HRQoL Other ”Indictors of quality” VAP Readmissions Kateterrel. infections …… Organisational performance Research

17. ICU 4131 – Performance monitoring

18. ITA 4131 - Aktivitets og kvalitetsmonitorering ( aldersgrupper )

19. ITA 4131 - Aktivitets og kvalitetsmonitorering ( diagnosegrupper )

20. ITA 4131 - Aktivitets og kvalitetsmonitorering ( fælles intensive grupper )

21. ITA 4131 - Aktivitets og Intensiv DRG registrering

22. ITA 4131 - Udvalgte kvalitetsindikatorer

23. ICU performance monitoring - comprehensive strategy to improve cost-awareness in ICUs Data : CIS 3.04. ICU 4131 & Abdominalcentret, centeradministrationen)

24. Key Performance Indicators (KPIs) – drug costs. * 2.586 EUR ** 36.853 EUR

25. ICU performance monitoring - comprehensive strategy to improve cost-awareness in ICUs Data : CIS 3.04. ICU 4131 & Abdominalcentret, centeradministrationen)

26. ICU performance monitoring - comprehensive strategy to improve cost-awareness in ICUs Data : CIS 3.04. ICU 4131 & Abdominalcentret, centeradministrationen)

27. ICU performance monitoring - comprehensive strategy to improve cost-awareness in ICUs Data : CIS 3.04. ICU 4131 & Abdominalcentret, centeradministrationen)

28. Impact of invasive fungal infections • Crude mortality 30 - 60 % • Attributable mortality 25 - 40 % • Prolongation of LOS 8 - 25 days • Increase of costs 5.000 - 40.000 EUR Ref.: Wey et al. Arch Intern Med 1988; Voss et al. Infection 1997; Blot et al. Am J Med 2002; Wisplinghof et al. CID 2004; Zaoutis et al. CID 2005

29. It seems possible to identify specific patient populations in the ICU with an apparently relatively constant use of resources

30. Conclusion: Intensive care unit are amongst the most costly departments in hospitals. The cost for staffing is the highest expenditure of ICU treatment with 50-60 % on average overall The severity of illness has ahuge impact on ICU cost (especially on the direct variable costs) It seems possible to identify specific patient populations in the ICU with an apparently relatively constant use of resources In Danish ICU’s of maximum medical care ( level 3 ICU) the mean average daily cost is estimated : 2.700 EUR With the increasing number of computerizedpatient data management systems in the ICU, the analysis of direct variable cost becomes easier

31. Virksomhedens fælles ledestjerne er hvor på landkortet og især på verdenskortet, • vi skal være i 2020………... ordet ”internationalisering” • Videreudvikle arbejdet med automatiseret dataopsamling og rapportgenerering. • Videreudvikle arbejdet med dokumentation til anvendelse for sundhedsfaglige, • administrative og forskningsmæssige formål. • Videreudvikle et nationalt/internationalt samarbejde omkring registreringsstandarder og fælles • begrebsforståelse ( SNOMED CT ) i samarbejde med SST.

32. xxxxxxxxxxxxxxxx CIS 2.4.

33. CIS 2.4.

34. Diagnostiske kriterier : Invasive svampeinfektioner (proven)

35. Diagnostiske kriterier : Invasive svampeinfektioner (proven) Invasive svampeinfektioner (probable)

36. Diagnostiske kriterier : Invasive svampeinfektioner (proven) Invasive svampeinfektioner (probable) Invasive svampeinfektioner (possible)

37. Svampeinfektioner I intensiv regi - er det et problem ? ________________________________________________________________________________________________ Incidensen af invasive svampeinfektioner er ~ 3 % Ref. : CIS.2.4 Incidensen af abnorm kolonisering med gær er ~10 % .

38. Severe septic patients with and without IFI. Conclusion: IFI is associated with excess risk for death in the hospital, prolonged LOS and greater consumption of medical resources. Guo-Hao Xie1 et. AlImpact of invasive fungal infection on outcomes of severe sepsis: a multicenter matched cohort study in critically ill surgical patients Critical Care 2008, 12:1. http://ccforum.com/content/12/1/R5

39. Ref.: CIS 2.4.2007.2008

40. Ref.: CIS 2.4.2007.2008

41. Svampeinfektioner i intensiv regi : Videreudvikle vores arbejde med automatiseret dataopsamling og rapportgenerering og hermed validering af diagnostik og behandling Videreudvikle arbejdet med dokumentation til anvendelse for sundhedsfaglige, administrative og forskningsmæssige formål Videreudvikle et nationalt/internationalt samarbejde omkring registreringsstandarder og fælles begrebsforståelse …..”målet er fortsat højeste kvalitet under optimal ressourceudnyttelse”….