Intensive Care Units (ICUs): Clinical

Outcomes, Costs, and Decisionmaking

November 1984

NTIS order #PB85-145928
HEALTH TECHNOLOGY CASE STUDY 28

Intensive Care Units (ICUs)

Clinical Outcomes, Costs,

and Decisionmaking

NOVEMBER 1984

This case study was performed as a part of OTA’S Assessment of

Medical Technology and Costs of the Medicare Program

Prepared under contract to OTA by:

Robert A. Berenson, M.D.

1

OTA Case Studies are documents containing information on a specific medical technology or area of application that supplements formal OTA assessments. The material

is not normally of as immediate policy interest as that in an OTA Report, nor does

it present options for Congress to consider.

CONGRESS OF THE UNITED STATES

Otlke of Technology Assessment

Washington, D C 20510
Recommended Citation:

Berenson, R. A., Intensive Care Units (ICUs): Clinical Outcomes, Costs, and Decisionmaking

(Health Technology Case Study 28), prepared for the Office of Technology Assessment,

U.S. Congress, OTA-HCS-28, Washington, DC, November 1984.

Library of Congress Catalog Card Number 84-601138

For sale by the Superintendent of Documents

U.S. Government Printing Office, Washington, D.C. 20402
Preface

Intensive Care Units (ICUs): Clinical Outcomes,

Costs, and Decisionmaking, is Case Study 28 in

OTA’S Health Technology Case Study Series. This

case study has been prepared in connection with

OTA’S project on Medical Technology and Costs

of the Medicare Program, requested by the House

Committee on Energy and Commerce and its Subcommittee on Health and the Environment and

the Senate Committee on Finance, Subcommittee on Health. A listing of other case studies in

the series is included at the end of this preface.

OTA case studies are designed to fulfill two

functions. The primary purpose is to provide

OTA with specific information that can be used

in forming general conclusions regarding broader

policy issues. The first 19 cases in the Health Technology Case Study Series, for example, were conducted in conjunction with OTA’S overall project

on The Implications of Cost-Effectiveness Analysis of Medical Technology. By examining the 19

cases as a group and looking for common problems or strengths in the techniques of cost-effectiveness or cost-benefit analysis, OTA was able

to better analyze the potential contribution that

those techniques might make to the management

of medical technology and health care costs and

quality.

The second function of the case studies is to

provide useful information on the specific technologies covered. The design and the funding levels of most of the case studies are such that they

should be read primarily in the context of the associated overall OTA projects. Nevertheless, in

many instances, the case studies do represent extensive reviews of the literature on the efficacy,

safety, and costs of the specific technologies and

as such can stand on their own as a useful contribution to the field.

Case studies are prepared in some instances because they have been specifically requested by

congressional committees and in others because

they have been selected through an extensive review process involving OTA staff and consultations with the congressional staffs, advisory panel

to the associated overall project, the Health Program Advisory Committee, and other experts in

various fields. Selection criteria were developed

to ensure that case studies provide the following:

● examples of types of technologies by func-

●

●

●

●

●

●

●

tion (preventive, diagnostic, therapeutic, and

rehabilitative);

examples of types of technologies by physical

nature (drugs, devices, and procedures);

examples of technologies in different stages

of development and diffusion (new, emerging, and established);

examples from different areas of medicine

(e.g., general medical practice, pediatrics,

radiology, and surgery);

examples addressing medical problems that

are important because of their high frequency or significant impacts (e.g., cost);

examples of technologies with associated high

costs either because of high volume (for lowcost technologies) or high individual costs;

examples that could provide information material relating to the broader policy and methodological issues being examined in the

particular overall project; and

examples with sufficient scientific literature.

Case studies are either prepared by OTA staff,

commissioned by OTA and performed under contract by experts (generally in academia), or written by OTA staff on the basis of contractors’

papers.

OTA subjects each case study to an extensive

review process. Initial drafts of cases are reviewed

by OTA staff and by members of the advisory

panel to the associated project. For commissioned

cases, comments are provided to authors, along

with OTA’S suggestions for revisions. Subsequent

drafts are sent by OTA to numerous experts for

review and comment. Each case is seen by at least

30 reviewers, and sometimes by 80 or more outside reviewers. These individuals may be from

relevant Government agencies, professional societies, consumer and public interest groups, medical practice, and academic medicine. Academicians such as economists, sociologists, decision

analysts, biologists, and so forth, as appropriate,

also review the cases.

Although cases are not statements of official

OTA position, the review process is designed to

satisfy OTA’S concern with each case study’s

scientific quality and objectivity. During the various stages of the review and revision process,

therefore, OTA encourages, and to the extent

possible requires, authors to present balanced information and recognize divergent points of view.

,.. 111
Health Technology Case Study Seriesa

Case Study Case Study

Series Case study title; author(s); Series Case study title; author(s);

number OTA publication numberb

number OTA publication numberb

1

2

3

4

5

6

7

8

9

10

11

12

13

Formal Analysis, Policy Formulation, and End-Stage

Renal Disease;

Richard A. Rettig (OTA-BP-H-9(1))C

The Feasibility of Economic Evaluation of

Diagnostic Procedures: The Case of CT Scanning;

Judith L. Wagner (OTA-BP-H-9(2))

Screening for Colon Cancer: A Technology

Assessment;

David M. Eddy (OTA-BP-H-9(3))

Cost Effectiveness of Automated Multichannel

Chemistry Analyzers;

Milton C. Weinstein and Laurie A. Pearlman

(OTA-BP-H-9(4))

Periodontal Disease: Assessing the Effectiveness and

Costs of the Keyes Technique;

Richard M Scheffler and Sheldon Rovin

(OTA-BP-H-9(5))

The Cost Effectiveness of Bone Marrow Transplant

Therapy and Its Policy Implications;

Stuart O. Schweitzer and C. C. Scalzi

(OTA-Bp-H-9(6))

Allocating Costs and Benefits in Disease Prevention

Programs: An Application to Cervical Cancer

Screening;

Bryan R. Luce (Office of Technology Assessment)

OTA-BP-H-9(7))

The Cost Effectiveness of Upper Gastrointestinal

Endoscopy;

Jonathan A. Showstack and Steven A. Schroeder

(OTA-Bp-H-9(8))

The Artificial Heart: Cost, Risks, and Benefits;

Deborah P. Lubeck and John P. Bunker

(OTA-BP-H-9(9))

The Costs and Effectiveness of Neonatal Intensive

Care;

Peter Budetti, Peggy McManus, Nancy Barrand,

and Lu Ann Heinen (OTA-BP-H-9(1O))

Benefit and Cost Analysis of Medical Interventions:

The Case of Cimetidine and Peptic Ulcer Disease;

Harvey V. Fineberg and Laurie A. Pearlman

(OTA-BP-H-9(11))

Assessing Selected Respiratory Therapy Modalities:

Trends and Relative Costs in the Washington, D.C.

Area;

Richard M. Scheffler and Morgan Delaney

(OTA-BP-H-9(12))

Cardiac Radionuclide Imaging and Cost

Effectiveness;

William B. Stason and Eric Fortess

(OTA-BP-H-9(13))

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

Cost Benefit/Cost Effectiveness of Medical

Technologies: A Case Study of Orthopedic Joint

Implants;

Judith D. Bentkover and Philip G. Drew

(OTA-BP-H-9(14))

Elective Hysterectomy: Costs, Risks, and Benefits;

Carol Korenbrot, Ann B. Flood, Michael Higgins,

Noralou Roos, and John P. Bunker

(OTA-BP-H-9(15))

The Costs and Effectiveness of Nurse Practitioners;

Lauren LeRoy and Sharon Solkowitz

(OTA-BP-H-9(16))

Surgery for Breast Cancer;

Karen Schachter Weingrod and Duncan Neuhauser

(OTA-BP-H-9(17))

The Efficacy and Cost Effectiveness of

Psychotherapy;

Leonard Saxe (Office of Technology Assessment)

(OTA-BP-H-9(18))d

Assessment of Four Common X-Ray Procedures;

Judith L. Wagner (OTA-BP-H-9(19))e

Mandatory Passive Restraint Systems in

Automobiles: Issues and Evidence;

Kenneth E. Warner (OTA-BP-H-15(20))f

Selected Telecommunications Devices for HearingImpaired Persons;

Virginia W. Stern and Martha Ross Redden

(OTA-BP-H-16(21))g

The Effectiveness and Costs of Alcoholism

Treatment;

Leonard Saxe, Denise Dougherty, Katharine Esty,

and Michelle Fine (OTA-HCS-22)

The Safety, Efficacy, and Cost Effectiveness of

Therapeutic Apheresis;

John C. Langenbrunner (Office of Technology

Assessment) (OTA-HCS-23)

Variation in Length of Hospital Stay: Their

Relationship to Health Outcomes;

Mark R, Chassin (OTA-HCS-24)

Technology and Learning Disabilities;

Candis Cousins and Leonard Duhl (OTA-HCS-25)

Assistive Devices for Severe Speech Impairments;

Judith Randal (Office of Technology Assessment)

(OTA-HCS-26)

Nuclear Magnetic Resonance Imaging Technology:

A Clinical, Industrial, and Policy Analysis;

Earl P. Steinberg and Alan Cohen (OTA-HCS-27)

Intensive Care Units (ICUs): Clinical Outcomes,

Costs, and Decisionmaking;

Robert A. Berenson (OTA-HCS-28)

available for sale by the Superintendent of Documents, U.S. Government dBackground pavr #3 to The Implications of Cost-Effectiveness Analysis of

Printing Office, Washington, D. C., 20402, and by the National Technical Medical Technology.

Information Service, 5285 Port Royal Road, Springfield, Va., 22161. Call ‘Background Paper #5 to The implications of Cost-Effectiveness Analysis of

OTA’S Publishing Office (224-8996) for availability and ordering infor- Medical Technology.

mation. IBackground paper #1 to OTA’S May 1982 report Technology and lfandiboriginal publication numbers appear in Parenth=s. capped People.

‘The first 17 cases in the series were 17 separately issued cases in Background gBackground paper #2 to Technology and Handicapped People.

Paper ,#2: Case Studies of Medical Technologies, prepared in conjunction

with OTA’S August 1980 report The Implications of Cost-Effectiveness Analysis of Medical Technology.

iv
OTA Project Staff for Case Study #28

H. David Bantal and Roger C. Herdman,2 Assistant Director, 0TA

Health and Life Sciences Division

Clyde J. Behney, Health Program Manager

Anne Kesselman Burns, Project Director

Pamela Simerly, Research Assistant

Virginia Cwalina, Administrative Assistant

Beckie I. Erickson,3 Secretary/Word Processing Specialist

Brenda Miller, PC Specialist

Jennifer Nelson,3 Secretary

Mary Walls,’ Secretary

1Until August 1983.

‘Since December 1983.

3

Since January 1984.

‘Until January 1984.
Medical Technology

— —

and Costs of the Medicare Program Advisory Panel

Stuart Altman, Panel Chair

Dean, Florence Heller School, Brandeis University

Frank Baker

Vice President

Washington State Hospital Association

Robert Blendon

Senior Vice President

The Robert Wood Johnson Foundation

Jerry Cromwell

President

Health Economics Research

Chestnut Hill, MA

Karen Davis

Chair, Department of Health Policy and

Management

School of Hygiene and Public Health

Johns Hopkins University

Robert Derzon

Vice President

Lewin & Associates

San Francisco, CA

Howard Frazier

Director

Center for the Analysis of Health Practices

Harvard School of Public Health

Clifton Gaus

President, Foundation for Health Services

Research

Washington, DC

Jack Hadley

Director

Center for Health Policy Studies

Georgetown University

Kate Ireland

Chair, Board of Governors

Frontier Nursing Service

Wendover, KY

Judith Lave

Professor

Department of Health Economics

University of Pittsburgh

Mary Marshall

Delegate

Virginia House of Delegates

Walter McNerney

Professor of Health Policy

J. L. Kellogg Graduate School of Management

Northwestern University

Morton Miller

Immediate Past President

National Health Council

New York, NY

James Morgan

Executive Director

Truman Medical Center

Kansas City, MO

Seymour Perry

Deputy Director

Institute for Health Policy Analysis

Georgetown University Medical Center

Robert Sigmond

Director, Community Programs for

Affordable Health Care

Advisor on Hospital Affairs Blue Cross/Blue

Shield Association

Anne Somers

Professor

Department of Environmental and

Community and Family Medicine

UMDNJ—Rutgers Medical School

Paul Torrens

School of Public Health

University of California, Los Angeles

Keith Weikel

Group Vice President

AMI

McLean, VA

vi
Contents

Chapter

CHAPTER 1: INTRODUCTION AND

Introduction . . . . . . . . . . . . . . . . . . . . . . .

Executive Summary . . . . . . . . . . . . . . . . .

Utilization oflCUs . . . . . . . . . . . . . . .

Outcomes of lntensive Care . . . . . . .

Payment for ICU Services . . . . . . . . .

Decision making in the ICU . . . . . . . .

Foregoing Life-Sustaining Treatment

Possible Future Steps, . . . . . . . . . . . . .

EXECUTIVE

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CHAPTER 2: EVOLUTION, DISTRIBUTION,

OF INTENSIVE CARE UNITS . . . . . . . . . . . .

The Development of the ICU . . . . . . . . . . . . . . .

Advantages and Disadvantages of ICU Care..

Definitions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Requirements of an ICU . . . . . . . . . . . . . . . . . . . .

Specialty. Multispecialty ICUs. . . . . . . . . . . . .

Distribution of ICU Beds . . . . . . . . . . . . . . . . . . .

Expansion of ICU Beds . . . . . . . . . . . . . . . . . . . . .

Regulation of ICUs . . . . . . . . . . . . . . . . . . . . . . . .

CHAPTER 3: COST OF ICU CARE . . . . . . . . .

Components of ICU Costs . . . . . . . . . . . . . . . . . .

Costs of an ICU Day . . . . . . . . . . . . . . . . . . . . . .

Total National Costs of Intensive Care.. . . . . .

CHAPTER 4: UTILIZATION OF ICES. . . . . . .

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Utilization by Type of ICU . . . . . . . . . . . . . . . . .

ICU Admission Rates . . . . . . . . . . . . . . . . . . . . . .

Sex and Age Distribution of ICU Use . . . . . . . .

ICU Case Mix. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Diagnoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Other Case Mix Parameters . . . . . . . . . . . . . . .

Readmission . . . . . . . . . . . . . . . . . . . . . . . . . . .

Length of Stay . . . . . . . . . . . . . . . . . . . . . . . . . .

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SUMMARY

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AND REGULATION

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CHAPTER 5: OUTCOMES OF INTENSIVE CARE: MEDICAL

AND COST EFFECTIVENESS . . . . . . . . . . . . . . . . . . . . . . . . . . .

Difficulties in Assessing Effectiveness. . . . . . . . . . . . . . . . . . . . . . . .

Clinical Outcomes of ICU Care . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Functional Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Characteristics of ICU Nonsurvivors . . . . . . . . . . . . . . . . . . . . . . . .

Age . . . . . . . . . . . . . . . . . . . . . . . . .

Severity of Illness . . . . . . . . . . . .

Resource Use . . . . . . . . . . . . . . . .

Distribution of ICU Costs Among

Monitored Patients . . . . . . . . . . . . .

Adverse Outcomes of ICU Care..

Iatrogenic Illness . . . . . . . . . . . . .

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. . . . . . . . . . . . . . . . . . . . . . . . . . Patients . . . . . . . . . . . . . . . . . .

...)., .!$.... . . . . . . . . . . . . .

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BENEFITS

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Contents—continued

Nosocomial Infections. . . . . . . . . . . . . . . . .

Psychological Reactions . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cost-Effectiveness Analysis of Adult Intensive Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

CHAPTER 6: PAYMENT FOR ICU SERVICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Traditional Hospital Reimbursement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Patient Copayments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Utilization Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Prospective Payment Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Medicare’s Current Inpatient Hospital Payment System . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Medicare Utilization of ICUs by DRGs.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Applicability of DRGs to Ices. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Physician Payment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

CHAPTER 7: THE ICU TREATMENT IMPERATIVE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The Highly Technological Nature of ICU Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The Nature of ICU Illnesses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Traditional Moral Distinctions in Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The Diffusion of Decision making Responsibility ........,.. . . . . . . . . . . . . . . . . . . . . . . . .

Problems of Informed Consent in the ICU . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Legal Pressures: Defensive Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Payment and the Treatment Imperative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The Absence of Clinical Predictors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

CHAPTER 8: FOREGOING LIFE-SUSTAINING TREATMENT . . . . . . . . . . . . . . . . . . . . .

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The Natural Process of Death . . . . . . . . . . . . . . . . . . . . . . . . .

Fundamental Ethical, Moral, and Legal Considerations. . .

Procedures for Review of Decisionmaking . . . . . . . . . . . . . .

Rationing ICU Care.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Explicit or Implicit Rationing of ICU Care? . . . . . . . . . . . . .

Explicit Rationing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Implicit Rationing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

CHAPTER 9: CONCLUSIONS AND POSSIBLE FUTURE STEPS . . . . . . . . . . . . . . . . . . .

APPENDIX A: ACKNOWLEDGMENTS AND HEALTH PROGRAM

ADVISORY COMMITTEE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

APPENDIX B: COST ESTIMATES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Page

40

40

41

45

45

45

45

46

46

46

48

48

51

55

55

55

56

57

58

59

60

62

63

67

67

67

68

70

71

72

72

73

77

81

84

89

Tables

Table No. Page

1. Distribution of ICU Beds in Short-Term, Non-Federal Hospitals,

by Size of Hospital 1982 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

2. ICU/CCU Beds as Percent of Total Beds by Hospital Size for Short-Term

Non-Federal Hospitals, 1982 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

3. Distribution of ICU and CCU Beds, by Region, 1981 . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

4. Percentage of ICU/CCU Beds in Short-Term Hospitals,

by Hospital Sponsorship, 1976 and 1982 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

5. Summary of Selected ICU Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Contents—continued

6.

7.

8.

9.

10,

Page

Use and Percentage of Hospital Charges Incurred in ICUs and CCUs for Medicare

Beneficiaries Discharged From Short-Stay Hospitals, 1979 . . . . . . . . . . . . . . . . . . . . . . . 26

Use and Percentage of Hospital Charges Incurred in ICUs and CCUs for Medicare

Beneficiaries Discharged From Short-Stay Hospitals, by Geographic Region, 1979.. 27

Use and Percentage of Hospital Charges Incurred in ICUs and CCUs for Medicare

Beneficiaries Discharged From Short-Stay Hospitals, by Age, 1980 . . . . . . . . . . . . . . . 27

Retrospective Outcome Studies of ICU Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Estimated Number of Special Care Days by Primary Diagnosis Based

on HCFA 20-Percent Sample of Medicare Discharges, 1980. . . . . . . . . . . . . . . . . . . . . . 49
——

Glossary of Acronyms

AHA –

APACHE –

CBA –

CCC –

CEA –

CON –

DHHS –

DRG –

HCFA –

HMO –

ICU –

American Hospital Association

Acute Physiology and Chronic Health

Evaluation Scale

cost-benefit analysis

coronary care unit

cost-effectiveness analysis

certificate-of-need

U.S. Department of Health and

Human Services

Diagnosis Related Group

Health Care Financing Administration

(U.S. Department of Health and

Human Services)

health maintenance organization

intensive care unit

Iv

LOS

NIH

OR

PSRO

SCU

TISS

UCR

UR

— intravenous

– length of stay

– National Institutes of Health (U.S.

Department of Health and Human

Services)

— operating room

— Professional Standards Review

Organization — special care unit

— Therapeutic Intervention Scoring

System — usual, customary and reasonable

physician charges for payment

purposes — utilization review

IRB – institutional review board

OTA Note

These case studies are authored works commissioned by OTA. Each author

is responsible for the conclusions of specific case studies. These cases are not statements of official OTA position. OTA does not make recommendations or endorse

particular technologies. During the various stages of review and revision, therefore,

OTA encouraged the authors to present balanced information and to recognize

divergent points of view.
1 .

Introduction and

Executive Summary

“The patient’s recovery will be watched not only by nurses but by electric eyes

too. Sensing devices will constantly monitor his heart rate, his temperature, his respiration rate, his electrocardiogram, and the blood pressure both in his veins and in his

arteries. The nurses will not rouse the patient early in the morning to poke a glass

thermometer between his gums and then spend much of the day checking up on his

and the other patients’ conditions. They will simply push a button at the console of

their station to get as many readouts as they want. The patient will not have to hope

that if he enters a crisis somebody may spot it.

If any single bodily function or combination of functions deviates beyond the fixed

limits the patient’s Physician has programmed into a computer, lights will flash and

a buzzer will sound the-alarm

plete array of equipment will

“Physicians tend to be 

Within seconds, nurses, technicians, doctors, andbe in action at his bedside.”

–Life Magazine, December 2, 1966unun

unimpressed with the published descriptions of units and

their working. It often seems to them that the assessment of the results is naive, survival being taken as equivalent of a life saved. They suspect that, however expert the

handling of the apparatus, there is often a shallow understanding of the disease and

an over-readiness to employ the most dramatic treatment;. . . One is tempted to say

that treatment is often more intense than careful . . .

I believe, therefore, with many of my colleagues, that the attempt to segregate

all medical emergencies on a basis of apparatus need will prove to have been an

aberration.”

—Professor A. C. Dornhorst, April 1, 1966
1

Introduction and Executive Summary

INTRODUCTION

Intensive care units (ICUs) exemplify the best

that American medicine has to offer—teams of

dedicated professionals using the latest technology to save lives that in the past would have

almost surely been lost. Formally developed only

in the late 1950s, ICUs are present in almost 80

percent of hospitals in the United States. They are

estimated to consume between 15 and 20 percent

of the Nation’s hospital budget, or almost 1 percent of the gross national product. Yet, despite

such large expenditures of public and private

resources, there has been remarkably little critical

evaluation of the effectiveness of ICU care by

either the public or the medical profession.

In recent years, however, there has been growing public and professional awareness of the emotional torment suffered by the patients and their

families related to the use of “lifesaving” medical

care which does not really benefit the patient.

Correspondingly, there has been increasing support for the notion that patients have the right

to reject measures that will prolong their lives

without improving their condition.

Along with the increasing public recognition

that there are times when extraordinary medical

care should not be employed, three key developments have made this an opportune time to analyze the costs and benefits of ICU care. First, the

President’s Commission for the Study of Ethical

Problems in Medicine and Biomedical and Behavioral Research issued a comprehensive report in

March 1983 on the medical, ethical, and legal

issues underlying decisions on whether to forego

life-sustaining treatment for seriously ill patients

(191), The recommendations of the expert commission have direct bearing on decisionmaking for

many ICU patients.

Also in March 1983, a Consensus Development

Conference sponsored by the National Institutes

of Health (NIH) formally evaluated the efficacy

and appropriateness

the first time (176).

of critical care medicine]

The Conference Report

for

examines the evidence for efficacy of critical care .

medicine for various clinical problems and provides recommendations for organization and

administration of ICUs.

Finally, in April 1983, Congress enacted a prospective payment system for Medicare in the

Social Security Act Amendments of 1983 (Public

Law 98-21). This new payment system, which

began to be phased in over a 3-year period beginning in October 1983, will dramatically alter payment for services provided in ICUs by placing a

limit on the amount of reimbursement available

for different categories of illnesses. These limits

may have a significant impact on the services

available for critically ill patients.

This case study has two purposes. The first is

to present what is currently known about ICUs

in terms of the distribution of ICU beds, the costs

of maintaining ICUs, the utilization of ICUs, the

characteristics of ICU patients, and the outcome

of ICU care. There are still important gaps in the

data, but a substantial body of knowledge exists

about the technical aspects of ICU care. The ICU

is examined as a discrete medical technology.

The second purpose of the study is to establish

a framework for considering some of the clinical,

moral, and legal issues that arise with respect to

ICU care. The study explores, for example, the

factors unique to the ICU that sometimes lead

physicians to continue life-support for patients

who have minimal hope of improving. It discusses

ways in which patients can make known their

wishes about foregoing or discontinuing lifesupport if their condition deteriorates and how

physicians and family members can decide whether to terminate life-support when the patient is

not capable of making such a decision. It also conIThis case study defines both “’intensive care” and “critical care”

as care provided in separate hospital units generally known as “intensive care units. ” See ch. 2 for a discussion of definitions.

3
4 . Health Case Study 28: intensive Care Units: Costs, Outcome, and Decisionmaking

siders how ICU treatment might be rationed in

the future if it becomes necessary to do so.

As is shown in the review of data on costs and

benefits of ICU care, the ICU is often an effective, lifesaving technology. However, it is effective at a high cost. Indeed, partially because of

its success in many clinical situations, it will not

be easy to simply find and eliminate the “waste”

in ICUs. Changing the economic incentives for

provision of ICU care, as under Medicare’s new

hospital payment system, has not made it any

easier for patients, families, and ICU staffs who

frequently face difficult decisions about how aggressively to treat individual patients. Indeed, as

the case study explores, the new prospective payment system may make ICU decisionmaking even

more difficult and contentious than in the past.

EXECUTIVE SUMMARY

The ICU has been called the hallmark of the

modern hospital but has come into existence only

over the last 25 years. Initially, the ICU was an

expansion of the surgical recovery room and was

subsequently an outgrowth of the respiratory care

units made possible by the development of the mechanical ventilator.

Today, almost 80 percent of short-term general

hospitals have at least one ICU. Overall, 5.9 percent of total hospital beds in non-Federal, shortterm community hospitals in 1982 were beds in

ICU and coronary care units (CCUS). Beds in

other types of special care units, including

pediatric, neonatal, and burn units, add another

1 percent to the total complement of special care

beds.

ICU beds are reasonably evenly distributed

among all sizes of hospitals, regions of the country, and types of hospital sponsorship. Over the

last 6 years, the number of ICU beds has risen

abouts percent a year, compared to a rise of general hospital beds of only 1 percent a year. A major rise of ICU beds occurred between 1979 and

1981, particularly in hospitals of greater than 500

beds. Federal and State policy, particularly certificate-of-need laws and Medicare reimbursement

The case study focuses on adult ICUS and not

neonatal, burn, or cardiac units. While some of

the issues raised here are applicable to these other

specialized care units, these other units generally

present different clinical, ethical, and public policy issues. Certainly, all units treat seriously ill

patients. However, the moral, ethical, and legal

problems raised by withholding care for seriously

handicapped newborns, for example, differ from

the problems raised by withholding care for an

elderly person with a terminal condition. The

issues related to treatment of such infants, which

has been the center of the recent “Baby Doe” controversy, deserve separate attention. Likewise, as

the study emphasizes, coronary care patients are

clinically different from general intensive care

patients.

policy until 1982, probably contributed to the

continued expansion of ICU beds and ICU utilization.

For a number of technical and conceptual

reasons, an accurate estimate of the cost of ICU

care is difficult to make. For example, there is

disagreement on whether consideration of ICU

costs should include the room and board costs of

ICU care only, the room and board and ancillary

care costs of patients while in the ICU, or the incremental costs of ICUs above that which the hospital would have to bear in any case for seriously

ill patients. The national average per diem charge

in 1982 of an ICU bed was $408 compared to a

regular bed per diem charge of $167, a ratio of

about 2.5:1. However, it is likely that the true cost

ratio is closer to 3-3.s:1. In addition, ICU patients

consume a greater proportion of ancillary services, particularly laboratory and pharmacy services, than regular floor patients.

Based on these and other considerations, it is

estimated that the costs of adult ICU and CCU

care—the cost to the hospital patients while they

are in the special care unit—represents about 14

to 17 percent of total inpatient, community hospital costs, or $13 billion to $15 billion in 1982.
Ch. l–Introduction and Executive Summary ● 5

Inclusion of the other types of specialized and Federal hospital ICUs would bring the percentage up

to about 20 percent.

Utilization of ICUs

According to 1979 Medicare data, 18 percent

of Medicare discharges included a stay in intensive care (including coronary care) in that year.

Unfortunately, similar data are not available for

the entire population. From reports from individual hospitals, however, certain general utilization

patterns do emerge (these reports are weighted

towards large and teaching hospitals). The representation of the elderly in ICUs seems to be the

same or slightly more than in the hospital as a

whole. Poor chronic health status, rather than

age, appears to be a predominant factor limiting

use of ICUs in individual cases in the United

States. In comparison to the United States, ICU

patients in other countries have a significantly

lower mean age.

There is no accepted classification scheme that

describes the clinical characteristics of ICU patients, largely because ICU patients are a heterogeneous population who have multiple underlying

medical problems and who exhibit varying physiologic disturbances. ICU patients range from

those who are in the ICU primarily for monitoring for potential disturbances to those who are

critically ill and receive life-supporting treatment

and continuous intensive nursing and physician

care.

Outcomes of Intensive Care

Unfortunately, it is difficult to separate the intensity of care from the setting in which it is provided, and therefore, to know whether intensive

care would be as effective if provided on the general hospital floor as in the physically and administratively separate ICU. Many believe that

randomized clinical trials of ICUs, at least for

unstable patients, are currently unethical, because

ICU care has become the accepted and standard

mode of treatment in the United States for most

severely ill and injured patients.

A recent NIH-sponsored consensus panel found

that it is impossible to generalize about whether

ICU care improves outcome for the varied ICU

patient population. The panel felt that ICU intervention is unequivocally lifesaving for some

conditions, particularly where there is an acute,

reversible disease such as drug overdose or major trauma. There is less certainty about the effectiveness of ICU care in other conditions, particularly in the presence of a severe, debilitating

chronic illness, such as cancer or cirrhosis of the

liver. Investigators believe that underlying disease

is probably the most significant predictor of the

outcome of ICU care, although patient age and

severity of illness are also important.

Recent data have emphasized the inverse relationship between the cost of ICU care and survival. At this time, however, there are no accepted

methods for determining ahead of time which patients will benefit from additional ICU care. From

a number of studies, it is clear that the sickest ICU

patients, many of whom do not survive, consume

a highly disproportionate share of ICU charges.

Two recent studies, for example, found that 17

and 18 percent, respectively, of the ICU patient

population generated half of the ICU charges.

Moreover, charges do not account for the substantial cross-subsidization of costs between ICU patients. It is likely, then, that the true proportion

of costs consumed by the sickest ICU patients are

substantially greater than even the charge data

suggest.

At the other end of the ICU patient spectrum

are patients in the ICU primarily for monitoring

of the development of a life-threatening complication. Some of these patients may be able to be

cared for safely and more cost effectively outside

of the ICU, either in intermediate care units or

on regular medical floors. On the other hand,

there may be a population of ICU patients who

are discharged prematurely from ICUs. Research

has only recently begun to better define which patients should be routinely monitored in an ICU

and which would do as well or even better if cared

for on other floors in the hospital.

Another consideration in deciding whether a

patient should be cared for in the ICU is the reality

of adverse effects of ICU care, so-called iatrogenic

illness. A list of major iatrogenic complications

of prolonged ICU care has been identified. Noso-
—. —

6 ● Health Case Study 28: Intensive Care Units: Costs, outcome, and Decisionmaking

comial infections—i. e., infections that were not

present or incubating at the time of hospital admission—and various serious psychological reactions are particular complications of ICU care.

Payment for ICU Services

To the extent that insurers distinguish ICU care

from other hospital care for purposes of payment,

the result has been to reward ICU care relative

to care in intermediate level special care units or

on general floors of the hospital. For example, in

1980, Medicare tightened the existing payment

limits on routine bed costs but not on ICU bed

costs—the so-called “section 223 limits. ” Furthermore, utilization review efforts generally have not

considered the appropriate level of care within the

hospital.

Medicare’s inpatient hospital payment policies,

however, have now changed dramatically as a result of the passage of the Social Security Act

Amendments of 1983 (Public Law 98-21). Under

the relatively new system, hospitals receive a fixed

payment per discharge based on the patient’s principal diagnosis. The classification system, which

identifies 467 different clinical conditions called

diagnosis-related groups (DRGs) appears ill-suited

for describing certain types of patients cared for

in ICUs. DRG payments are based largely on a

single diagnosis. Yet, ICU patients often have

multiple serious underlying illnesses. For these patients, designation of a single, principal diagnosis is likely to be arbitrary, and the resources used

due to the presence of additional diagnoses would

not be accounted for.

In addition, the DRG scheme does not take severity of illness into account. For some diagnoses, particularly noncardiac medical conditions,

the DRG category does not reflect the use of ICUs

for the more severely ill patients with that principal diagnosis. For example, only 3.5 percent of

the average total hospital stay for Medicare patients with cirrhosis (DRG 202) represent ICU

days. Yet, the sickest patients with cirrhosis are

among the highest cost ICU patients.

Furthermore, the outlier policy that the Health

Care Financing Administration has implemented

pays hospitals less than the marginal costs of caring for the sickest ICU patients. In short, it appears that under Medicare’s DRG payment system, the sicker ICU patients will be substantial

financial “losers” to the hospital.

Decisionmaking in the ICU

The new incentives of the DRG payment system

may conflict with an ICU decisionmaking environment in many hospitals in which the cost of

care has been of minor concern in the past. Indeed, a number of factors, some of which are

somewhat unique to the ICU, have led to a decisionmaking process that often has led physicians

to provide life-support care in the ICU after the

initial rationale for doing so no longer exists. Factors that have created an ICU treatment imperative include:

●

●

●

●

●

●

●

The highly technological nature of ICU care,

which often results in focus on the technical

details of treatment rather than the rationale

for continued treatment.

The nature of ICU illnesses, which often require “technologically oriented” treatment

even when the primary intent is to provide

comfort rather than cure to a desperately ill

patient.

Traditional moral distinctions in medicine

that in some cases result in more care than

the patient would choose if able to do so.

Diffusion of decisionmaking responsibility,

especially in relation to decisions to forego

or terminate life-support.

Problems of informed consent in the ICU

where many patients are temporarily or permanently incompetent.

The practice of defensive medicine by physicians, which involves taking or not taking

certain actions more as a defense against potential legal actions than for the patient’s benefit. Defensive medicine may be a particular

problem in the ICU, because of the life-anddeath nature of ICU care, the relative visibility of ICU decisions, and great uncertainty

about likely court decisions on these kinds

of cases.

A payment environment which, until 1982,

provided financial rewards to hospitals and

physicians for provision of ICU care. Physi-
Ch. I—Introduction and Executive Summary ● 7

cian payment methods continue to pay generously for the procedure-oriented ICU care.

● The absence of a data base for the common

ICU conditions on which to make reliable

clinical predictions of individual ICU patients’ chances of immediate and long-term

survival.

Foregoing Life=Sustaining Treatment

The Critical Care Consensus Development

Conference sponsored by NIH has concluded that

it is not appropriate to devote limited ICU

resources to patients without reasonable prospect

of significant recovery or to simply prolong the

natural process of death.

In general, a terminally ill patient’s right to

forego or discontinue life-sustaining treatment has

been established and is usually protected by the

constitutional right to privacy. Practical difficulties arise when the patient is not competent

to decide, and when other decisionmakers, including physicians, families; and patient surrogates, do not agree on what medical treatment

to pursue. State courts have differed on the decisionmaking procedures to use when a patient is

not able to choose for himself.

Recent court decisions differ even over when

a patient is considered “terminal” and over what

constitutes “medical” treatment. Likewise, many

courts have continued to invoke a distinction between ordinary and extraordinary care, while

some have explicitly rejected the distinction.

Possible Future Steps

Because of the increasing burden of medical care

costs on individuals and on society as a whole,

it is likely that the funds available for intensive

care will be much more strictly limited than in

the past. Because Medicare’s DRG payment system in general makes many ICU Medicare patients

financial losers for the hospital it may, therefore,

alter the prevailing provider attitudes about the

appropriateness and extent of ICU care in individual situations.

In recent years, the number of ICU beds has

expanded to meet increased demand for beds, except in public hospitals in financial distress or at

times when there was a shortage of ICU nurses

to staff available beds. In the future, there will

need to be greater attention paid to how to ration ICU beds. The DRG system used by Medicare

is a form of “implicit” rationing, because the payment limitations place greater pressures on physicians and hospitals to make resource allocation

choices without setting “explicit” limitations on

services or eligible patients. Under this form of

rationing, there will be a need to consider expanding the procedural safeguards used on behalf of

patients who become major financial losers for

the hospital. ICU decisionmaking will become

even more difficult than it has been in the past

due to potential financial conflict between patients, physicians, and hospitals.

A number of steps might improve the environment for intensive care decisionmaking:

Research on developing accurate predictors

of survival for patients with acute and

chronic illnesses could be expanded in order

to permit better informed decisions based on

the likelihood of short- and long-term survival. In the absence of valid and reliable

data, hospitals could consider formalizing an

institutional prognosis committee whose

function would be to advise physicians, families, and patients on the likelihood of survival with ICU care.

The suitability of the current DRG method

of payment for ICUs should be tested and

modified if necessary to take sufficient account of severity of illness.

The legal system may need to recognize the

possible conflict between malpractice standards which assume quality of care that meets

national expert criteria, and a decisionmaking environment in which resources may be

severely limited.

Health professionals who are involved in decisionmaking on critically ill patients might

benefit from more education in medical ethics

and relevant legal procedures and obligations.

The actual decisionmaking process for critically ill patients may need greater attention.

For example, hospitals might explore formalizing decisionmaking committees to lessen the
8 . Health Case Study 28: ]ntensive Care Units: Costs, Outcome, and Decisionmaking

burden on individuals faced with difficult through formal hospital committees, through

choices about terminating life-support. More government-imposed procedures which can

generally, society will need to decide how it follow fixed rules and regulations, or other,

wishes conflicts over decisions on terminating perhaps more decentralized, mechanisms.

life-support to be resolved—i.e., in courts,
2.

Evolution, Distribution, and

Regulation of Intensive Care Units
2 ■

Evolution, Distribution, and

Regulation of Intensive Care Units

THE DEVELOPMENT OF THE ICU

The intensive care unit (ICU) has been called

the hallmark of the modern hospital (205), yet it

is a recent development, having come into existence only in the last 25 years. The development

of ICUs was preceded by the rapid growth of postoperative recovery rooms (115) following World

War II. As early as 1863, however, Florence

Nightingale had foreseen the utility of a separate

area for observing patients recovering from the

immediate effects of surgery (172).

To a large extent, the initial stimulus for a separate recovery area for specialized care was a

managerial response to overwhelming medical

demands. The Massachusetts General Hospital,

for example, when suddenly faced with treating

39 survivors of the Boston Coconut Grove Fire

in 1942, set up a makeshift “burn unit” which it

maintained for 15 days, until the majority of patients had been sent home (115). In the North

African and Italian campaigns of World War II,

shock wards were established to resuscitate battlefield casualties and to care for injured soldiers

before and after surgery (115). After the war, an

acute shortage of nurses provided much of the impetus for the spread of recovery rooms in the

United States.

Although recovery rooms were established initially as a means of managing large numbers of

patients more efficiently, the medical benefits of

better postoperative nursing care soon became

apparent, and recovery rooms flourished. In 1951,

only 21 percent of community hospitals had recovery rooms; a decade later, virtually all hospitals had them (205).

During the 1950s, using the recovery room as

a model, a few ICUs began appearing on both

sides of the Atlantic. An early version of what

has become known as a respiratory ICU, for example, was set up in Denmark during the 1952

polio epidemic in Scandinavia. After 27 of 31 patients suffering from respiratory or pharyngeal

paralysis at Copenhagen’s Blegdam Hospital died,

the hospital’s senior anesthetist performed a tracheotomy on a 12-year-old girl and inserted a

cuffed endotracheal tube. The patient underwent

prolonged manual ventilation and survived.

With this new lifesaving, if laborious, technology in hand, a separate area to care for polio victims was established in the hospital. “At an early

stage the following measures were adopted: 1) patients who were likely to develop respiratory complications were transferred to special wards for

observation and recording vital signs, etc.; 2)

tracheotomies were done under general anesthesia and cuffed tubes were used; 3) manual, intermittent positive-pressure ventilation was used instead of or to supplement respirators; and 4)

secondary shock was treated” (121).

In addition, the hospital developed an elaborate

personnel system, involving anesthetists, epidemiologists, nurses, medical students, and hospital

workers, to provide continuous care for patients

and to maintain the machinery being used. As a

result of these measures, the mortality rate for

polio victims was reduced from 87 to 40 percent.

With the exception of Danish experience, ICUs,

like recovery rooms, were established initially

more for managerial than for medical reasons. A

major factor in their early development was the

need to relieve nurses who were so busy caring

for a few critically sick patients that they were

neglecting the remaining patients on the wards

(30). In addition, ICUs were even seen as a means

of reducing the cost of medical care (115).

By the late 1950s, the rapid development of the

mechanical ventilator provided the medical rationale for establishing ICUs. This life-supporting

technology needed to be monitored too closely

to be dispersed throughout the hospital (136,200).

In a number of hospitals, the general ICU was a

direct outgrowth of a respiratory ICU set up to

11
——.

12 ● Health Case Study 28: ]ntensive Care Units: Costs, Outcome, and Decisionmaking

care for patients suffering respiratory paralysis ing an ICU. By the last half of the 1960s, most

caused by polio (36) or tetanus (155). U.S. hospitals had established at least one ICU

In 1958, only about 25 percent of community (205).

hospitals with more than 300 beds reported havADVANTAGES AND DISADVANTAGES

Early advocates of ICUs identified a number of

advantages for establishing a separate intensive

care unit (frequently called an “intensive therapy

unit” in England and Europe) (25,47,178,208,231):

●

●

●

●

●

●

●

maintenance of high standards of care for

seriously ill patients by using specially trained

physicians and nurses;

provision of more continuous observation

and frequent measurements of relevant indicators of clinical condition;

concentration of technologies in one location

to avoid duplication of equipment and personnel;

direct access to patients for major procedures

and therapies, including resuscitation;

avoidance of upsetting the regular ward routine and disturbing less ill ward patients;

fostering high staff morale and team work;

and

opportunities for concentrated education and .

research.

From the outset, there was disagreement on

which patients would benefit from ICU care. Early

units attempted to exclude “terminal care cases,

chronic cases, and disturbed or disturbing patients” (23). Some emphasized that intensive therapy should be provided to support vital functions

until the underlying disease process could be corrected or run its course (200). Other early commentators saw the ICU simply as the place for the

“critically ill” (187), or advocated the use of the

ICU as a last resort for a “final desperate attempt”

to save a life (36). Lack of agreement persists on

which patients should have priority access to ICU

care.

While the advantages of the ICU were recognized early, so were the potential disadvantages

(25,64,178):

OF ICU CARE

a noisy, intrusive environment for seriously

ill patients;

interrupted continuity of medical responsibility;

mental and physical strain on the ICU staff;

overenergetic treatment—for both hopeless

and less serious cases;

decreased nursing skills on the general wards

as the sickest patients are removed;

potential for high cost with unfair claims on

the hospital budget; and

increased cross-infections among seriously ill

patients in the same area.

Stated another way, in some situations, application of intensive care maybe unnecessary because

the condition is not serious enough; unsuccessful

because the condition is too far advanced; unsafe

because the risk of complications is too great; unsound because it serves no useful purpose for the

patient; or unwise because it utilizes too many

resources (125).

Despite recognized patient care problems and,

more recently, cost concerns, ICU beds have continued to proliferate. There is substantial evidence

that, at least for some types of patients, care provided in ICUs is extremely effective. For many

medical problems, care of patients outside an ICU

would be unthinkable to the modem clinician. At

the same time, it is remarkable that such an allpervasive and cost-generating innovation has developed primarily because of “a priori” considerations, with few critical evaluations of its effectiveness (198). The growth of ICUs has been fostered

by a highly favorable reimbursement system (6o),

by the development of professional medical and

nursing critical care societies which constitute a

strong constituency for continued expansion of

ICUs (166), and by Federal policies which either
Ch. 2—Evolution, Distribution, and Regulation of Intensive Care Units .• 13

have directly stimulated ICU development (e.g., preferentially to exempt ICUs from expansion

the Regional Medical Program) or have tended restraints (205).

DEFINITIONS

In the broadest sense of the term, “critical care

medicine” has been used to include management

of critical illness or injury at the scene of onset,

during transportation to a medical facility, in the

emergency department, during surgical intervention in the operating room, and finally in the

hospital-based ICU (207). Some consider critical

care to be the highly technical treatment that is

provided to the most severely ill or injured subset

of the population receiving concentrated care in

a specialized unit (128,208). Thus, critical care

may be considered a higher level of management

than intensive care. This case study, however, will

follow the lead of the 1983 NIH Consensus Development Conference on Critical Care Medicine

and not distinguish the two terms (262); it will

consider both intensive care and critical care to

be the care provided in separate units generally

known as “intensive care units.”

From the original recovery rooms and ICUs,

other types of units providing specialized care

have evolved. In fact, the Joint Commission for

the Accreditation of Hospitals provides standards

for “special care units,” which encompass a broader spectrum of functions than ICUs (126). Since

the early 1960s, when the ability to identify and

treat potentially life-threatening arrhythmias was

first developed, most cardiac patients have been

treated in coronary care units (CCUs) (59). CCUs

generally developed independently of ICUs to

utilize the new technology of rhythm monitoring

to preserve the health of relatively stable patients,

rather than to relieve nurses faced with caring for

ward patients, which was the primary impetus for

the development of ICUs (205). Today, CCUs

treat patients with a relatively narrow range of

diagnoses, primarily patients with suspected or

actual heart attacks and related problems. CCU

patients are not as ill, have fewer physiologic systems involved, require fewer therapeutic services

(67), have better outcomes (31,249), have a greater

need for a quiet, stress-free environment (28), and

pose different evaluation and policy issues than

do patients in ICUs. In short, CCUs serve a different primary function from ICUs (238), and

most hospitals with more than 100 beds have separate CCUs and ICUs (4). Because they cannot

afford to operate separate units, smaller hospitals frequently combine the separate functions of

coronary and intensive care. As a result, some of

the data sources cited in this study, including

Medicare cost reports, have necessarily combined

ICUs and CCUs as critical care or special care

units.

In recent years, special care units have diversified in other ways (166). First, they have evolved

along specialty or subspecialty lines. Thus, burn,

cardiovascular surgery, pediatric, neonatal, and

respiratory as well as medical and/or surgical intensive care units are now common. Neonatal, pediatric, and burn units raise distinct issues and will

not be considered in this case study. Second, units

have differentiated into increasingly distinct levels

of intensity of care, e.g., step-down and intermediate care units. These newer types of units,

usually adjacent to the coronary or intensive care

unit, generally provide more concentrated nursing levels than those on the general medical or

surgical floors, but they do not provide intensive

therapy.
.

14 • Health Case Study 28: Intensive Care Units: Costs, Outcome, and Decisionmaking

REQUIREMENTS OF AN ICU

A detailed consideration of the design, organization, staffing levels, skills, personnel policies,

and other components of an ICU is beyond the

scope of this study. Yet in general, all intensive

care units meet these requirements:

care for severely ill or potentially severely ill

patients;

employ specially trained registered nurses on

a one-nurse to one- to three-patient basis;

identify a physician as the director of patient

care and administrator of the unit;

have 24-hour acute care laboratory support;

and

provide a wide range of technological services, with the help- of expert medical subspecialists and ancillary personnel (51,166).

While the availability of physicians in ICUs varies

with the size and type of hospital, all ICUs combine intensive nursing care and constant patient

monitoring (116). In community hospitals, the

ICU medical director is frequently not full-time

and shares patient care responsibilities with other

staff physicians who also have major non-ICU

responsibilities. In these units, day-to-day management and administrative decisions are made

by the head nurse of the ICU (283). Large hospital ICUs tend to have full-time medical directors.

The NIH Consensus Panel has identified the

minimal technological capabilities that an ICU

should provide, regardless of the type of facility

in which it is located (176):

A. cardiopulmonary resuscitation;

B. airway management, including endotracheal

incubation and assisted ventilation;

C. oxygen delivery systems and qualified respiratory therapists or registered nurses to

deliver oxygen therapy;

D. continual electrocardiographic monitoring;

E. emergency temporary cardiac pacing;

F. access to rapid and comprehensive, specified laboratory services;

G. nutritional support services;

H. titrated therapeutic interventions with infusion pumps;

I. additional specialized technological capability based on the particular ICU patient

composition; and

J. portable life-support equipment for use in

patient transport.

SPECIALTY V. MULTISPECIALTY ICUs

Since their development two decades ago, hospitals have differed on whether to establish one

or more multispecialty ICUs to treat the range of

seriously ill medical and surgical patients or to

set up separate ICUs for patients with similar

problems (208). For reasons of efficiency and

economy, smaller hospitals generally have a combined medical and surgical ICU. The smallest hospitals also combine coronary care with intensive

care in a single unit (4)0

Larger hospitals, particularly teaching hospitals, often have separate general medical and surgical units as well as separate subspecialty units

for specific types of medical problems, e.g., cardiac surgery and respiratory care. The Massachusetts General Hospital, for example, has nine separate subspecialty ICUs (248). However, even

hospitals of similar size and type have adopted

different approaches to the issue of multispecialty

v. separate specialty ICUs (136).

The major rationale for multispecialty ICUS is

a medical one, namely, that regardless of the

underlying disease, many life-threatening physiological disturbances are quite similar in seriously

ill patients (43,208,265). Thus, a basic purpose of

ICU care is to support general physiologic responses to stress in order to provide time for a

specific therapy for the underlying illness to take

effect (89,116,199,222). At times, ICUs primarily treat physiologic disturbances, not diseases;

they save lives primarily by supporting oxygenation, often with respirators (209), and by prevent-
Ch. 2–Evolution, Distribution, and Regulation of intensive Care Units ● 15

ing circulatory collapse and shock (222). Since

physiologic complications are similar regardless

of precipitating factors, there is a strong medical

rationale for multispecialty intensive care provided by comprehensively trained generalists (8).

Increasingly, concerns about efficiency and rising costs have supported maintaining multispecialty units rather than separate subspecialty units.

With multispecialty units, there maybe less duplication of expensive equipment, although ICUs

generally do not utilize “big ticket” technologies

(6). More importantly, because of highly variable

clinical demands for ICU care, ICU occupancy can

vary dramatically, and combining medical and

surgical specialty and subspecialty units permits

greater efficiency in the use of personnel, particularly nurses, which is a major cost factor in ICUs

(212).

Traditionally, however, demand for ICUs has

developed along subspecialty lines, usually in response to the availability of new medical technology. For example, the mechanical respirator led

to the respiratory ICU, and the advent of coronary artery bypass surgery led to the postcardiac surgery ICU. In addition, specialists often feel

that physicians trained in other fields do not have

sufficient understanding and skill to care for patients with particular “subspecialty” problems. Indeed, some have advocated a separate surgical

DISTRIBUTION OF ICU BEDS

It is difficult to estimate precisely the number

of ICUs and ICU beds in this country because of

the ways in which hospitals report their bed capacity. This is particularly a problem with smaller

hospitals, which may designate their ICUs as

CCUs or mixed ICU/CCUs in the annual American Hospital Association (AHA) survey. In addition, the annual AHA survey includes multiple

ICUs reported from single hospitals. From 1981

AHA survey tapes, it can be estimated that 78 percent of short-term general hospitals have at least

one ICU or CCU, and that 93 percent of hospitals larger than 200 beds have a separate ICU

(106). Overall, in 1982, 5.9 percent of the total

ICU for each surgical specialty in a large hospital (81). Others feel that nursing personnel skilled

in one subspecialty, such as cardiology, may be

unsuited by temperament, motivation, and training for work in other subspecialties (147).

In short, the debate over the desirability of

generalists v. specialists which exists in medicine

generally is also being waged in the intensive care

world. The trend, which is supported by the

Society for Critical Care Medicine, is to cross

traditional departmental and specialty lines and

to create a “multidisciplinary specialty” equally

skilled at caring for medical and surgical problems (95,274). An attempt to define the boundaries of critical care medicine by examination and

prescribed training has recently been developed

by the American Board of Medical Specialties (8).

In 1980, the Boards of Internal Medicine, Pediatrics, Anesthesiology, and Surgery joined together to offer a certificate of special competence

in critical care medicine (95). This examination

has yet to be given. In 1982, some 50 fellowship

programs in critical care medicine in the United

States were training approximately 150 physicians

to become critical care generalists (91,92). Another

36 programs were training fellows in pediatric

critical care medicine. Despite the new cadre of

critical care generalists, however, many hospitals

continue to maintain separate specialty and subspecialty ICUs along departmental lines.

hospital beds in non-Federal, short-term community hospitals were ICU and CCU beds. This figure does not include pediatric ICU beds, neonatal

beds, or burn care beds, which add another 0.2

percent, 0.7 percent and 0.1 percent, respectively,

to the total number ICU beds (4).

Table 1 shows the distribution of reported ICU

beds by size of hospital. In general, ICU beds are

fairly evenly distributed across all sizes of hospitals. In 1982, for example, hospitals larger than

500 beds, which account for 22.6 percent of total

short-term general hospital beds (4), have 24.8

percent of reported ICU beds. Table 2 shows the
-—— — ——

16 ● Health Case Study 28: intensive Care Units: Costs, Outcome, and Decisionmaking

Table 1 .- Distribution of ICU Beds in Short-Term, Non-Federal Hospitals, by Size of Hospital, 1982

Hospital bed size Total hospital beds Percent of total Total ICU/CCU beds Percent of total

<100 . . . . . . . . . . . . . . . . . . . . . 146,706 14.5 5,889 9.9

100-199 . . . . . . . . . . . . . . . . . . . 195,425 19.3 10,677 17.9

200-299 . . . . . . . . . . . . . . . . . . . 179,312 17.7 11,302 18.9

300-399 . . . . . . . . . . . . . . . . . . . 144,012 14.2 9,312 15.6

400-499 . . . . . . . . . . . . . . . . . . . 120,682 11.9 7,692 12.9

>500 . . . . . . . . . . . . . . . . . . . . . 229,043 22.6 14,826 24.8

Total . . . . . . . . . . . . . . . . . . . 1,015,180 99.3 59,698 100.0

SOURCE: American Hospital Association, Hospital Statistics, 1983 edition.

Table 2.-lCU/CCU Beds as Percent of Total Beds

by Hospital Size for Short-Term Nonfederal

Hospitals, 1982

Hospital bed size Percent ICU/CCU beds

<1oo . . . . . . . . . . . . . . . . . . . . . . . . 4.0

100-199 . . . . . . . . . . . . . . . . . . . . . . 5.5

200-299 . . . . . . . . . . . . . . . . . . . . . . 6.3

300-399 . . . . . . . . . . . . . . . . . . . . . . 6.5

400-499 . . . . . . . . . . . . . . . . . . . . . .

>500 . . . . . . . . . . . . . . . . . . . . . . . . : : :

Total . . . . . . . . . . . . . . . . . . . . . . 5.9

SOURCE: American Hospital Association, Hospital Statistis, 1983 edition,

percent of ICU/CCU beds as a percentage of total

beds by hospital size in 1982. For hospitalsof200

beds or more, the ICU/CCU bed percentage is

very consistent.

Table 3 indicates the distribution of combined,

non-Federal intensive and coronary care bedsby

region as of 1981. (Coronary care beds makeup

about 25 percent of the total.) There are some

variations in the number of these beds as a percent of total beds, with the Pacific, East North

Central and Mountain States having the highest

percentages. However, as Russell pointed out, the

distribution of ICU/CCU beds is much more uniform when considered in relation to population,

rather than to hospital beds (205).

Finally, as shown in table 4, the distribution

of ICU beds varies somewhat according to hospital sponsorship.

EXPANSION OF ICU BEDS

While the number of community hospital beds

increased only about 6 percent between 1976 and

1982, reported ICU and CCU beds in community

Table 3.–Distribution of ICU and CCU Beds,

by Region, 1981

Per 10,000 Per 100

Region population hospital beds

New England . . . . . . . . . . . . . . 5.8

Middle Atlantic . . . . . . . . . . . . ; : :

South Atlantic . . . . . . . . . . . . . 2.9 : : :

East North Central . . . . . . . . . 3.3 6.7

East South Central . . . . . . . . . 5.3

West North Central . . . . . . . . ; : ; 5.0

West South Central . . . . . . . . 2.6 5.2

Mountain . . . . . . . . . . . . . . . . . 2.6 6.2

Pacific . . . . . . . . . . . . . . . . . . . 2.7 7.0

Total . . . . . . . . . . . . . . . . . . . 2.9 5.9a

aHospital data in this table includes Federal hospitals and specialty service shortterm hospitals.

SOURCE: American Hospital Association, Hospital Statistics, 1982 edition; and

U.S. Department of Commerce, Bureau of the Census, State and

Metropolita Area Data Book, 1982,

Table 4.—Percentage of ICU/CCU Beds in Short-Term

Hospitals, by Hospital Sponsorship, 1976 and 1982

Percent of hospital

beds that are ICU

or CCU beds

hospitals increased by 29 percent, or an average

of almost 5 percent a year. Moreover, over half

of that reported increase occurred between 1979
Ch. 2–Evolution, Distribution, and Regulation of Intensive Care Units ● 17

to 1981. In this 2-year span, reported ICU beds

increased 14.3 percent and reported CCU beds

grew 15.4 percent (4), despite the absence of any

dramatic medical breakthroughs that would explain such a sharp rise. While the number of coronary artery bypass graft surgery procedures performed in the country was increasing by perhaps

20 percent a year during these years (257), the increase in the number of such operations could explain only a very small increase in ICU beds.

One can speculate, therefore, that the Medicare

policy implemented in 1980 (73) that tightened

limits on routine bed charges—commonly known

as the “section 223 limits”—but not on special care

REGULATION OF ICUs

Along with the medical and organizational reasons for their expansion, ICUs and CCUs were

encouraged by the Federal Government in the

1960s initially in the Regional Medical Programs

(205).

In the 1970s, State certificate-of-need (CON)

statutes were passed in most States. CON statutes

require a prior determination by a governmental

agency that certain major capital expenditures or

changes in health care facilities are needed (19).

Early evaluations showed that CON programs

helped forestall the addition of general hospital

and long-term care beds (19). However, ICU beds

have generally been approved by CON agencies.

In addition, Salkever and Bice (211) found that

while CON programs controlled expansion in bed

supply to some extent, they stimulated other types

of hospital investment. Specifically, they found

that assets per hospital bed, for equipment and

other nonlabor products, actually increased as a

result of CON. A subsequent, more definitive

study confirmed the findings that the CON requirement generally has been successful in limiting

the number of beds, but not the intensity of resource use or costs (188). Ironically, the threat of

CON review may have encouraged hospitals to

bed charges or ancillary services, created a strong

stimulus for hospitals to add more ICU beds (60)

or, perhaps, to reassign beds to special care where

possible. The most dramatic rise in ICU/CCU

beds between 1979 and 1981 occurred in hospitals with more than 500 beds, which accounted

for almost 55 percent of the total increase in ICU/

CCU beds in these two years (4). In 1982, the

number of ICU/CCU beds increased 4 percent,

while total community hospital beds increased

only 1 percent. Thus, while ICU bed expansion

has continued at a much faster rate than hospital

beds generally, the pace of growth found in 1980

and 1981 has slowed. ,

convert low-asset routine care beds into comparatively high-asset ICU beds (166).

Equipment used in ICUs rarely requires CON

approval. The national threshold for requiring

CON approval in the National Health Planning

and Resources Development Act of 1974 (Public

Law 93-641) was $150,000, and most ICU equipment is well below that level. The cost per bed

of typical ICU cardiac monitoring equipment in

1978, for example, ranged from $6,000 to $8,500

(6). A new ICU respirator costs between $10,000

to $15,000 (87).

The construction costs of each patient unit in

the ICU was estimated to cost between $44,ooo

and $75,000 in 1978 dollars (6), Renovation costs

were much less. Thus, hospitals with sufficient

capital can escape CON review altogether by

gradually expanding and upgrading already existing ICUs (119,166). As was noted earlier, hospitals reported about a 15-percent increase in ICU

beds between 1979 and 1981, a time when CON

programs were functioning in virtually every

State. The current trend toward raising CON

thresholds practically assures that CON regulation of ICUs will remain a minor issue.
3 ■

Cost of ICU Care
3.

Cost of ICU Care

COMPONENTS OF ICU COSTS

The cost of intensive care units (ICUs) can be

divided into the direct costs of operating the ICU

and the indirect costs for central services that are

allocated to the ICU (6). Sanders estimates (212)

that for Massachusetts General Hospital in Boston about 65 percent of ICU costs (for labor,

equipment, etc. ) are direct, and that about 35 percent of costs (for hospital overhead, housekeeping, etc. ) are indirect.

Direct costs include fixed costs and variable

costs. Fixed costs exist no matter how many patients are treated in the ICU and include depreciation for the cost of construction, renovation, and

COSTS OF AN ICU DAY

It has become increasingly clear that hospital

charges do not represent the true costs of providing hospital services (80). Generally, charges are

greater than operating costs, in order to pay for

bad debts, to support nonreimbursable educational and preventive health programs, and to pay

for costs disallowed by cost-based insurers, including many Blue Cross plans, Medicaid, and

Medicare (80). For example, by analyzing cost and

billing data, the Health Care Financing Administration has calculated the national ratio of allowable Medicare inpatient operating costs to

Medicare inpatient charges at 0.72 (74).

ICUs are different from most hospital services

(including generaI room and board’), however,

in that charges for ICU room and board are often

set below cost (6,212,240). In one detailed econometric analysis, ICU charges for room and board

in one hospital were found to be only slightly

more than half of calculated costs (109). ICU data

from U.S. hospitals consist mostly of room and

board charge data, unadjusted for actual cost. The

1Overall, room and board charges make up slightly less than half

of total hospital inpatient charges; the rest is made up of various

categories of ancillary services.

equipment, as well as equipment maintenance (6).

Variable costs are dependent on the volume of

services provided. Some variable costs, such as

personnel costs, are fixed over a specific range in

patient volume, but change when the patient volume exceeds the range. Other variable costs, such

as nondurable equipment and oxygen, are dependent directly on total patient days (6). Data

from both foreign and domestic ICUs indicate that

50 to 80 percent of direct costs are variable personnel costs, primarily for nursing (42,101,155,

212). On average, ICUs use almost three times as

many nursing hours per patient day as do general floors (205).

charges or costs for the ancillary services used by

ICU patients are not matched to their ICU stays,

because hospitals report their charges for the

various ancillary services by department, not by

site of patient location. If one considers only ICU

room and board charges in estimating ICU costs,

one may significantly underestimate the relative

costliness of ICU care, then, because ICU charges

underestimate ICU costs and because the costs of

ancillary services that are performed when patients are in the ICU are not included.

With the exception of certain administrative

costs that support ICU physician staff, the costs

of physician services to ICU patients generally are

not included in hospital cost reports or in hospital charges. As will be discussed further in chapter

6, there is reason to believe that ICU patients receive a greater intensity of billable physician services than non-ICU patients.

Cost data from other countries provide an opportunity to determine relative costliness of ICU

v. non-ICU care, particularly in countries where

hospitals receive operating budgets. In those fixed

revenue systems, hospitals do not need to charge

more than costs in some departments to make up

21
—.

22 ● Health Case Study 28: Intensive Care Units: Costs, Outcome, and Decisionmaking

for losses in other departments. Estimates of costs

for a day of ICU care compared to a day of ward

care have ranged from a 2.5:1 ratio in France

(182), to 3:1 in Canada and Australia (29,89), and

to 4:1 in Great Britain (174). An attempt in the

early 1970s to estimate actual costs (including

ancillary services) in the United States yielded an

estimate of 3.5:1 in a large, teaching hospital (97).

But anecdotal reports now suggest that relative

costs of ICU to non-ICU care in some institutions

are as much as 5:1 (93).

Numerous U.S. studies of the per diem charge

ratio for room and board in the ICU compared

to non-ICU floors have shown a range of 2:1 to

2.5:1 in small community hospitals (43,140) to

about 3:1 in large community and teaching hospitals (140).

The Equitable Life Assurance Hospital Daily

Service Charge Survey of 2,519 hospitals in 1982

(71) showed an average charge of $408.50 for an

intensive care bed and $167.50 for a private bed,

a ratio of about 2.5:1.

Patients in ICUs have a relatively greater percentage of their charges attributed to ancillary

services than to accommodations compared to

general floor patients. In a recent study of a

large-sized community hospital, for example, 45.7

percent of the total charges for ICU patients were

for room and board, while 57.1 percent of the

total charges for non-ICU patients were for room

and board (175). Generally speaking, the more

acutely ill the patient, the greater the percentage

of the bill attributable to ancillary services

(49,67,162,271).

In short, ICU patients consume more direct

resources, mostly for nursing, than regular floor

patients, as well as a greater proportion of ancillary services, particularly laboratory and pharmacy services (49,101) than regular floor patients.

TOTAL NATIONAL COSTS OF INTENSIVE CARE

There is a notable lack of precision in estimates

of the portion of hospital care costs that can be

attributed to intensive care. In a major review of

ICUs in Technology in Hospitals (205), Louise

Russell provided a method for indirectly estimating the national cost of ICU care. Recent reviews

using Russell’s method (described in app. B) estimate that 15 to 20 percent of total costs of hospital care can be attributed to intensive care (40,

136,206).

Before refining and updating this estimate, it

is important to present the alternative ways of

analyzing the costs of intensive care, including

calculations of: 1) the direct and indirect costs of

operating an ICU; 2) the total hospital costs, including the costs of ancillary services as well as

ICU costs, incurred by patients when they are in

the ICU; 3) the total hospital costs attributable

to patients who spend any time in ICUs; and 4)

the incremental cost generated by ICUs above the

cost that a hospital would have to absorb for

treating very sick patients who would remain in

the hospital even if ICUs did not exist. The last

definition is particularly relevant to this case

study, since it is consistent with the concept that

the ICU is a separate technology, independent of

the patients treated in it.

Estimates of the total hospital cost of patients

when in an ICU (Definition 2) and of the incremental costs of operating an ICU (Definition 4)

are probably the most relevant in terms of public

policy considerations, but are not easily made

from available hospital accounting sources (267).

The direct and indirect costs of an ICU (Definition 1) and the total costs of intensive care patients (Definition 3) are more easily estimated

from hospital accounting data, but have much

more limited policy relevance.

Based on these considerations, estimates of the

percentage of total national inpatient hospital

costs attributable to intensive care according to

the

●

●

different definitions can be made:

Definition 1: The direct and indirect costs of

running the ICU, as reflected in charges for

ICU room and board—8 to 10 percent.

Definition 2: The total hospital costs of patients when in the ICU—14 to 17 percent.
Ch. 3–Cost of ICU Care ● 23

●

●

Definition 3: The total hospital costs for pa- costs associated with most physician services,

tients who spend any time in the ICU dur- neonatal, pediatric, or burn units, or the proviing a hospitalization—28 to 34 percent. sion of intensive care in Federal hospitals, operDefinition 4: The incremental cost generated ated mainly by the Veterans Administration and

by ICUs above the cost that a hospital would

have to absorb for treating ICU-type patients

if the ICU did not exist—cannot be estimated.

The assumptions underlying the estimates and the

calculations are available in appendix B.

Given these percentages, one can estimate the

national cost of adult intensive care. It should be

emphasized that these estimates necessarily include the costs of coronary care, but not those

the Department of Defense. In 1982, total national

expenditures for hospital care were $136 billion,

of which 84 percent were for acute care in community hospitals—or $114 billion (87a). Since an

estimated 87 percent of community hospital costs

are inpatient costs (4), $13 billion to $15 billion

were spent in 1982 for costs associated with patients in adult ICUs and coronary care units,

according to Definition 2 above.

25-338 0 - 84 - 3
4

Utilization of ICUs
4

Utilization of ICUs

INTRODUCTION

there is little systemcharacteristics of inFor a number of reasons,

atic information about the

tensive care unit (ICU) patients, i.e., their age,

sex, length of stay, and case mix. Hospitals and

physicians vary considerably, for example, in the

way they treat patients with the same disease. Furthermore, as was noted earlier, there is no single

model of ICU organization—some hospitals have

an ICU combined with a coronary care unit (CCU),

while others have separate units; some combine

medical and surgical ICUs, and others do not; still

others have multiple subspecialty ICUs. Community hospitals, which usually do not have full-time

salaried physicians, may put less sick patients in

ICUs primarily to provide them with concentrated

nursing care (67).

There is no national data base which describes

ICU utilization in any detail. The American Hospital Association (AHA) survey data provides information only on ICU and CCU beds and days

by hospital size and type (see ch. z). A more

detailed profile of ICU patients is based on published studies from individual hospitals. A comUTILIZATION BY TYPE OF ICU

Surgical ICU patients tend to be younger (49,

155,175,227), to have more limited or reversible

diseases with reasonably well-defined therapeutic endpoints (50,56,129,175,178), and to be more

homogeneous than medical ICU patients (49).

Even so, there are substantial differences among

surgical ICU patients. The patient profile of surgical trauma patients, for example, differs significantly from that of postcardiac surgery patients.

Trauma patients on average are younger and have

ICU ADMISSION RATES

It is not known what percentage of the population, or even how many hospitalized patients are

placed in an ICU for any defined period of time.

Relman suggests that 15 to 20 percent of all papilation of many, but not all, such studies is presented in table 5. It should be emphasized that

these studies are from teaching hospitals and large

community hospitals and may not be representative of the ICU care provided in small community hospitals.

Recently, the Health Care Financing Administration (HCFA) has developed a profile of Medicare hospital utilization, including ICU/CCU utilization, based on its short-stay hospital inpatient

stay record file for 1979 and 1980 (111,112). This

file, called the MEDPAR file1, is generated by linking information from three HCFA master program

files for a 20-percent sample of Medicare beneficiaries. The MEDPAR file is the only data base

which provides population-based rather than

hospital-based ICU utilization data, and, of course,

it only profiles the Medicare population.

‘The MEDPAR file also contains billed charge data and clinical

characteristics, such as principal diagnosis and principal procedure,

in addition to utilization data.

longer ICU stays than postcardiac surgery patients.

Medical ICU patients tend to be older, have

more progressive, chronic diseases (29,174,248,

265) and have more concurrent illnesses (265).

These differences must be kept in mind when evaluating reports of utilization and outcome from

particular ICUs.

tients are cared for in an ICU or CCU at some

point during their hospital stay (195).

According to the 1979 MEDPAR sample, 18

percent of Medicare patients who were discharged

25
———

26 ● Health Case Study 28: lntensive Care Units: Costs, Outcome, and Decisionmaking

Table 5.—Summary of Selected ICU Studies

Dates of

Type of data Number Mean ICU Percent ICU Percent hospital

Study author* Country ICU collection in study age LOS mortality mortality for ICU patients

Safar . . . . . . . . . . . U.S.

Bates . . . . . . . . . . . Canada

Boyd . . . . . . . . . . . U.S.

Crockett . . . . . . . . G.B.

Callahan . . . . . . . . U.S.

BMA a . . . . . . . . . . . G.B.

Rogers . . . . . . . . . U.S.

Carroll . . . . . . . . . . U.S.

Skidmore . . . . . . . G.B.

Safar and

Grenvik

(1971). . . . . . . . . Us.

Pessi . . . . . . . . . . . Finland

Spagnolo . . . . . . . U.S.

Bell . . . . . . . . . . . . G.B.

Petty (1974) . . . . . U.S.

Nun. . . . . . . . . . . G.B.

Turnbull . . . . . . . . U.S.

Tagge (1975) . . . . . U.S.

Tomlin . . . . . . . . . . G.B.

McLeave . . . . . . . . Australia

Vanholder . . . . . . . Belgium

Chassis . . . . . . . . . U.S.

Byrick . . . . . . . . . . Canada

Fedulo . . . . . . . . . . U.S.

Porno ........,.. U.S.

Thibault . . . . . . . . . U.S.

Legal . . . . . . . . . . France

Murata. . . . . . . . . . U.S.

Hauser . . . . . . . . . U.S.

Franklin . . . . . . . . . U.S.

Knaus, et al.

(CCM,1982 )

b

. . U.S.

M-S

R

M-S

M-S

M-C

M-S

R

M

M-S

M-S

i

M-S

M-S

M-S

M-S(ca)

M-S

M-S

M-S

M,R

M-S

M-C

M-S

M

M

M

M-S

1959-1961

1958-1962

1963

1963-1965

1964-1966

1966-1967

1965-1968

1968

1965-1969

1965-1970

1965-1971

1970-1971

1966-1972

1964-1973

1970-1974

1971-1974

1972-1974

1973-1976

1975-1976

1976

1977

1978

1978

1978

1977-1979

1978-1979

1979

1978-1980

1979-1980

1980-1981

561

336

608

1,000

5,521

200

95

1,162

4,918

1,001

231

2,896

1,598

422

1,035

2,878

1,718

843

380

489

58

182

558

2,693

228

149

724

512

1,408

—

48.0

—

44.3

—

—

—

54.0

—

—

50.0

56.0

45.2

—

—

63.0

53.0

53.0

54.0

59.1

65.0

54.7

60.0

50.0

62.7

—

—

54.0

—

—

5.0

—

3.9

4.0

—

—

—

6.2

4.8

4.4

—

—

5.2

—

3.0

3.4

—

5.1

8.0

3.6

3.4

—

3.9

—

—

4.1

30.3

43.0

21.0

18.0

10.7

14.7

18.0

29.8

18,5

20.1

28.0

16.6

25.3

16.4

22.3

8.2

13.5

14,4

32.6

21.0

11.7

6.0

16.7

19.3

26.0

—

—

26.0—

—

—

28.9

47.0

—

38.6—

19.7

42.6

14.0

—

29.0

17.3

10.0

34.0

26.8—

—

16.9

“Full citations found in References section.

aweighted average from 14 ICUs.

bWeighted average from 6 ICUs.

KEY: M-S Medical-Surgical ICU; M Medical ICU; M-C Medical-Cardiac ICU; R Respiratory ICU; S Surgical ICU.

SOURCE: Office of Technology Assessment.

from the hospital used intensive or coronary care.

Fifteen percent used both general ward and ICU/

CCU beds, while 3 percent used only ICU/CCU

beds. As table 6 indicates, use of ICU/CCU beds

by Medicare patients does not vary significantly

by hospital size, except for hospitals under 100

beds. Table 6 also shows that there is little variation in ICU use by Medicare patients by size of

hospital when ICU/CCU use is considered as a

percentage of the patients’ total charges. Interestingly, there was also little variation in ICU/

CCU charges as a percent of total charges by type

of hospital sponsorship (not shown); 7 percent of

all charges for Medicare patients in voluntary,

Table 6.—Use and Percentage of Hospital Charges

incurred in ICUs and CCUs for Medicare Beneficiaries

Discharged From Short-Stay Hospitals, 1979

Percent Percent total

using charges incurred

Hospital bed size lCU/CCU in ICU/CCU

1-99 beds. . . . . . . . . . . . . . . . 12 5

100-199 beds. . . . . . . . . . . . . 18 7

200-299 beds. . . . . . . . . . . . . 20 8

300-499 beds. . . . . . . . . . . . . 19 8

>500 beds . . . . . . . . . . . . . . 20 7

All hospitals . . . . . . . . . . . m 7

SOURCE: C. Helbing, “Medicare: Use of and Charges for Accommodation and

Ancillary Services in Short-Stay Hospitals, 1979,” Office of Research,

Health Care Financing Administration, U.S. Department of Health and

Human Services, undated.
Ch. 4–Utilization of ICUs ● 27

proprietary, and public, non-Federal hospitals

were room and board charges for ICU/CCUs.

Given the significant regional variations in the

concentration of ICU/CCU beds (see ch. 2), it is

not surprising that utilization of ICU/CCU beds

by Medicare patients also varied somewhat according to region (see table 7). Perhaps part of

the explanation for the higher per diem costs and

shorter lengths of stay in ICUs on the west coast

is a result of the greater use of relatively costly

ICU/CCUs in that region (255).

There are also variations by State in the use of

ICU/CCUs by Medicare patients; with a range

from 12 percent of Medicare hospital discharges

in Louisiana, Kansas, and South Dakota, to 27

percent in Connecticut.

Table 7.—Use and Percentage of Hospital Charges

Incurred in ICUs and CCUs for Medicare Beneficiaries

Discharged From Short-Stay Hospitals,

by Geographic Region, 1979

Region

New England . . . . . . . . .

Middle Atlantic . . . . . ., .

South Atlantic. . . . . . . . .

East North Central ., ., .

East South Central . . . .

West North Central . . . .

West South Central . . . .

Mountain . . . . . . . . . . . . .

Pacific ... , . . . . . . . . . . .

Percent using

Icwcc u

Percent total

charges incurred

in ICU/CCU

SOURCE: C. Helbing, “Medicare: Use of and Charges for Accommodation and

Ancillary Services in Short-Stay Hospitals, 1979,” Office of Research,

Health Care Financing Administration, U.S. Department of Health and

Human Services, undated.

Studies of ICU patients demonstrate a remarkably consistent male to female ratio of about 3:2

(16,47,56,67,146,175,178,248). Only Chassin reports a slight female predominance (40). In general, the ratio represents the prevalence of serious

cardiovascular diseases among males and females

under the age of 70. Above that age, female representation in ICUs increases (248).

A major issue with respect to Medicare is the

representation of elderly people in ICUs. With

aging comes an increase in the incidence of critical

illness. Thus, elderly people might be expected to

require more intensive care than their proportion

of the general population (34) and, possibly, more

than their proportion of the hospitalized population (76,175). On the other hand, to the extent

that ICU beds are in short supply (248,265) or that

poor patient prognosis is considered (34,54,56,76),

elderly patients might receive less intensive care

than younger patients.

In the United States, the representation of elderly

patients in ICUs seems to be the same or only

slightly more than as it is in the hospital as a whole

(76,139,175). Data from ICUs do not address the

effect of screening on the basis of age that may

take place prior to ICU entry. Speculation on the

extent of such screening differs (33,76,137). The

recent HCFA MEDPAR data is somewhat helpful

20

19

18

17

15

15

15

18

23

7

7

7

7

6

7

6

7

10

SEX AND AGE DISTRIBUTION OF ICU USE

on this issue. As table 8 shows, use of ICU/CCUs

by elderly people does not vary from that of the

general population until age 85. Even for people

85 and older, however, the decrease in ICU/CCU

use is slight.

Once in the ICU, elderly patients generally receive more interventions than younger patients

(34). However, when an attempt is made to control for acute severity of illness, the age of ICU

patients does not appear to be a factor in the

amount of resources expended in the ICU (137,

140). Rather, health status, independent of age,

Table 8.-Use and Percentage of Hospital Charges

Incurred in ICUs and CCUs for Medicare Beneficiaries

Discharged From Short-Stay Hospitals, by Age, 1980

Percent total

Beneficiary age Percent using charges incurred

group lCU/CCU in ICU/CCU

<65 . . . . . . . . . . . . . 18 7

65-69 . . . . . . . . . . . . 18 8

70-74 . . . . . . . . . . . . 18 7

75-79 . . . . . . . . . . . . 18 7

80-84 . . . . . . . . . . . . 17 7

>85 . . . . . . . . . . . . . 15 6

Total all ages . . . 18 7

SOURCE: C Helbing, Supervisory Statistician, Office of Research, Division of

Beneficiary Studies, Health Care Financing Administration, U.S. Department of Health and Human Services, personal communication, June

6, 1983. Data derived from the MEDPAR file.
—

28 ● Health Case Study 28: ]ntensive care Units: Costs, Outcome, and Decisionmaking

seems to be the key factor influencing the use

of ICU resources once the patient is in the ICU

(33,137).

Age does appear to be an important determinant of ICU admission in other countries. While

the populations are not strictly comparable, table

5 clearly demonstrates a younger mean age of ICU

patients in foreign countries. Knaus compared the

ICUs in five U.S. teaching hospitals and seven

French teaching hospitals and found that 45.5 percent of U.S. emergency ICU admissions were 60

years or older compared to only 31 percent of the

French patients (142). Vanholder in Belgium acknowledged that when there is a lack of space in

the ICU, older patients are less apt to be admitted

(265). With many fewer ICU beds per capita available in Britain, age appears to be a primary facICU CASE

Diagnoses

One characteristic of the ICU, particularly in

comparison to other special care units (i.e., coronary, burn, and neonatal units), is the wide variety of underlying diseases that are present. As

Chassin emphasized, medical ICUs treat a wide

spectrum of illnesses; any specific disease represents a very small proportion of the total number

of diseases that are present (40,238,265). Similar

findings have been described for mixed ICUs and

nonsubspecialty surgical ICUs (49,54,129, 139).

Even respiratory ICUs treat a variety of primary

diseases (10,29).

In surgical ICUs in major regional centers,

trauma patients may represent 40 to 50 percent

of the ICU population (129,178). In other surgical

ICUs and mixed ICUs, trauma victims represent

a much smaller percent of the overall ICU population (139), but are still a large proportion of the

most critically ill patients (54). Trauma patients

are much younger than the overall ICU profile

(54,129).

There is no accepted classification scheme that

describes the clinical characteristics of ICU patients. Perhaps the major problem with identifying ICU case mix is the fact that many critically

tor for limiting access to the scarce ICU beds (1).

When they were first developed, use of renal

dialysis machines were rationed partly on the basis

of age, and it has been suggested that age was similarly a factor in the United States in rationing

scarce beds in the early days of ICUs (248). In fact,

as can be seen in table 5, in the last 15 years or

so, there has been no dramatic trend toward older

ICU patients even though the mean age of the

population has increased. Unfortunately, data on

the age of ICU patients in the late 1950s and early

1960s, when ICUs were first opened, are not available. In addition, there appears to be no consistent age difference in ICU use based on size or type

of hospital. Finally, it should be pointed out that

mean ages reported in ICU studies are a few years

lower than the median ages (248).

ill patients have multiple underlying medical problems which interact to produce severe physiologic

complications. Vanholder found, for example,

that, excluding coronary care patients, each patient in his ICU had an average of 4.39 significant, distinct diagnoses (265). Questionable diagnoses, disorders not likely to have vital consequences, and previous diseases that had been

cured at the time of admission to the ICU were

not included in his calculation. The sicker the patient, the more likely it is that the ICU is treating

failure of major organ systems, in addition to the

underlying disease or the disease that precipitated

the failure.

Other Case Mix Parameters

Recognizing that the complexity and severity

of illness of ICU patients are generally not reflected by the primary diagnosis, other descriptions of ICU case mix have been used. Patients

can be grouped according to those referred directly from emergency rooms, those transferred

from the regular hospital floors, and those

transferred from other hospitals (31). Interhospital

ICU transfer of patients is relatively infrequent
Ch. 4–Utilization of ICUs ● 29

in the United States, but common in some other

countries (81,142,146).

ICU admissions can be characterized as emergency or elective, the latter usually referring to

postoperative admissions. Medical ICU admissions are usually emergencies, whereas the majority of surgical admissions are elective (49,

52,227), unless the hospital is a major trauma center. Elective, postoperative patients may, nevertheless, be critically ill, or at least need close

monitoring and observation (54).

ICU patients can be characterized as those requiring close observation and monitoring and

those requiring intensive therapy. As was pointed

out earlier, there is no general agreement on how

to classify patients into these groups. Some have

employed subjective medical assessments of severity of illness and treatment needs (42,163,179).

Others have employed objective measures of therapeutic resource use developed by Cullen and

colleagues at Massachusetts General Hospital in

Boston to separate patients into discrete groups

requiring different personnel and treatment requirements (51,129,144). Recent work has attempted to ascribe a severity-of-illness score to

each patient and has found a good correlation between scores of severity and treatment requirements (144,270).

Because authors use varying approaches to describe the intensity of ICU therapy, it is difficult

to summarize the data. Nevertheless, it would appear from the literature—most of which is from

teaching or major community hospitals—that patients receiving the most concentrated intensive

treatment, involving fairly continuously direct

physician involvement and various forms of life

support, represent less than half and sometimes

as little as 10 to 20 percent of the ICU patient

population (54,129,144). At the other end of the

spectrum, patients who receive technical monitoring and nursing care but only routine physician

care probably represent about 20 to 30 percent

of patients in general ICUs (136,137,178,246,269).

The remaining 30 to 70 percent of ICU patients

are those that receive actual therapeutic intervention to maintain and stabilize one or more physiologic functions, but do not require constant

physician involvement in their care or nurse-topatient ratios of greater than 1:1. The percentage

of “monitor patients” is much higher in ICUs that

also serve a CCU function (31,249).

Because most research has come from teaching

hospitals, the pattern of case mix in community

hospitals may be different, although anecdotal

reports do not indicate a consistent difference between teaching and community hospitals (67,

163,175).

Readmission

Recently, attention has focused on the fact that

high-cost users of hospital care are often patients

with chronic illnesses who have repeated hospital admissions (161,218). This pattern is being increasingly recognized for intensive care as well

(231,248). As might be expected, readmission to

the same unit are less frequent for surgical ICU

patients (178). In a 5-year period, almost 19 percent of all patients seen in a major teaching hospital medical/cardiac ICU were readmissions, and

6 percent were patients readmitted to the ICU during the same hospital stay (so-called “bounce

backs”) (248).

Length of Stay

The mean length of stay (LOS) in an ICU for

all Medicare ICU/CCU patients in 1980 was 4.2

days (112). The LOS in ICUs is about 0.5 days

longer than in CCUs (49). The LOS is reportedly

longer in non-U.S. ICUs (29,88,142,178), probably because there are fewer monitor patients in

these ICUs. The average LOS in U.S. hospitals

has been notably stable over the past 15 years (see

table 5).

As expected, mean LOS is significantly longer

than median LOS (42). The mean does not reflect

the great variation in LOS of ICU patients. In a

study of 1,001 consecutive patients in a surgica]

ICU, Pessi (178) found that 27 percent stayed less

than 2 days, while 15 percent stayed longer than

10 days. In one medical ICU, Chassin (40) found

that 10 percent stayed longer than 10 days. ICU

stays of more than a month are not uncommon

(49).

While the mean hospital LOS before the recent

changes in Medicare reimbursement in U.S. hos-
— ————

30 ● Health Case Study 28:: intensive Care Units: Costs, Outcome, and Decisionmaking

pitals was 7.6 days (4) and 10.4 days for Medicare sumably because of case mix differences (40,49,

patients (113), ICU patients have significantly 175). Part of the variation in published studies

longer total hospital stays. From the few reports may also represent the general pattern of shorter

that present both ICU and total hospital LOS, hospital lengths of stay on the west coast (256).

there is significant variation in hospital LOS, pre-
5 .

Outcomes of Intensive Care:

Medical Benefits and Cost

Effectiveness
5 m

Outcomes of Intensive Care:

Medical Benefits and Cost Effectiveness

DIFFICULTIES IN ASSESSING EFFECTIVENESS

Evaluating the effectiveness of the care provided

in the general adult intensive care unit (ICU)

presents a number of problems. Unfortunately,

it is difficult to separate the intensity of the care

from the setting in which it is provided (97,98),

and therefore, to know whether the same care

would have been equally effective whether it was

provided in an ICU or in a general hospital floor.

Theoretically, at least, intensive therapy could

be provided on regular medical floors (120). In

fact, there are institutional differences about who

is treated in ICUs and for how long (142). Moreover, the level and style of intensive care for similar health problems differ significantly among

ICUs (67). These differences have developed because of the particular circumstances of individual hospitals, rather than because established criteria were available (247).

For some complex medical problems, many

physicians feel that the necessary care can only

be provided in an ICU (65). In the late 1960s and

1970s, admission to an ICU became routine for

a number of medical problems, despite the lack

of evidence that ICU care improved outcome.

There have been no prospective clinical trials in

which patients with similar problems were randomly allocated to two groups, one of which was

treated in an ICU while the other received intensive care outside the ICU (98,222). There is general agreement that such randomized studies would

be unethical (262,279), and it is felt that for many

problems, treatment in an ICU is necessary if a

patient is to have a chance of survival (50).

Since, as noted, randomized clinical trials of

ICUs are considered by many to be unethical,

most ICU outcome studies have been historical

controls and pre-ICU/post-ICU designs (166).

These types of studies, however, have been seriously flawed by the absence of acceptable criteria

for stratifying ICU patients by diagnosis and

severity of illness to assure comparability of patient populations between different ICUs and in

the same ICU over time (226,248,281).

In the coronary care unit (CCU), for example,

it is felt that patients suffering myocardial infarction should be stratified into clinically coherent

subpopulations based on the type of myocardial

infarction suffered in order to assess outcome

properly (28). The problem of stratification is

especially complicated in the ICU, because patients often have multiple diagnoses, which make

categorization difficult (16,265), and because their

severity of illness varies (136).

There are other practical problems in conducting research on ICU outcome, including:

1.

2.

3.

4.

In

the fact that any individual institution will

have a relatively small number of patients

in any clinical subset;

the lack of a standard format for collecting

data;

the difficult yin obtaining informed consent

from ICU patients in need of immediate, lifesaving intervention (176); and

the difficulties in conducting studies that follow patients after their discharge from the

hospital.

short, because of the absence of an accepted

classification scheme for stratifying ICU patients

into accepted subpopulations and because prospective clinical trials have not been performed,

very little is known about the effectiveness of the

ICU as a distinct, discrete technology. Investigators who report on changes in ICU mortality

rates or lengths of stay can only speculate on

whether their patient populations have changed

over time (227,248).

33
34 . Health Case Study 28: ]ntensive Care Units: Costs, Outcome, and Decisionmaking

Finally, while the primary measure for assess- presence of ICUS may adversely affect the quality

ing the effectiveness of ICUs is patient outcome, of nursing care on the regular medical and surgiit should be recognized that the ICU as a discrete cal floors (25,136). As difficult as it is to measure

unit within the hospital may be a focus for edu- the effectiveness of ICU treatment for patients in

cation and research activities which have positive the ICU, it is nearly impossible to assess objec-

“trickle down” effects on care for non-ICU pa- tively the benefits or drawbacks of the ICU for

tients (55,86,97). At the same time, however, the the hospital as a whole.

CLINICAL OUTCOMES OF ICU CARE

Because of the varied case-mix in ICUs, it is impossible to generalize about whether ICU care improves outcome. The NIH consensus panel, which

was asked to assess this issue, concluded that

evidence of the benefit of ICU care was unequivocal for a portion of the heterogeneous ICU patient population (176). The NIH panel identified

different outcomes for three categories of patients

(176):

First is the patient with acute reversible disease

for whom the probability of survival without ICU

intervention is low, but the survival probability

with such interventions is high. Common clinical examples include the patient with acute reversible respiratory failure due to drug overdose, or

with cardiac conduction disturbances resulting in

cardiovascular collapse but amenable to pacemaker therapy. Because survival for many of

these patients without such life-support interventions is uncommon, the observed high survival

rates constitute unequivocal evidence of reduced

mortality for this category of ICU patients. These

patients clearly benefit from ICU care.

Another group consists of patients with a low

probability of survival without intensive care

whose probability of survival with intensive care

may be higher—but the potential benefit is not

as clear. Clinical examples include patients with

septic or cardiogenic shock. The weight of clinical opinion is that ICUs reduce mortality for many

of these patients, though this conviction is supported only by uncontrolled or poorly controlled

studies. Often these studies do not allow one to

distinguish between ICU effectiveness and/or differences in cointerventions that do not require the

ICU.

A third category is patients admitted to the

ICU, not because they are critically ill, but because they are at risk of becoming critically ill.

The purposes of intensive care in these instances

are to prevent a serious complication or to allow

a prompt response to any complication that may

occur. It is presumed that the prompt response

to a potentially fatal complication made possible

by continuous monitoring plus the concentration

of specialized personnel in the ICU increases the

probability of a favorable outcome. The risk of

complication may be high (as in the patient with

an acute myocardial infarction and complex ventricular ectopy) or low (as in the patient with

myocardial infarction suspected because of chest

pain in the absence of electrocardiographic abnormalities). Also, the differences in probability of

a favorable outcome following a complication inside rather than outside the ICU may be large (as

in the patient with postcraniotomy intracranial

bleeding) or small (as in the patient with gastrointestinal bleeding). The strength of evidence supporting the effectiveness of the ICU varies with

the probability of a complication and with the difference in expected outcome inside and outside the

ICU. When the risk of complication is high and

the potential gain large, a decrease in mortality

is likely. Similarly, when the risk is low and the

potential gain small, an observable decrease in

mortality is unlikely. These patients are not likely

to benefit from ICU care.

The differences in outcomes of ICU care by

diagnosis has been demonstrated in all studies that

have looked at the issue, from the earliest studies

(17) to the most recent (248). Table 9 gives examples of specific retrospective outcome studies

on the effect of ICU care for certain illnesses.

(Note that contradictory findings are sometimes

found for the same condition. ) In general, conditions which respond well to ICU care are reversible illnesses without significant underlying chronic

illness (e.g., respiratory arrests as a result of drug

overdoses, major trauma, reversible neuromuscular diseases such as Guillain-Barre Syndrome,

and diabetic ketoacidosis) (198,214). Conditions

which generally do not respond well are exacer-
Ch. .5-Outcomes of intensive Care: Medical Benefits and Cost Effectiveness • 35

Table 9.—Retrospective Outcome Studies of ICU Care

Study Condition

A. Studies showing definite reduction in

mortality for condltlon:

Petty (1975). . Respiratory failure treated with ventilators

Rogers. . . . . . Respiratory failure treated with ventilators

Bates . . . . . . . Status asthmatics and emphysema

Drake . . . . . . . Non-hemorrhagic strokes

Skidmore . . . Postoperative trauma patients

Feller. . . . . . . Severe burns

B. Studies showing no reduction in mortality for condition:

Pitner. . . . . . . Strokes

Piper . . . . . . . Drug overdose

Jennet . . . . . . Head injuries with coma

Casali . . . . . . Postoperative acute renal failure

Griner . . . . . . Pulmonary edema

Hook . . . . . . . Pneumococcal bacteremia

NOTE Studies are cited in the Reference section

SOURCE Off Ice of Technology Assessment

bations of chronic conditions for which there has

been no definitive treatment (e.g., cirrhosis with

gastrointestinal hemorrhaging, and advanced

cancer).

FUNCTIONAL OUTCOME

Different investigators have used varying measures of functional status to gauge outcomes other

than mortality. These measurements have been

subjective and depend to a large extent on the patient’s prehospital functional status. For patients

with a chronic disability, posthospital functional

status is almost never better than their prehospital

functional status (34,40,146), although improvement has occasionally been found (29).

Surgical patients suffering an acute injury or

illness have a reasonable chance of returning to

Most studies have looked at mortality in the

ICU or in the hospital as a measure of the efficacy

of ICU care. However, for some physiologic conditions, such as cardiac arrest, ICU care may be

lifesaving in the short term but may not affect the

ultimate course of the underlying illness (174,214).

Indeed, in some instances, patients with severe

underlying illnesses, such as terminal cancer and

cystic fibrosis, have not been offered ICU care because of the dismal prognosis associated with the

underlying illness (58,110,252,253).

Investigators have only recently begun to look

at posthospital survival. As might be expected,

the ability to follow patients for 6 months or

longer after their ICU stay depends to a great extent on the population being studied. In general,

chronically ill and medical patients are more likely

than acutely ill and surgical patients to die shortly

after discharge from the hospital (29,34,50,129,

146,174,175,178,248) .

a normal functional status (54,178). In a followup

study, Cullen reported that the l-year mortality

rate was similar to the rate in a previous study

of similarly critically ill patients, but that the patients’ quality of life as measured by the number

of patients who were fully recovered or returned

to full productivity was significantly improved

(54,56). This finding suggests that Outcome COme measures other than survival should also be examined

when determining effectiveness of ICU care.

CHARACTERISTICS OF ICU NONSURVIVORS

As noted above, certain diseases and conditions Age

are associated with particularly high ICU mortality rates. Underlying disease is probably the most A number of investigators have looked at the

significant single predictor of outcome of ICU care association of age and mortality in ICUS. Most

(54,139). Other factors, including age and sever- have found a direct relationship between increasity of illness, are important as well. ing age above 65 and hospital mortality (54,107,
—- —————

36 ● Health Case Study 28: Intensive Care Units: Costs, Outcome, and Decisionmaking

116,178,214,248). In addition, for medical patients

in particular, some have found that patients 70

and over who leave the hospital have very high

posthospital mortality rates (29,174,248,249).

Others, however, have found either a small or no

association between age and survival (40,50,76,

165,265).

When an attempt is made to control for chronic

health status in a multivariate logistic regression

analysis, age has been found to remain a reliable

independent predictor of mortality (268). This

finding suggests that age is not simply a surrogate

for chronic health status. Fedullo (76), on the other

hand, suggests that with the passage of time, elderly patients have already gone through a process of selection, and therefore “healthy” elderly

patients are as able as younger patients to survive an acute major illness.

Severity of Illness

Vanholder (265) found that ICU survivors had

an average of 3.13 major diagnoses whereas nonsurvivors had 6.09 diagnoses. LeGall (146) found

a strong positive correlation between the number

of organ system failures and the likelihood of not

surviving a stay in an ICU. In a number of settings, the George Washington University ICU Research group in Washington, DC (143) has tested

an acute severity-of-illness measure based primarily on the deviation from normal of certain clinical and laboratory measurements. Using their

scoring system, they found a direct relationship

between acute severity of illness and ICU mortality and concluded that acute physiologic derangement (i.e., acute severity of illness) is second only to the underlying disease as a risk factor

of hospital mortality (139). Less sophisticated

severity-of-illness classification systems have consistently demonstrated a positive relationship between increasing severity of illness and likelihood

of mortality (51,178).

Resource Use

In comparing resource use of ICU nonsurvivors

to survivors, it is necessary to look at the patient’s

entire hospitalization, not just the stay in the ICU.

In a number of studies from different types of hospitals, 25 to 40 percent of ICU patients who died

in the hospital did so after they were transferred

from the ICU to the regular medical floor (see

table 5 in ch. 4). Presumably, many of these nonICU deaths were anticipated and represented the

transfer of “hopeless” patients out of the ICU.

It is now recognized that a significant number

of deaths in the ICU occur after “no resuscitation”

orders have been written. In two large medical

centers, as many as 40 to 70 percent of ICU deaths

occurred under these circumstances (9,96). In a

large community hospital, 19 percent of ICU nonsurvivors had no hope of recovery and were in

the ICU solely for terminal care (165). In short,

a substantial portion of ICU care for nonsurvivors occurs after hope of recovery has been

abandoned.

Some nonsurvivors have very short and some

have very long ICU stays. Pessi (178) found that

one-third of surgical ICU nonsurvivors died within

2 days and 80 percent died within 10 days of ICU

admission. More recently, Cromwell (49) found

that while 20 percent of ICU nonsurvivors died

within 3 days of ICU admission, 10 percent died

after 2 months in the ICU. On average, nonsurvivors stay in the ICU about 1.5 to 2 times longer

than survivors (42,48,76,248)

In 1973, Civetta (42) first described the inverse

relationship between ICU charges and survival.

Since then, whenever it has been examined, the

same relationship has been found—ICU nonsurvivors accumulate up to two times more hospital charges than survivors (40,49,61). Byrick (29)

found the same correlation in Canada when he

considered actual ICU costs rather than charges.

Furthermore, nonsurvivors have incurred proportionately higher charges for ancillary services

(e.g., laboratory tests, X-rays, and blood) than

survivors (61,76). Only Parno (175), in a study

involving a large community hospital, found no

substantial difference in ICU charges between survivors and nonsurvivors.

The inverse relationship between charges and

survival is not as simple as it might first appear,

however. Detsky (61) looked at the relationship

between charges and patients assigned to various

subjective prognostic categories. He found the
Ch. 5—Outcomes of Intensive Care: Medical Benefits and Cost Effectiveness ● 37

highest per capita charges in two groups: survivors who initially had been thought to have a

poor chance of survival, and nonsurvivors who

had initially been felt to have the best chance of

survival. Predicted nonsurvivors who died and

predicted survivors who lived consumed fewer

resources. The two groups with highest charges

would logically be the ones who might benefit the

most from intensive medical care.

In another study utilizing a severity-of-illness

measure, Scheffler (214) found a nonlinear, Ushaped relationship between the use of resources

available in the ICU and the probability of survival. The first segment—45 percent of patients

and 19 percent of therapeutic interventions-exhibited an overall decrease in the probability of

death as therapy increased. The second segment,

found at the bend of the curve, showed little correlation between probability of death and resource

use. However, in the third segment, the rising portion of the U-shaped curve, there was an overall

increase in the probability of death as resource

use increased. This last segment represented only

9 percent of the ICU population, but those patients consumed as much as 30 to 40 percent of

the ICU resources. Thus, many patients, even the

most seriously ill, may benefit from additional

ICU resources applied to their care. While, in retrospect, some resources may prove to have been

“wasted” in the sense that individuals did not survive despite consuming these ICU resources, it is

clear that many patients do benefit from increased

use of ICU resources. The patients who will benefit from additional ICU resources cannot currently be identified ahead of time with any certainty.

DISTRIBUTION OF ICU COSTS AMONG PATIENTS

The data demonstrate that a small percentage

of the ICU patient population consumes a substantial proportion of total ICU resources. Cromwell’s

group (49) found that 1 percent of all ICU patients

incurred 10 percent of hospital charges, and 5 percent of ICU patients incurred 25 percent of the

charges. In Chassin’s ICU study (40), 7.4 percent

of the patients incurred 31 percent of the charges,

and 17 percent of patients incurred so percent of

the charges. The 7.4 percent subgroup averaged

$63,000 in charges in 1977 dollars. In general, the

high cost subgroup was broadly representative of

the total ICU patient population in terms of age,

diagnosis, and other patient characteristics. Similarly, Parno (175) found that 18 percent of the

ICU population in his hospital generated half of

the ICU charges.

In addition, it is likely that within the ICU,

there is substantial cross-subsidization of charges.

As noted in chapter 4, ICU populations include

patients who are there primarily to be observed

and monitored for the development of complications as well as patients who are receiving complex life-sustaining therapy. The nurse-to-patient

ratio can vary from 1:4 or 1:5 for patients with

cardiac arrhythmias to 1:1 or greater for the

sickest patients (176). While a portion of fixed direct costs and allocated indirect costs should be

distributed evenly among all patients, the ICU

charge structure does not reflect the substantial

differences in variable labor costs between patients.

The Therapeutic Intervention Scoring System

(TISS) (53,130) is a relative value scale which reduces most of the tasks commonly performed

within an ICU to 75 items which are assigned

varying weights. It has been used as a direct measure of the use of labor in the ICU. Wagner (270)

found that patients recuperating from coronary bypass surgery utilized 2.5 times more TISS points per

day than ICU patients recovering from brain

surgery.

The difference in labor resource use appears to

be even greater for other types of patients (51,54).

The distribution of TISS points suggests that all ICU

patients receive a minimum amount of treatment beyond that provided on the regular wards (67). The

data also suggest, however, that even if indirect and

fixed ICU costs are distributed evenly among all patients, perhaps 50 percent of actual ICU resource

costs—particularly labor costs—vary dramatically

among patients.

25-338 0 - 84 - 4
38 ● Health Case Study 28: Intensive Care Units: Costs, Outcome, and Decisionmaking

As noted earlier, the sickest ICU patients incur

substantially more total hospital charges than those

who are relatively less sick. Yet, the actual cost differences between these two groups is even greater.

Under the new Medicare payment system, which

MONITORED PATIENTS

Increased attention has been paid recently to

ICU patients who do not receive active intensive

therapy but rather are monitored and observed

for the development of potentially fatal complications which must be responded to promptly (176).

Progress has been made in identifying the characteristics of coronary patients who do not routinely require coronary intensive care (85,90,141,

189,190), and in recognizing CCU patients who

can be discharged to the general floor after 24

hours rather than the usual 3 days (163). Similarly, national and regional data on intensive care

for patients with burns suggest that a substantial

number of patients suffering relatively minor

burns do not benefit from treatment in an intensive bum unit but receive it nevertheless (78,151).

Researchers at George Washington University

(269) found that 513 of 1,148 admissions (45 percent) to a mixed medical-surgical ICU in a teaching hospital could be considered “monitoring

only” patients. Using a multivariate logistic regression analysis of several variables, including a

severity-of-illness measure, they found that 154

patients (13 percent of the total ICU patient population) had less than a 5-percent predicted risk

of requiring active intensive therapy. For those

patients, the authors felt that the risks of iatrogenic illness’ might outweigh the benefits of ICU

monitoring. In fact, only of the 154 low-risk patients actually received intensive therapy, and in

no case did those patients require therapy for an

immediately life-endangering condition. After updating their data base and looking at preliminary

data from other university hospitals, the authors

concluded that all ICUs have significant proportions of predictably low-risk, monitor admissions

(141). The conclusions were supported in a recent

‘An iatrogenic illness is an illness that results from clinical therapy rather than from the patient’s disease.

pays a fixed price per diagnosis regardless of actual

cost of the treatment provided, hospitals ‘may

become more aware of the highly disproportionate

share of ICU resources consumed by the most

severely ill, long-term ICU patients (see ch. 6).

study by Fineberg that looked at patients with a

risk of myocardial infarction that is low, but not

low enough for home care to be desirable (about

5 percent). He calculated that admission to an

intermediate care unit, rather than a CCU, was

highly cost effective (79).

Others who have studied monitored patients

are not as sanguine about the ability to predict

low risk. In a coronary care-oriented ICU, Thibault

(248) found that 1 of 10 patients admitted for

careful monitoring subsequently required a major ICU intervention. Using primarily subjective

criteria, he could not predict which of the monitored patients would do well.

Teplick, et al. (246), studied patients routinely

admitted to a surgical ICU after uneventful, major surgery of various types. Using a fairly conservative definition of benefit, the authors found

that overall, 33 percent of the patients benefited

medically from an overnight stay in the ICU.

There was a broad range in the percentage of patients who benefited from ICU care across types

of surgery, from 44 percent of patients who had

vascular surgery to no patients who had anterior

cervical Iaminectomies. A number of the unanticipated complications were immediately lifethreatening. Furthermore, using both a preoperative risk assessment and an evaluation of intraoperative problems, the authors were unable to

identify the patients within each surgical category

who were more likely than others to develop serious postoperative problems.

Another study of the same ICU, however, found

that less than 1 percent of patients routinely admitted overnight to the ICU for certain other surgical conditions suffered significant adverse postoperative effects (220). These contrasting findings

demonstrate the importance of stratifying even

the monitored ICU patients in order to determine
Ch. 5—Outcomes of lntensive Care: Medical Benefits and Cost Effectiveness Ž 39

which subgroups of monitor patients do well without routine admission to the ICU.

Attention has also been focused recently on patients who may be discharged from the ICU prematurely. Schwartz (220) found that 15 percent

of patients electively discharged from the ICU,

and 23 percent of patients transferred out of the

ICU because of lack of space, suffered a significant adverse effect on the surgical floor. Adverse

effects included death, return to the ICU, or

residence in hospital 1 month after completion of

the study. The researchers also found that approximately one-third of patients undergoing abdominal vascular surgery developed serious respiratory and/or circulatory conditions after discharge from the ICU. They did not speculate on

whether outcomes for these patients would have

been different had the complications occurred in

the ICU.

In a retrospective chart review, Franklin (82)

noted that 62 percent of readmission to a mixed

ICU might have benefited if they had not been

discharged from the ICU initially. The authors did

not indicate whether the patients readmitted to

the ICU differed in any predictable manner from

patients who did not need to be readmitted. Nor

did the study address how many lives were lost

because of early discharge. Mulley (163), who recommended identification of low-risk patients for

early transfer from the ICU, acknowledged that

2 percent of the low-risk group had major complications during their stay in the ICU that would

have occurred after transfer if an early transfer

policy had been in effect.

By stratifying ICU-monitored patients, it may

be possible to reduce or eliminate ICU stays for

some patients with a low risk of resulting adverse

effects. This risk may, in fact, be lower than the

risk of iatrogenic ICU illness for some patients.

At the same time, other moderately sick ICU patients are probably discharged too soon or not admitted to the ICU at all because of lack of bed

space or recognition that the patients are at risk

for serious complications. As a result, they suffer avoidable adverse health effects.

Work is only now beginning on attempts to predict which ICU discharge patients are most likely

to suffer adverse effects on the regular medical

or surgical floor.

ADVERSE OUTCOMES OF ICU CARE

Iatrogenic Illness

The possibility that the adverse effects of ICU

care may outweigh the potential benefits for some

patients is being increasingly recognized (176,275).

However, the rates of iatrogenic illness and other

untoward physical and psychological reactions to

ICU care are not known with any precision (176).

As with the problems of measuring the positive

effects of ICU care, it is difficult to distinguish between the negative effects that occur among critically ill patients regardless of location and those

that are specific to the ICU.

An iatrogenic illness is any illness or other

harmful occurrence that results from a diagnostic procedure or therapy that is not a natural consequence of the patient’s diseases (239). The major iatrogenic complications that result from prolonged ICU care include nosocomial infections

(defined below), stress-induced gastrointestinal

bleeding, alterations of consciousness associated

with metabolic disorders, coagulation disorders

associated with multiple transfusions and infection, drug interactions, complications of intravascular catheterization, complications of prolonged endotracheal and nasogastric incubation,

and sleep disorders and psychoses (41,275). Some

of these complications, such as drug interactions

and bleeding, would likely occur in seriously ill

patients regardless of location. Nosocomial infections and various psychological reactions are often

a result of the ICU itself.

Recently, Steel found that 36 percent of patients

on the medical service of a university teaching

hospital had an iatrogenic illness (239). In 9 percent of the cases, the incident was life-threatening
. —

40 ● Health Case Study 28:: Intensive Care Units: Costs, outcome, and Decisionmaking

or produced considerable disability. In 2 percent

of the cases, the iatrogenic illness was believed

to have contributed to the death of the patient.

The authors did not specify which problems specifically occurred within the CCU or ICU section

of the medical service. Nevertheless, a number of

the complications came from drugs, such as lidocaine, and procedures, such as Swan-Ganz catheterization, that are, for the most part, only used

in ICUs.

In a different teaching hospital, Abramson (3)

identified 145 reports of significant adverse occurrences in 4,720 ICU admissions during a 4-year

period. Ninety-two of these incidents were felt to

be the result of human error, and 53 were equipment malfunctions. However, 43 of the 92 incidents linked to human error involved equipment, mostly mechanical ventilators. Thus, about

two-thirds of the adverse events involved the

technically complex equipment used in ICUs. The

incidence of equipment-related adverse occurrences would probably be much higher if the

equipment and the staff operating it were dispersed throughout the hospital (208). On the other

hand, ICU technology may sometimes be used unnecessarily for less sick patients, producing some

incidence of avoidable iatrogenic illness (198). As

noted in chapter 7, the ICU milieu provides a bias

to the use of technology, which at times may be

of only marginal benefit and can produce adverse

reactions (242).

Finally, it is clear that the sophisticated care

provided in the ICU requires skilled nurses and

other technicians. Adverse effects in ICUs have

been particularly noted during periods of nursing shortages (3,136). The ICU environment produces “technology-oriented” treatment protocols

(100), and physicians are less apt to tailor therapy based on the specific skills of the nurse and

technicians on duty or on the particular nurseto-patient ratios during a particular shift. In other

words, certain ICU monitoring and therapy protocols may work well under ideal circumstances

but may be particularly subject to human and mechanical error under less favorable circumstances.

Nosocomial Infections

Nosocomial infections are infections occurring

during hospitalization that were not present, and

not incubating, at the time of hospital admission

(117). All patients in an ICU are at increased risk

of developing nosocomial infections (117). The

rate of significant nosocomial infection in an ICU

is about 20 percent, or three to four times that

of a patient on a general ward (63,173). This increased rate stems in part from unalterable factors, including the severity of the underlying illness; the greater use of invasive procedures; and

the greater use of prior antibiotic therapy, which

may predispose a patient to a superimposed infection (63,117,192). However, at least part of the

increased rate of ICU infection is due to crossinfection between very sick patients in the confined area of the ICU (63,204). Nosocomial infection “outbreaks” in ICUs are not uncommon

(63). Bacterial infections may be spread directly

from one person to another, often via personnel,

or may require an intermediate reservoir, such as

respirator nebulizers or tubing (117). While difficult to estimate precisely, the costs of nosocomial

infections in terms of increased morbidity, mortality, and hospital charges are undoubtedly substantial (108).

Psychological Reactions

There is a substantial body of literature on the

psychological reactions of patients in ICUs. It appears that the frequency of psychiatric syndromes

is considerably less in a CCU, where patients are

relatively stable, than in an ICU, where seriously

ill patients suffer organic impairments of cerebral,

renal, and pulmonary function (104,131,156).

The so-called “intensive care syndrome” (156)

described a “madness,” or acute delirium, that had

originally been seen in the postoperative recovery

room (168). However, many psychiatric syndromes

have been noted, from acute anxiety, fear, and

sustained tension to agitated depression and acute

delirium (132).
Ch. 5–Outcomes of Intensive Care: Medical Benefits and Cost Effectiveness ● 41

The unique environment of the ICU has been

graphically implicated as a cause of the varied and

often dramatic psychological reactions:

Immobilized, weak, inhibited from moving by

a network of wires and tubes which connect every

orifice in his body with bottles and machines, he

lies watching the light pattern move from left to

right on the monitor, disappear, then start again.

He listens to the suction of the draining apparatus, the on and off of the pulmonary respirator,

the hissing sound of the steam from the vaporized

oxygen; steam which sometimes clouds his vision

in the tent. He adds his own fantasies to this

bewildering environment. Fear and tension mount

. . . . In the ICU, the lights are on constantly, and

there is little or no change in the level or type of

sensory input. The activity, in spite of its decrease

toward early morning, remains high. Hours and

days merge and blend. Privacy is almost impossible. The patient is exposed; his most private acts

become public. . . . Strangers control the machines. Their authority is absolute. In this seemingly irrational environment, he is deprived of

any volitional control. He becomes an object

rather than a participant in the struggle for life

(62).

Sleep deprivation, sensory deprivation, sensory

overload, medications, and various emotional factors related to coping with serious illness have

been cited as causes for ICU psychiatric syndromes

(38,104,131,145).

Given the dramatic behavioral responses to ICU

care, it is remarkable that most patients remember

very little about the “terror in the ICU” (216). In

surveys taken both shortly after transfer out of

the ICU and many months later, ICU patients generally remember few details of their stay (24,29,

115,127,162,216). Whether due to the serious

nature of the underlying illnesses (104,127), the

lack of sleep, which produces general fogginess

(24,127), or a powerful psychological defense

mechanism of denial called “psychoplegia” (104,

216,217), survivors of ICU care generally do not

carry unique psychological scars of their ICU experience.

COST-EFFECTIVENESS ANALYSIS OF ADULT INTENSIVE CARE

Cost-effectiveness analysis (CEA) is intended

primarily to measure and compare the costs of

different ways of arriving at similar outcomes

(256). This type of analysis has not been done for

ICUs, because it is considered unethical to deny

ICU care for most ICU patients (see ch. 6). The

few “before ICU/after ICU” studies focused on

relatively small ICU subpopulations and are clearly dated (99,183).

For the low-risk monitored patient, it may be

ethically permissible to compare ICU observation

with non-ICU observation to determine the cost

effectiveness of ICU care. Both Mulley (163) and

Wagner (269) have projected cost savings that

would be generated by more selective admission

and earlier discharge policies. Using conservative

economic assumptions, Mulley found that a more

selective policy would result in a 6-percent reduction in ICU charges. Similarly, Wagner estimated

a 4-percent reduction in total ICU days with earlier discharge of low-risk patients. Neither author

accounted for the possibility that earlier transfer

from the unit might either increase or, conceivably, decrease the rate of major complications,

which, in turn, would affect costs (163). Fineberg

estimated that for patients with about a 5-percent

probability of having sustained a myocardial infarction, admission to a CCU would cost $2.04

million per life saved and $139, ooo per year of

life saved, as compared to care in an intermediate

care unit (79). Teplick (246) concluded that routine overnight ICU admission for postoperative

patients at an additional cost of $3OO would reduce overall patient costs if only 13 of the 88

routinely admitted patients in their study who

benefited from the ICU were prevented from becoming critically ill.

Another factor in considering the overall cost

effectiveness of earlier discharges of low-risk ICU

patients is the fact that the costs of caring for these

patients on the regular floors would increase,

mostly because of the need for additional nursing, probably from private duty nurses (97,220).

There might also be a need for additional monitoring equipment on the regular floors. Finally, projecting savings based on charges probably over-
42 ● Health Case Study 28: Intensive Care Units: Costs, Outcome, and Decisionmaking

estimates the savings from early discharge of

low-risk patients because of the cross-subsidization that is reflected in the ICU charges (see ch. 6).

Attempts have been made to assess average

charges necessary to achieve one survivor for

various subpopulations of ICU patients. For example, Parno (175) found that hospital charges

in 1978 dollars for a survivor alive 2 years after

discharge averaged $15,000, with a range of $1,650

for drug overdose patients to $46,000 for renal

medical patients. In a population of the most critically ill surgical ICU patients, Cullen (50) found

that in 1977-78 dollars, it required $71,000 in hospital charges to achieve a survivor alive 1 year

after hospital discharge. Neither additional posthospitalization expenses nor physician charges

were included in this estimate. For the category

of illness that includes gastrointestinal bleeding,

cirrhosis, and portal hypertension, Cullen found

that it cost $260,000 to achieve one survivor.

An interesting variation on this approach is to

look at “life-years” saved (134). The method is

not a true cost-benefit analysis (CBA), however,

since CBA requires that benefits be assigned a

monetary value in order to provide a direct comparison of the costs and benefits of a particular

technology (256). Assigning monetary values to

the varied and controversial outcomes of the ICU

has not been done. Theoretically, the life-years

saved method could be extended into CBA. Recognizing that longevity is generally considered a

benefit, Bendixen used the life-year saved model

to view the cost of ICU care in relation to predicted remaining lifespan. He used the following

equation:

cost = (cost per day) X (duration of stay)

(survival fraction) X (predicted remaining lifespan)

This approach assumes not only that survival

is a benefit, but also that survival value is a multiple of survival time, i.e., that 2 years of survival

has twice the value of 1 year of survival. The approach theoretically permits one to weigh the factors of a patient’s age and the prognosis associated with chronic disease. The formula, however,

does not discount the future value of costs and

benefits into present dollars; in essence, it overstates the importance of predicted remaining lifespan (256).

The unavailability of disease-adjusted actuarial

data for diagnostic subgroups makes prediction

of life expectancy for chronic diseases inexact

(215). ICU survival fraction and predicted remaining lifespan are the major determinants of cost effectiveness according to this formula. Using this

approach in 1977, Bendixen estimated a cost-peryear saved of $84 for barbiturate overdose and

$180,000 for hepatorenal failure.

When better estimates of life expectancy for patients with chronic illnesses become available, this

cost-effectiveness approach may be more useful.

Nevertheless, application of this approach documents the importance of the underlying disease

process and the patient’s age in determining the

cost effectiveness of ICU care (215). The formula

currently does not permit quantitative consideration of quality of life, which is obviously important for patients with debilitating chronic illnesses

(18). Methods for adjusting life-years saved for

quality of life have been attempted (213), but have

been criticized as representing “bad science” and

for ignoring considerations of justice and equity

(7).
6

Payment for ICU Service;
6.

Payment for ICU Services

TRADITIONAL HOSPITAL REIMBURSEMENT

Derzon (60) emphasized that several features

of the American health financing and payment

system operate to reinforce use of expensive technology, such as intensive care units (ICUs). These

factors include payment certainty, consumer insurability, government assumption of risk, and

benefits based on “medical” necessity. These factors have provided the major impetus to expansion of ICUs in the 1960s, 1970s, and early 1980s.

Most patients are covered for all or part of their

hospital costs through private or government insurance. With the exception of small indemnity

insurance companies, which pay a fixed dollar

amount per day or a fixed coinsurance rate based

on hospital charges, most private insurance companies pay full hospital charges, sometimes after

an initial deductible. Other major payers, including many Blue Cross plans, Medicare, and

Medicaid, have traditionally reimbursed hospitals on the basis of the actual cost of providing

the service to their beneficiaries.

To the extent that many insurers distinguish

ICU care from other hospital care for purposes

of reimbursement, the result has been both to

reward ICU care and to penalize intermediate level

special care units. For example, until 1982, Medicare paid hospitals different per diem rates for

only two levels of hospital care—routine care and

“special care” (ICU and coronary care unit (CCU)

care. ) Levels of care below special care were reimbursed at routine care levels. The other cost-based

payers have tended to follow Medicare’s definitional guidelines (166). Also, in 1979 and 1980,

as was noted in chapter 2, Medicare tightened existing payment limits on routine bed costs but not

on ICU bed costs—the so-called “section 223

limits” (73).

Furthermore, two reimbursement mechanisms

designed, in part, to curb unnecessary utilization

of care (including ICU care) have no impact on

ICU utilization. These mechanisms—patient copayments and utilization review—are discussed

below.

Patient Copayments

Little is known directly about the effect of direct patient payments on the utilization and cost

of ICU care. Cullen (56) found that only 100 of

189 seriously ill patients in a Boston surgical ICU

were billed directly for any amount. The average bill for patients who did get billed was $1,856,

which was equal to 9 percent of their total hospital bills. Cromwell (49) found that 80 percent of

ICU patients in a different Boston teaching hospital had direct bills of less than $100, and most

of the patients, 42 percent of whom had Medicare coverage, were well covered for the costs of

ICU care. Only 2.5 percent of the sample had outof-pocket bills above $3,000, and they were responsible for 67 percent of all uncovered hospital charges for ICU care. This pattern may differ

in other parts of the country where private insurance coverage is not as extensive.

Finally, Cromwell found little correlation between coinsurance rates and the utilization of ICU

beds and ancillary services after the completely

uninsured patients were discounted. He did find,

however, that patients with no insurance coverage had hospital and ICU stays about half as long

as those patients with more extensive insurance

coverage. Uninsured patients may exhibit a different case mix that explains at least part of the

difference in utilization.

Utilization Review

Theoretically, hospital utilization review (UR)

programs have the potential for limiting hospital

reimbursement for ICU care by denying payments

to patients “inappropriately” in the ICU. In re45
— -.

46 ● Health Case Study 28: Intensive Care Units: Costs, Outcome, and Decisionmaking

ality, hospital UR programs, administered for the than on appropriate level of care within the hoslast decade in accordance with the Federal Pro- pital (234). It would be most unusual for a UR

fessional Standards Review Organization pro- committee or insurance company to deny paygram, have focused almost exclusively on whether ments for a patient in the ICU or recommend

the admission is appropriate and whether the transfer to a lower cost unit in the hospital.

length of the hospitalization is necessary, rather

PROSPECTIVE PAYMENT PROGRAMS

Evidence is accumulating that State-based hospital prospective payment programs have been

somewhat successful in reducing hospital cost inflation (20,45). There is almost no published data,

however, on how ICUs have fared relative to

other hospital services in States with prospective

payment systems.

OTA’S analysis shows that between 1976 and

1981, in the eight States that had established hospital prospective payment (rate-setting) demonstration programs (Connecticut, Maryland, Massachusetts, New Jersey, New York, Rhode Island,

Washington, and Wisconsin), increases in ICU/

CCU beds were below the national average (4).

However, some of these States, including Connecticut and Washington, had relatively high

levels of ICU and CCU beds to begin with, so a

decreased rate of increase may not necessarily

be attributable to the State regulatory payment

system.

Indeed, as demonstrated by Cromwell and

Kanak (48), it is difficult to separate the effect of

the presence of a State’s hospital prospective payment program from many other factors that may

influence hospital costs and utilization of specific

technologies. These factors include the mix of hospitals, the effectiveness of a complementary certificate-of-need program, the length of time the

prospective payment program has been in effect,

the type of rate review, and the baseline level of

costs and services. When they reviewed the period

between 1969 and 1978, Cromwell and Kanak (48)

did find that in some States, the presence of a prospective payment system appeared to retard the

diffusion of ICUs. It should be noted, however,

that their analysis looked at the diffusion of intensive and coronary units, not at ICU/CCU beds.

By 1969, the majority of hospitals already had

established ICUs (205).

There is no systematic information available on

whether ICU length of stay (LOS) is reduced in

States with prospective payment programs.

MEDICARE’S CURRENT INPATIENT HOSPITAL PAYMENT SYSTEM

Description

Title VI of the Social Security Act Amendments

of 1983 (Public Law 98-21) provided a dramatically new payment system for Medicare inpatient

hospital services. A full discussion of the implications of Medicare’s prospective payment system for ICU care is beyond the scope of this case

study.1 Nevertheless, a few preliminary observations on likely effects of the system on the provision of ICU care can be offered.

In brief, the current payment system is based

on the concept of diagnosis-related groups (DRGs),

Under this DRG system, which began to be phased

in over a 3-year period on October 1, 1983, hospitals receive a fixed payment per discharge based

on the patient’s diagnosis. Hospitals that treat pa-

‘See the Office of Technology Assessment’s technical memorandum, entitled Diagnosis Related Groups (DRGs) and the Medicare

Program: Implications for Medical Technology, which describes the

potential impact of the new payment system on medical technology (254).
—

Ch. 6—Payment for ICU Services ● 47

tients for less than Medicare’s payments are allowed to keep the difference. Those hospitals that

spend more have to absorb the loss.

More specifically, under the DRG payment system, rates are set for each of 470 different DRGs.2

More complex DRGs, such as kidney transplants

(DRG 302), receive much higher payments than

simpler cases, such as hernia repairs (DRG 161).

Certain types of cases with complications or a secondary diagnosis receive a higher payment than

cases without complications. For example, heart

attacks with complications (DRG 121) receive a

somewhat higher payment than uncomplicated

heart attacks (DRG 122).

The DRG classification system, however, does

not directly take into account severity-of-illness

variations of patients who have the same primary

diagnosis. For example, in one teaching hospital

a group of only four patients in DRG 206 (disorders of the liver, excluding malignancy, cirrhosis, alcoholism, and hepatitis, age less than 70

without complications or comorbidities) had a

range of charges from $1,171 to $114,515 (118).

The U.S. Department of Health and Human

Services (DHHS), which proposed the DRG-based

payment system, has recognized that within some

DRGs, some patients may be more severely ill

(264). DHHS argues that in DRGs where severity of illness is strongly associated with treatment

cost, most hospitals will have patients who exhibit a range of severity levels, thus producing on

balance only minor financial advantages or disadvantages to most general hospitals. In addition,

as enacted, the DRG payment system provides for

additional payments in “outlier” cases—atypical

cases which have particularly long lengths of stay

or which are unusually expensive. For those cases,

the additional costs, which must range between

5 and 6 percent of the total national payments for

discharges in a year, are based on the marginal

cost of care beyond established LOS or cost cutoff points.

Regulations implementing the new law were

published on January 3, 1984 (75). Under the regulations, a discharge could become either a “day”

‘Although there are 467 DRGs for clinical conditions, there are

3 additional categories for payment purposes. Two of these categories involve reassigning the original classification and have no

rates assigned.

outlier or a “cost” outlier. A day outlier is a discharge that exceeds the mean LOS for discharges

within that DRG by the lesser of 20 days or 1.94

standard deviations. The mean LOS for each DRG

are included in the regulations. If the discharge

is considered a day outlier, the hospital will be

paid 60 percent of the average per diem Federal

rate for the excess days considered medically necessary. The 60-percent factor is intended to approximate the marginal cost of care for the excess days. However, a hospital will not be paid

60 percent of the actual costs of outlier days, but

rather 60 percent of the average DRG per diem

rate based on the DRG price.

Additional payments will be made for cost

outliers if a hospital requests such payment and

if the cost of a discharge exceeds the greater of

1.5 times the wage-adjusted Federal DRG payment

or $12,000. Additional payment will equal 60 percent of the difference between the hospital’s adjusted cost for the discharge and the cutoff amount.

The adjusted cost will be determined by multiplying the billed charges for the covered services by

72 percent, the charge-to-cost adjustment factor.

Importantly, a discharge will not be considered

a cost outlier if it qualifies as a day outlier.

DHHS estimates that initially 5.1 percent of all

discharges will qualify as day outliers and only

0.9 percent as cost outliers. Indeed, DHHS intentionally established criteria that would result in

substantially more day outliers than cost outliers

for two reasons: the information necessary to determine day outliers is automatically and routinely

available in the bill processing system; and payments to hospitals that may simply be high-cost,

inefficient providers of care will be minimized.

Another payment decision in the DRG payment

regulations could have specific relevance to ICU

care. Hospitals transferring a patient to another

institution are paid a per diem rate based on the

average LOS for the DRG treated. Full payment

for the DRG treated is made to the hospital from

which the patient is finally discharged. For example, if hospital A treats a patient in a DRG with

an average LOS of 10 days for an initial 4 days

and then transfers the patient to hospital B, hospital A will receive 40 percent of the DRG payment and hospital B will receive a full DRG payment, regardless of the actual LOS in hospital B.
48 ● Health • Study 28: Intensive Care Units: Costs, Outcome, and Decisionmaking

Finally, Medicare previously reimbursed hospitals for the reasonable costs of capital, which

include depreciation, interest, and rent. Under the

current law, capital expenses are specifically excluded from the prospective payment system and

continue to be reimbursed on a reasonable cost

basis until October 1, 1986. At that time, Congress will decide whether to continue to pay reasonable costs or to incorporate payment for capital into the DRG system.

Medicare Utilization of ICUs by DRGs

Because ICU patients often have multiple diagnoses and suffer serious physiologic abnormalities

that frequently do not correspond to disease

entities, the DRG classification scheme may be

poorly suited to describing ICU patients. Nevertheless, a preliminary analysis has been performed

of the DRG case mix of Medicare ICU/CCU3 patients based on available Health Care Financing

Administration (HCFA) data for 1979 and 1980

(259,260). For the purpose of this analysis, multiple DRGs for the same primary diagnosis were

combined. For example, DRGs 121 to 123—myocardial infarctions with differing clinical characteristics—were considered together.

Of the 15 DRG-based primary diagnoses with

the longest average LOS in special care in 1979,

14 involved operating room procedures. The exceptions were the DRGs for myocardial infarctions. Another way to view DRG case mix is to

consider special care as a percentage of total hospital stay. Of the 16 primary diagnoses in which

special care represented at least 10 percent of the

total hospital stay, 9 were medical diagnoses.

However, these medical diagnoses were mainly

for the cardiovascular system—mostly related to

coronary artery disease. One can conclude that

for DRGs involving certain operating room procedures and coronary artery disease, stays in

special care units are standard and, therefore, captured by the DRG category. For example, 92 percent of cases for cardiac valve procedure with

pump support (DRG 105) included special care.

For many common surgical procedures and cardiac diagnoses, special care was utilized in more

than !70 percent of cases. For the remaining,

predominately medical diagnoses, the DRG category does not reflect the use of special care units

for the more severely ill patients with that principal diagnosis. For example, a number of ICU

studies indicate that gastrointestinal bleeding in

patients with cirrhosis is one of the ICU problems

associated with both long ICU lengths of stay and

high cost (40,50). Yet, the DRG for this condition, “cirrhosis and/or alcoholic hepatitis” (DRG

202), has a mean special care length of 0.6 days,

or only 4.5 percent of the average total hospital

LOS for discharges with this DRG.

A somewhat different picture of ICU use emerges

when frequency of diagnosis is taken into account.

By multiplying the number of discharges in the

20-percent MEDPAR sample4 by the average LOS

in special care, the number of special care days

by diagnosis can be estimated. Table 10 shows

the 15 diagnoses which use the most special care

days. Again, cardiovascular disease predominates. However, diseases involving operating

room procedures become less important as major special care diagnoses.

Applicability of DRGs to ICUs

As noted above, the current DRG classification

system may not be suitable for describing certain

types of patients cared for in ICUs. DRGs are

based on a principal diagnosis, with some additional categories available for patients with a

single substantial secondary diagnosis, called a

“comorbidity,” or a significant “complication. ”

Yet ICU patients often have multiple, serious

underlying illnesses. In one study (265), ICU patients had on average over four major diagnoses,

and the high-cost nonsurvivors had over six diagnoses. For these patients, designation of a principal diagnosis is likely to be arbitrary and

unreliable at times. Furthermore, the additional

diagnoses would not be accounted for.

As discussed earlier, many cardiac diseases,

particularly those involving coronary diseases,

and many of those surgical diagnoses involving

operating room procedures, include stays in the

ICU and CCU as a matter of routine. For exam3Available HCFA data combines ICU and CCU patients as special

care patients. 4

For a description of HCFA’s MEDPAR data base, see ch. 4.
Ch. 6—Payment ICU Services ● 4 9

Table 10.-Estimated Number of Special Care (lCU/CCU) Days by Primary Diagnosis

Based on HCFA 20-Percent Sample of Medicare Discharges, 1980a

Special care Routine care

Percent of total

Diagnosis DRG Total days hospital days Total days

1. Myocardial infarctions . . . . . . . . . . . . . . . . . . . . . ..121-123 176,963 33 ”/0 362,013

2. Atherosclerosis . . . . . . . . . . . . . . . . . . . . . ........132-133 103,781 14 625,450

3. Heart failure and shock . . . . . . . . . . . . . . . . . . . . . . 127 87,347 11 693,439

4. Pneumonia and pleurisy . . . . . . . . . . . . . . . . . . . . . 89-91 78,211 13 555,115

5. Unrelated OR procedure . . . . . . . . . . . . . . . . . . . . . 468 66,451 9 734,684

6. Arrhythmia . . . . . . . . . . . . . . . . . . . . . . . . . . .......138-139 54,464 21 200,923

7. Angina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 53,926 22 194,653

8. Ungroupable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 470 51,100 6 734,684

9. Cerebrovascular accident . . . . . . . . . . . . . . . . . . . . 14 42,120 5 715,668

10. Chronic obstructive pulmonary disease. . . . . . . . 88 41,203 8 467,825

11. Pacemaker implant. . . . . . . . . . . . . . . . . . . . . . ....115-118 37,109 30 83,586

12. Coronary artery bypass surgery . ..............106-107 30,169 32 64,968

13. Pulmonary edema and respiratory failure . . . . . . . 87 28,371 25 83,276

14. Major bowel OR procedure . ..................148-149 27,191 10 242,188

15. Major reconstructive vascular procedure . ......110-111 20,543 18 94,077

aMultiple DRGs for the same primary diagnosis were combined for this analysis.

SOURCE: Office of Technology Assessment.

pie, in the United States it is standard to treat all

patients with acute myocardial infarctions (heart

attacks) in CCUs or ICUs. The average DRG price

per discharge will reflect the portion of the hospital costs consumed in the higher cost special care

unit.

However, the DRG categories for many medical diagnoses are so broad that ICU days represent only a small proportion of total hospital days.

For example, in 1980, hospital stays for chronic

obstructive pulmonary disease (DRG 88) and for

cirrhosis of the liver (DRG 202) averaged only

0.82 and 0.60 days of intensive care, respectively

(260). Yet, the sick patients within these DRGs

may spend many days in the ICU and use more

total hospital resources than patients within DRGs

that include a much longer average special care

stay. In other words, it appears that variations

in severity of illness are particularly great for noncoronary, medical diagnoses that represent the

medical patients in medical or mixed ICUs. Likewise, the DRG classification system does not

satisfactorily account for patients with a primary

surgical diagnosis who suffer major medical complications. For example, in a series of critically

ill surgical patients, Cullen (54) found that renal

failure (a costly medical complication) was a

powerful predictor of ultimate survival. Many clinicians might agree that renal failure had become

a patient’s major clinical problem, but the DRG

system requires that the operating room procedure take precedence in DRG assignment. The

presence of renal failure, then, would not significantly affect DRG payment.

Unfortunately, there is no data base available

to test whether there are systematic differences by

hospital type in severity of illness in ICU populations. DHHS’S initial evaluation found that teaching hospitals do have higher costs per case, suggesting, at least in part, that they treat more

seriously ill patients (75). Survey tapes of the

American Hospital Association document that

major teaching hospitals do have 50 percent more

ICU days as a percentage of total hospital days

than nonteaching hospitals (106). These additional

ICU days probably explain some of the higher

costs per case in teaching hospitals.

However, without an accurate severity-ofillness measure, one does not know whether the

additional ICU use in teaching hospitals represents

the presence of a sicker population or a different

threshold for transferring and maintaining patients in the ICU. Likewise, differences in resource

use between ICUs may represent differences in

severity of illness or differences in intensity and

style of care. Preliminary results from 15 tertiary

care hospitals recently surveyed by Knaus’ group

at George Washington University in Washington,

DC, suggest that severity of illness, in fact, ac-
50 ● Health Case Study 28:: ]ntensive Care Units: Costs, outcome, and Decisionmaking

counts for a substantial portion of the differences

in ICU resource use for patients with the same primary diagnosis (268).

Under Medicare’s DRG payment system, many

costly ICU cases will likely become outliers for

whom only marginal costs above a day or cost

threshold are paid. As was described earlier, by

design, day outliers will predominate over cost

outliers. Utilizing HCFA’S 1980 MEDPAR data,

OTA has estimated that 12 percent of cases involving special care would be classified as day

outliers, in comparison to 9 percent of total cases.

By definition, the marginal costs for day outliers

are calculated based on the DRG price, not the

actual cost for that patient. Yet, as was noted in

chapter 3, the cost per day in the ICU is over three

times greater than the cost for a general hospital

day. Thus, a hospital may receive far less than

the actual marginal costs for caring for a longterm ICU patient. In short, the outlier payment

rules generally favor less severely ill, non-ICU,

long-stay patients, such as those with strokes or

certain types of cancer, over more severely ill,

long-stay ICU patients.

It would appear, then, that severely ill Medicare patients, especially if they are in the ICU,

will be “revenue losers” to the hospital, even with

an outlier policy in effect. This fact, combined

with the lack of a financial penalty for transferring patients to a second hospital, may result in

more interhospital transfers of the sickest ICU patients to tertiary care hospital ICUs. A regionalized system of ICU care that is common in some

parts of Europe might thereby be stimulated in

the United States, perhaps desirably. It should be

noted, however, that unless either a severity-ofillness measure or a different outlier policy is

adopted, the tertiary care hospital receiving

severely ill transferred patients will be likely to

lose financially. These hospitals would then face

the dilemma of either not accepting these patients

in transfer or of accepting these patients into their

high-quality ICUs at a financial loss. At the extreme, tertiary care hospitals could, in effect,

become large ICUs (212). Public hospitals and

some teaching hospitals, however, may simply be

unable to sustain the costs of ICU care and be

forced to ration care even more strictly than they

do now (212).

The 3-year capital cost exclusion in the DRG

law is not likely to affect ICUs, at least in the short

run. ICU care is relatively costly largely because

it is so labor-intensive. Common ICU technologies, such as cardiac monitors, respirators, pulmonary artery (Swan-Ganz) catheters, central

feeding lines, etc., are labor-generating rather than

labor-reducing technologies, because they require

fairly constant attention.

As was noted in chapter 5, the monitor-only

and other less severely ill ICU patients have been

subsidizing the care of the most critically ill ICU

patients. Under the DRG system, there may be

a new incentive to treat monitor patients on regular floors or perhaps in intermediate care units.

In addition, hospitals will attempt to pass on to

charge payers the unreimbursed cost of ICU care

to Medicare patients. The additional “pass-on,”

combined with nonadmission and earlier discharge

of some of the less sick ICU patients, should result in substantially increased charges for an ICU

day. The current 2.5:1 ratio of ICU bed charges

to routine bed charges (71) will correspondingly

rise.

In short, ICU care to Medicare patients will not

be financially rewarding to hospitals under DRG

payment. Almost all ICU cases are likely to be

“losers” to the hospital—ICU days are about 3 to

3.5 times more costly than non-ICU days and ICU

patients have longer hospital stays than non-ICU

patients. The new incentives of the DRG payment

system will be imposed on an ICU decisionmaking environment in many hospitals in which the

costs of care had previously been a relatively minor concern. The implications of the collision between the hospital’s new interest in reducing the

cost of ICU care and a decisionmaking environment that results in expanding ICU care will be

discussed in chapters 7 and 8.
Ch. 6–Payment for ICU Services ● 51

PHYSICIAN PAYMENT

In a fee-for-service system that pays on the basis

of “usual, customary, and reasonable” standards,

“technological and procedural” medicine has been

rewarded (202). The ICU is a focal point for technological and procedural medicine within the hospital. Incubation, use of respirators, and arterial

line placement are among the many ICU procedures that generally require ICU admission and

numerous followup ICU visits by the patient’s primary and consulting physicians. Payment for ICU

procedures and visits is generally high and is

rarely questioned by insurers (166).

Patients in ICUs have multiple diagnoses and

often multiple organ system failures. It is not surprising, therefore, that ICU patients have many

physicians. Murata and Ellrodt (164), found in a

large community hospital in which the ICU had

full-time housestaff that at least one physician

consultation was requested in 65 percent of the

private admissions. In this study, private ICU patients had an average of nearly 2.5 physicians caring for them, in addition to round-the-clock housestaff coverage.

The situation is somewhat different in teaching

hospitals and other large nonteaching hospitals.

In these hospitals, there is usually one or more

full-time staff physicians who help administer the

ICU, provide staff education and, to varying

degrees, participate in direct patient care. Although the specific payment method adopted by

a particular hospital may be unique, compensation arrangements can generally be classified into

one of four categories: fee-for-service, percentage

of income arrangements, salary only, and combinations of the first three (77). Straight salary

arrangements represent the only compensation

method that does not include a financial incentive component (77). In terms of ICU care, ICU

staff physicians who are not paid on strict salary

basis have a financial incentive to keep the unit

filled and to perform procedures and provide technical services (166). Surveys on the prevalence of

various compensation methods in U.S. hospitals

have not specifically included ICU physicians (77).

Similarly, the extent of ICU physician double billing (submitting fees for reimbursement for professional services while receiving salaries for

administrative and educational activities, which

are reimbursed as a hospital cost) is unknown.

Under DRG payment, ICU staff physicians may

face conflicting payment incentives unless they are

paid on a strictly salary basis. Given the high costs

of ICU care, it may be in a hospital’s interest to

increase the cost control function of ICU staff physicians and to pay them salaries as their primary

form of remuneration. Hospitals could even provide incentive bonuses for reduced costs or decreased lengths of stays. In addition, hospitals

which do not currently have ICU directors may

find it in their economic interests to hire one to

monitor the costs of care provided by private physicians who admit patients to the ICU. Thus, it

is possible that a hospital’s attempt to reduce hospital ICU costs, paid under Part A of Medicare,

might also indirectly result in a reduction in Part

B physician payments.
7

The ICU Treatment Imperative
7 ■

The ICU Treatment Imperative

INTRODUCTION

Medical decisionmaking involving seriously ill

patients is often difficult and uncertain. In many

cases, physicians do not know ahead of time

whether the treatment they prescribe will benefit

their patient. Physicians in the intensive care unit

(ICU) frequently face the similar dilemma of not

knowing whether to employ available life-support

for critically ill patients and whether or when to

withdraw such support when it seems clear that

continued treatment will merely prolong his life

with no improvement in his grave condition. One

reason ICU decisionmaking is so difficult is that

it is so successful; most ICU patients survive. Yet,

it is also clear that in some cases ICU care is

provided—at a very high cost—to patients who

are beyond help. In other cases, ICU care may

be immediately lifesaving but results in returning

the patient either to a condition that still has a

very short life expectancy or to a condition with

a severely limited functional status.

At the present time, there is no reliable way to

predict outcome for most critically ill patients, and

therefore, it is usually reasonable and appropriate to initiate intensive care treatment for severely

ill patients. However, because of certain factors

somewhat unique to the ICU, care is sometimes

continued beyond the point of benefit to the

patient.

This chapter explores those factors—including

the underlying chronic illnesses suffered by many

ICU patients, the diffused nature of decisionmaking that often prevails in the ICU, the frequent

inability of patients themselves to make informed

choices about continuing therapy in the face of

a hopeless situation, the concern over the possibility of malpractice lawsuits or even criminal

prosecution and the inability to predict outcome—that often lead physicians to provide lifesupport after the initial rationale for doing so no

longer exists. Together, these factors create an

ICU treatment imperative.

THE HIGHLY TECHNOLOGICAL NATURE OF ICU CARE

The “technological imperative,” which has been

defined by Fuchs as the desire of physicians to do

everything that they have been trained to do,

regardless of the benefit-cost ratio (84), flourishes

in the ICU. ICU technology can dramatically and

consistently sustain life for long periods of time.

The ICU is a prototype of what Thomas has called

a “halfway technology, ” one that attempts to

compensate for the incapacitating effects of certain diseases whose courses one is unable to affect. It is a technology designed to make up for

disease or to postpone death (250). Many of the

individual technologies used in an ICU, including

respirators, defibrillators, and balloon pumps,

sustain vital functions but do little to correct

underlying disease processes.

In a well-functioning ICU, patients rarely die

immediately of respiratory failure or circulatory

collapse, because the available technology can delay these complications (50). Some patients, particularly those with the common ICU problems

of cardiovascular, respiratory, and necrologic

failure (139) have their vital functions sustained

by technology so as to forestall death, but their

basic disease or diseases do not improve. For some

disease processes, then, ICU care does not change

the ultimate outcome, but rather results in a pro-

.55
——

56 ● Health Case Study 28: ]ntensive Care Units: Costs, Outcome, and Decisionmaking

longed, yet inexorable course, with death occurring sometimes from complications of ICU care

(135) or after a decision is finally made to terminate the special life-support.

Measurements and monitoring are often pursued as ends in themselves in the ICU (198). Patient care may become depersonalized. As one

critical care specialist noted, the paradox is that

ICU staff treasure life highly and go to any length

to salvage lives, yet often ignore, or actually

debase, the very qualities that render patients

uniquely human (35). The technological imperative, which frequently results in more effective

methods of managing very sick patients, can lead

to the uncritical adoption of harmful therapies on

the assumption that the most critically ill have little to lose from new approaches (198). In addition, new ICU therapies that are demonstrably efficacious in expert hands for specific problems

may become widely adopted and routinely used

in situations and under conditions where demonstration of their effectiveness is absent (243).

Physicians who become intensive care specialists—“intensivists” —by predilection and training

are generally believers in technological intervention (95). ICU-oriented physicians naturally are

THE NATURE OF ICU ILLNESSES

As was noted in chapter 5, diseases of the cardiovascular, respiratory, and neurological systems, both medical and surgical, predominate in

the ICU. Failure of these systems often results in

acute respiratory distress, which is manifested by

severe smothering or “air hunger, ” and circulatory

collapse or shock, which results in altered states

of consciousness. Even when the impulse on the

part of the medical professional is simply to make

a desperately sick patient more comfortable and

not to initiate heroic measures in an attempt to

reverse the illness, that impulse may require the

use of the full panoply of ICU technologies, particularly the respirator. Some patients with cancer and other chronic debilitating illnesses may

believers in the highly complex technology that

they have mastered and often save lives that

would have been lost under non-ICU conditions.

Likewise, some nurses who choose ICU-based

careers tend to be therapeutic activists, not prone

to accepting the inevitability of a patient’s deteriorating condition (278).

The highly technical nature of ICU care itself

affects the way in which life and death decisions

are made. The most critically ill patients have

multiple organ systems failure and receive multiple interventions. The very exacting nature of this

form of patient management results in standard

protocols of treatment, perhaps at increased expense (100), and in concentration on the details

of treatment.

In such situations, the fundamental consideration of the long-term benefits to the patient receiving care is often overlooked among the seemingly endless technical decisions that are made

throughout the course of an ICU stay. Yet, the

most critically ill patients, who require the most

concentrated focus on the details of day-to-day

management, are precisely those for whom fundamental likelihood and quality of survival questions are most appropriate.

be cared for outside the hospital, perhaps in

hospices, with appropriate use of pain medication

and emotional support. Many terminal illnesses,

however, produce symptoms that cause severe

distress to the patient and that are frightening to

their families. The need for relief often results in

hospitalization and treatment in the ICU. For example, symptoms of smothering from emphysema

cannot be treated with medication alone—at least,

not without the very real possibility of depressing the patient’s respiration to the point of risking immediate death (102). “Naturalness,” therefore, may have to be sacrificed for comfort, which

at times can only be achieved with ICU management and technologies (191).
Ch. 7–The ICU Treatment Imperative ● 57

“ICU diseases” often develop rapidly-sometimes in seconds. When a severely ill, perhaps dying patient is seen in an emergency room or on

a medical floor, physicians, who are often not familiar with the patient, naturally and appropriately attempt resuscitation (179). Frequently, the

basic physiological and other clinical data which

are necessary for a medical judgment on the severit y and likely outcome of an illness cannot be acquired before admission to the ICU (55).

With some terminal diseases there is time to anticipate and plan the degree and nature of intervention in the event of a sudden deterioration

in the patient’s condition. Because end-stage

emphysema, severe heart disease, or generalized

arteriosclerosis are, rightly or wrongly, not considered terminal diseases in the same way that cancer is, patients experiencing a sudden decompensation are routinely and responsibly treated with

all available technology. Once initiated, however,

treatment modalities that have been initiated primarily to respond to acute, disabling symptoms

may become difficult to stop for the reasons described below.

TRADITIONAL MORAL DISTINCTIONS IN MEDICINE

Along with the notion that physicians should

not “play God, ” the traditional medical ethic has

been to disregard subjective views of quality of

life in making life and death decisions. In terms

of ICU care, this general ethic has been characterized as one in which “survival is being taken

as equivalent to a life saved” (64).

Underlying the other considerations which play

a part in ICU decisionmaking is the generally

activist attitude of many physicians, who may embody a fundamental and somewhat unique attitude of American culture. The decision to pull

back is frequently more difficult to make than the

decision to push ahead with aggressive support,

using the complex and sophisticated medical technology available (269). As other reviewers of intensive care have observed, this attitude has been

captured in T. S. Elliot’s The Family Reunion (18):

Not for the good that it will do

But that nothing may be left undone

On the margin of the impossible.

In situations where patients are in acute distress

and where decisions must be made in seconds or

minutes, there are powerful reasons initially to

apply a lifesaving technology. Having done so,

it is often quite difficult to reverse the course

of treatment in the light of new information or

thoughtful judgment because of traditional moral

distinctions in medicine. Specifically, fundamental

moral and ethical distinctions are frequently made

between actively causing death and allowing it to

occur by declining to intervene; between withholding and withdrawing treatment; and between

ordinary and extraordinary treatment (191).

Many primary decisionmakers in the ICU feel,

for example, that having decided to put a patient

on a respirator, one is committed to its continued

use and thus make a fundamental distinction between intentionally withholding and actively

withdrawing the respirator. Likewise, while some

prominent medical ethicists have abandoned the

distinction between “ordinary” and “extraordinary” obligations to dying patients, physicians

generally continue to use the distinction (160). The

ordinary-extraordinary distinction has been affirmed consistently in Catholic moral theology,

notably in a major address by Pope Pius XII in

1957 (185). Certainly, most of the public consider

that there is a difference between care that is common and reasonably simple and care that is

unusual, complex, expensive, and uses elaborate

“unnatural” technology. Similarly, most physicians consider intravenous fluids to be ordinary

and standard therapy and resuscitation an extraordinary measure (160). Other physicians,

however, consider even the use of respirators and

other common ICU technologies to be routine, ordinary treatment (191). Many physicians do not

use the ordinary-extraordinary distinction at all,

but rather fundamentally consider whether an

intervention, however invasive, is “medically

indicated. ”
— — . —

58 ● Health Case Study 28: Intensive Care Units: Costs, outcome, and Decisionmaking

As the President’s Commission for the Study

of Ethical Problems in Medicine and Biomedical

and Behavioral Research has observed, invocation of these moral distinctions is often so mechanical that it neither illuminates an actual case nor

provides an ethically persuasive argument (191).

Nevertheless, the moral distinctions cited above

have great importance in ICU decisionmaking. Because many different individuals typically participate in ICU decisions, a range of moral attitudes

are represented (278). There is a natural tendency

to defer to the individual, whether physician,

nurse, or family member, who firmly holds a

traditional moral view.

In addition, there is still uncertainty about the

legal interpretation of these moral distinctions. For

example, a New Jersey appeals court recently

reversed a lower court order allowing removal of

a feeding tube in an extremely ill, demented patient with no hope of recovery.1 The two courts

differed in their interpretation of whether nasogastric feedings (nourishment) constituted ordinary or extraordinary treatment for this particular patient in question.

A California appellate court, on the other hand,

in vacating a lower court’s reinstatement of murder charges against two physicians for terminating

certain treatments for a patient they diagnosed as

hopelessly comatose, explicitly rejected the distinction between ordinary and extraordinary care.

The court, rather, invoked an ethical measure of

“proportion,” writing:

Proportionate treatment is that which has at

least a reasonable chance of providing benefits to

‘See In re Conroy, 188 A/.}, Super. 523, 532 (Ch. Div. 1983).

the patient, which benefits outweigh the burdens

attendant to treatment. Thus, even if a proposed

course of treatment might be extremely painful

or intrusive, it would still be proportionate treatment if the prognosis was for complete cure or

significant improvement in the patient’s condition.

On the other hand, a treatment course which is

only minimally painful or intrusive may nonetheless be considered disproportionate to the potential benefits if the prognosis is virtually hopeless

for any significant improvement in condition.z

Ironically, as was pointed out by the President’s

Commission, if there is any reason to draw a

moral distinction between withholding and withdrawing treatment, it generally cuts the opposite

way from the usual formulation: greater justification ought to be required to withhold treatment

rather than to withdraw it (191). Whether a particular intervention will have positive effects is

often uncertain until the therapy has actually been

tried (50). If therapy is initiated and it then becomes clear that the patient is not benefiting from

it, this is actual demonstration, rather than mere

surmise, to support terminating that treatment

(191). Yet, physicians who believe in a moral

distinction between withholding and withdrawing treatment, or who are concerned that another

individual or the courts would judge their actions

based on this distinction, might choose not to utilize the lifesaving treatment in the first place out

of concern that the treatment could not subsequently be readily withdrawn.

‘Neil Leonard Barber, Robert Joseph Nedjl v. Superior Court of

the State of California for the County of Los Angeles; Court of Appeals of the State of California, Second Appellate District, Civil No.

60350; Oct. 12, 1983.

THE DIFFUSION OF DECISIONMAKING RESPONSIBILITY

Because of the nature of ICU care, many professionals become important decisionmakers, including nurses who attend to the patient full time,

housestaff, consultants, and the patient’s personal

physician. In larger hospitals, there are frequently

one or more ICU-based physicians in attendance

who also are involved in the decisionmaking process. In some ICUs, particularly in large, teaching

hospitals, the primary legal responsibility for a

patient’s care is transferred to the ICU or to an

ICU-oriented specialist (165,244). often, the patient’s personal physician feels intimidated by the

clinical complexity and the bureaucracy perceived

in the ICU and gives up an active role in decisionmaking (136). As a result, the patient’s personal

physician, who often has the best understanding
Ch. 7—The ICU Treatment Imperative . 59

of the patient’s baseline medical condition, quality

of life, and personal values, goals and concerns,

does not participate in important decisions about

the care the patient receives in the ICU (194). At

the same time, physicians who do not treat many

ICU patients may have unrealistic expectations

about what ICUs can accomplish and do not

know how or when to address fundamental issues

about terminating particular kinds of care (243,

244).

Many ICU patients enter the hospital through

the emergency room, often in a hospital where

their personal physician, if they have one, is not

on staff. Victims of acute trauma or sudden severe

illness may not have a previously established relationship with the physician(s) who is caring for

them.

ICUs in large hospitals utilize a team approach

to individual patients, which is felt to result in

a higher quality of care (207,208). Some have

wondered, however, whether a patient cared for

by an ICU team in fact has a doctor (212). With

the team approach, decisionmaking responsibility

may be diffused, and the difficult issue of terminating special care is frequently deferred or

deflected. Families who are interested in addressing this painful issue may not know how to engage

a diverse team of busy professionals in discussion.

With multiple professionals in decisionmaking

roles, there may well be different medical and

moral views expressed. Unanimity among professionals is desirable, especially when the issue is

withdrawing life-support (233,243). In such situations, there is a natural tendency to defer to a

member of the group who holds a traditional

moral view, such as the distinction between withholding and withdrawing treatment.

Decisions not to treat a debilitated patient in

a nursing home (27), not to transfer to the ICU

a patient with end-stage cystic fibrosis (58) or cancer (253), or to choose a hospice rather than a hospital, can often be addressed privately by patients

and their doctors. In the ICU, however, such important decisions are more visible and often controversial (278). When the responsible physician

addresses the issue of termination of special lifesupport with a family or patient, for example,

counterpressures from other physicians and nurses

may make decisionmaking extremely difficult and

emotionally charged.

PROBLEMS OF INFORMED CONSENT IN THE ICU

As the President’s Commission has emphasized,

the voluntary choice by a competent and informed

patient should determine whether or not a lifesustaining therapy will be undertaken or continued (191). Unfortunately, the ICU environment

is ill-suited to guaranteeing patient competence

and to providing the necessary flow of information to ensure fully informed consent.

Case studies have demonstrated that patients

in ICUs, as well as other seriously ill patients, do

not always act or communicate in their own interest (124). As noted in chapter 5, ICU patients

may undergo acute psychological reactions to

sleep deprivation, sensory overstimulation, dependency, and nearness of death. This is true in

other life-threatening situations as well, but unlike

the ICU, there is usually sufficient time and a

satisfactory environment in such cases for working with the patient before taking an irrevocable

decision.

Moreover, ICU patients suffer from subtle, but

real, metabolic disturbances which alter their

judgment. They are frequently in severe, although

often reversible, pain or discomfort. Furthermore,

a patient on a respirator may be reasonably competent to give informed consent but unable to

satisfactorily communicate his or her wishes. This

is due to the extreme difficulty ICU patients experience in communicating, often because they

have an endotracheal tube in their throat or have

had a tracheotomy, which makes verbalizing impossible (225).
60 ● Health Case Study 28: Jntensive Care Units: Costs, Outcome, and Decisionmaking

The natural response to some situations is to

defer decisionmaking, particularly with respect to

terminating care, until the patient is able to give

informed consent. Indeed, physicians may have

to salvage the life of a critically ill patient in order to obtain his or her informed consent to stop

care (69). Medical professionals naturally have a

bias toward supporting patient survival until it

can be determined that a patient is competent and

that the choice to stop treatment is truly informed

(245).

When the patient lacks the capacity to give informed consent, the family is normally recognized

as having the authority to make a decision on the

patient’s behalf. In practice, this procedure generally works well (191). Yet, in some cases, family

members may have motivations which do not

necessarily support the best interests of the patient (152,244) or, they may disagree among themselves. Again, because of the uncertainty of who

should make life and death decisions on behalf

of an incompetent patient, physicians naturally

adopt a policy of continuing intensive care until

resolution of disputes and roles occurs.

Finally, it has been noted that patients with serious acute illnesses are generally more passive and

distant from treatment decisions than patients

with chronic stable diseases (150). For many medical decisions, patients and their families can participate in decisionmaking with full appreciation

of the medical issues involved. Because of the

highly technical nature of ICU care, however, patients and families may not fully understand the

implications of the many decisions that must be

confronted in the ICU and are more prone to defer to physicians (280). In the ICU, the doctor’s

orientation toward the patient is to be active and

in control of the situation, while the patient is

passive and dependent (280). Some even consider

it to be the ICU physician’s responsibility to bring

a family to the point where it can look at the patient’s situation from the physician’s perspective

(278).

Whether the physician adopts a controlling attitude or not, it may nevertheless take some time

for patients or their families to accept the fact that

continued therapy is hopeless, and the process of

informing them of the condition places the physician in a difficult position. “It is extremely difficult to tell a critically ill patient that all is not

going well” (232).

LEGAL PRESSURES: DEFENSIVE

The past decade has seen an explosion in the

number of malpractice lawsuits brought against

medical professionals, particularly suits charging

that a physician was negligent in his or her duty

to provide adequate medical care. For this case

study, malpractice is defined as a wrongful act,

committed by one or more parties upon another

person; the injured party may seek monetary

damages from the person(s) responsible as compensation for an injury. The injured party must

demonstrate that the injury was caused by conduct which failed to conform to the “standard of

care” for that medical problem and that class of

provider (199).

While many malpractice claims ultimately are

unsuccessful, they have caused doctors and other

medical personnel to become more cautious and,

MEDICINE

in effect, to practice “defensive medicine,” which

involves taking or not taking certain action more

as a defense against potential legal liability than

for the patient’s benefit (68). Although the extent

to which defensive medicine is practiced is not

known, it clearly has contributed to the provision of costly, unnecessary, and sometimes hazardous medical care.

Physicians, under certain circumstances, may

also be subject to potential criminal prosecution,

The criminal law confines people’s freedom of action in order to protect society, not simply individuals, and therefore, consent is never accepted

as a defense against the crime of murder (191).

Taking innocent human life is seen as a wrong

against the entire society, not just against the dead

person. As such, criminal prosecution is the ex-
Ch. 7—The ICU Treatment Imperative ● 61

elusive prerogative of the State and may be brought

against a physician whose patient died because

of the physician’s failure to perform the duty of

treating the patient according to accepted medical standards (191). Reported criminal prosecutions of health care professionals for killing patients are rare, and it is felt that merely the threat

of prosecution provides appropriate protection

against abuse (191).

Although all practitioners face the possibility

of a malpractice suit and, to a much lesser extent,

criminal prosecution, concern is certainly great

among those who work with ICU patients. In

large part, this is because ICU patients are critically ill, and death, therefore, is a common occurrence. Indeed, the physician may permit a patient’s death by withholding or withdrawing a

particular treatment or technology, an action that

is likely to make the doctor feel vulnerable to

subsequent legal liability. In fact, however, the

legal problems with the treatment and nontreatment of terminally and critically ill patients appears to have been exaggerated—there are no

known cases of liability in the United States concerning the withholding of medical care from a

terminally or critically ill patient (272). Yet the

physician’s sense of vulnerability to malpractice

litigation is likely to increase, because decisionmaking in the ICU is unusually visible. The attending physician, the patient, and the next-ofkin have direct decisionmaking responsibility, but

others, including ICU staff, family members, and

other physicians, who may have strong opinions

on a life and death decision, are also involved,

although less directly (278).

In the determination of standards of care by

which to judge physician’s actions, malpractice

courts have traditionally imposed on physicians

the duty to provide medical care at the level which

is considered usual practice within their own or

a similar locality. However, with the advent of

standardized medical training and rapid dissemination of information, this “locality rule” has been

replaced in many States by a standard of care

based on the usual practice of the national medical community (199).

Thus, physicians are more likely to utilize an

ICU in the first place if its use is the prevailing

national standard of care for a particular medical problem, Once the patient is in the ICU, the

physician’s actions in this highly specialized arena

are likely to be judged by often higher national

standards of care than by the standard of other

local practitioners. To avoid charges of negligence, physicians are likely to use ICUs more frequently and for longer periods of time than they

might otherwise feel is appropriate.

Although the threat of criminal prosecution is

generally remote for most health professionals,

it has arisen in the context of the delivery room

and the neonatal ICU, when State prosecutors

found criminal intent to murder in cases involving an abortion3 and the care of severely disabled

newborns (197). Even in the adult ICU, criminal

intent may be alleged by prosecutors who view

actions such as failing to resuscitate, “pulling the

plug,” and “overdosing” with painkilling or sedating medications as intentionally causing a person’s

death. In 1982, for example, homicide charges

were brought against two Los Angeles physicians

who withdrew intravenous fluids and nasogastric

feedings from a comatose patient, with the approval of the patient’s family (5,133). Although

the California Court of Appeal ultimately ruled

that charges against the physicians be dropped

(171), the case undoubtedly caused significant

concern in the medical community (169).

Defensive medicine is also a factor in decisions

to use the ICU in routine, monitor cases. Where

the standard in the community is to use the ICU

for monitoring of specific conditions, such as postoperative neurosurgery cases or uncomplicated

myocardial infarctions, individual practitioners

may put themselves out on a legal limb if they

choose to care for the patient outside the ICU

(141).

Decisions to terminate life-support are seldom

challenged in court and would seem to be reasonably well protected if the hospital has established

explicit criteria and procedures for reaching such

decisions and if medical personnel follow the hospital’s guidelines (191). Some hospitals have formal policies for issuing “do not resuscitate” orders

(191). These policies were initially adopted in the

3

See Commonwealth v. Edelin, 359 N.E. 2014 (Mass. 1976).
— .

62 ● Health Case Study 28: Intensive Care Units: Costs, Outcome, and Decisionmaking

mid-1970s (154,193,243,253) in recognition that

nonresuscitation was appropriate when a patient’s

well-being would not be served by an attempt to

reverse a cardiac arrest. Yet a recent study of nonresuscitation decisionmaking suggested that physicians frequently for-m opinions about a patient’s

desires for resuscitation without involving the patient or the patient’s family, and often physicians

take actions which do not conform to the patient’s

preference (15).

For difficult ICU decisions that do not involve

resuscitation, however, physicians and staff may

not have formal procedures to follow and therefore must speculate about their potential legal

liability. The President’s Commission survey

found that only 1 percent of hospitals in this country, and just 4.3 percent of hospitals with more

than 200 beds, have ethics committees to help doctors and families reach decisions about withholding or withdrawing life-support (191). That number may have increased dramatically—to perhaps

20 percent of hospitals—in the 2 years since the

President’s Commission survey (21). Among their

other functions, these committees may provide

information to the hospital’s medical staff on their

legal responsibilities in certain situations.

In the absence of an institutional mechanism

for advising staff on the possible legal implications of their actions, physicians, understandably,

tend to adopt a cautious, “defensive” approach

to decisionmaking. This is especially true in hospitals where legal responsibility for care of a patient in the ICU is not turned over to an ICU-based

physician. It is not unusual, for example, for patients who are “brain dead” to remain on an ICU

respirator for days because of unfounded physician or hospital concern about a possible malpractice suit or criminal prosecution. Physicians may

feel more confident to disconnect the respirator

if hospital guidelines indicate when it is appropriate to do so. Even when a hospital does establish written guidelines and procedures for making life and death decisions, however, they are

necessarily cautious and conservative in content

(111). Thus, whether physicians decline to withhold or withdraw ICU technology for fear of legal

liability or whether the institution provides guidelines, the result is the same: the continuation of

ICU care for a longer time than is often necessary

or desirable for the patient’s well-being.

PAYMENT AND THE TREATMENT IMPERATIVE

Methods of hospital and physician payment described in chapter 6 have tended to be permissive

factors for provision of excessive ICU care. It is

unlikely that the care is performed primarily to

receive greater income. Rather, the payment system has not interfered with the factors described

in this section which do produce an ICU treatment imperative.

Until 1982, hospitals in States without prospective rate-setting programs were reimbursed by

some insurers for actual costs of ICU care and by

other insurers according to charge schedules which

permitted hospitals to recoup the costs of caring

for very high-cost, seriously ill ICU patients. Physician payments based on a usual, customary, and

reasonable charge system or even on a fixed fee

schedule have tended to amply reward physicians

who provide technical ICU services. While the incentives for the hospital have now changed, at

least for Medicare patients, physician payment

systems still permit physicians to provide continued, high-level ICU care without direct consideration of the costs to either the patient or

society.
Ch. 7–The ICU Treatment Imperative ● 63

THE ABSENCE OF CLINICAL PREDICTORS

As with many chronic or terminal illnesses,

there is an absence of data for the common ICU

conditions on which to make predictions of an

individual ICU patient’s chances of immediate survival, as well as the likelihood of his or her longterm survival. Probabilities based on quantitative

information for populations of similar patients are

used as a reference point on which to base decisions about treatment of patients (277). This approach is common for cancer, for example, where

there are defined stages of disease and accumulated outcome data based on alternative modes

of therapy.

Were it possible to predict which risk factors

consistently yield poor outcomes, many patients

might be considered unsalvageable at an earlier

point in their ICU stay (247). With reliable predictors of ICU survival, many of the other factors

that result in excessive ICU care would become

less important. For example, physicians would

have less concern about legal liability if reliable

data were available to support their clinical judgment that special care should be terminated for

a particular individual.

It has been argued that the use of predictive

scores should have its greatest application to decisions involving groups of patients or on how to

expend societal resources and may have more

limited application to decisions involving individual patients (157). Unfortunately, accurate quantitative approaches to clinical decisions are difficult. Collecting large, accurate data bases is

expensive and time-consuming; verifying their

relevance to other patient populations is costly

and sometimes not feasible. Data bases can rapidly become obsolete for predictive purposes once

new tests or procedures become available (157).

Collecting data on heterogeneous ICU populations

in which diagnostic monitoring and therapeutic

intervention often occur simultaneously is particularly problematic. Yet, unfortunately, as will be

pointed out below, purely subjective prognostication in the ICU is especially uncertain.

In recent years, work has begun on establishing quantitative predictive models which would

aid in predicting outcome of ICU care (143,223,

236,247,270). Up to this point, no such model of

clinical predictions has been accepted for general

ICU use (176). However, the Acute Physiology

and Chronic Health Evaluation (APACHE) scale

developed by Knaus and colleagues has begun to

receive particular attention as an objective measure of the severity of illness of ICU patients for

research and evaluation purposes, much as the

Therapeutic Intervention Scoring System scale of

Cullen (see ch. 5) has been used as an objective

measure of ICU resource use. A recent simplification of the APACHE model may make this approach more widely useful to help physicians

make more precise treatment decisions (138). By

design, however, the APACHE scale is more

appropriate for predicting outcomes of populations of ICU patients rather than prognosticating

for individual patients.

A generally reliable predictive model is available in burn units, and has been used to make

decisions about individual patients (123). Its use

in clinical decisionmaking, however, has not been

generally accepted by experts in the field (263).

Recently, a scale of rating the likelihood of survival for patients in coma (149) has been developed and is used in some ICUs for individual decisionmaking. For the great majority of ICU patients,

however, no predictive scale is available. Even if

such scales were available, it would be difficult

to apply a population-based scale to individuals

(229), especially where a “wrong” decision can

have such profound implications.

For a patient-care area that is as technologically

based as the ICU, judgments on outcome have

been remarkably subjective. Subjective prognostication near the end of life is notoriously uncertain (201) and varied (177). Some feel that physicians tend to maintain overly pessimistic prognoses

because patients with poor outcomes claim greater

physician attention (70). Some physicians employ

a strategy that has been called the “hanging of

crepe, ” i.e., predicting the worst so that anything

less dire will be viewed as a major achievement

(229). Others feel that physicians remember the
64 ● Health Study 28:: ]ntensive Care Units: Costs, Outcome, and Decisionmaking

rare “miraculous” recovery, forget the more common failures, and act on that faulty memory

(280).

Other problems with ICU outcome prediction

include the fact that recognition of terminal patients during an acute admission is difficult (198);

as noted earlier, an acute illness is often not seen

in the context of the patient’s overall condition.

Furthermore, in many community hospitals, only

a few physicians ever handle a significant number of ICU patients. Most physicians have limited

experience with the relative prognoses of these

very sick patients (165). Very few hospitals recognize an institutional responsibility to advise

physicians, patients, and families on likely outcomes of ICU care, even for the group of patients

who might be in a vegetative, nonrecoverable

state (191). Opinion on likely prognosis remains

an individual physician’s responsibility and, not

infrequently, dramatically different opinions are

offered by the various physicians involved in a

particular case.

Another major problem is the lack of meaningful predictors of the outcome of chronic illness

(215). Many ICU patients suffer an acute, major

ICU episode as part of a deteriorating chronic condition, e.g., emphysema, cancer, cirrhosis, or renal failure. Often the issue is not the likelihood

of surviving the acute episode, but rather what

the natural course of the illness would be even

with a favorable acute recovery. As was noted

in chapter 5, it is generally accepted by ICU experts that ICU care does not favorably affect the

course of a chronic illness, but rather reverses an

acute deterioration in the illness. Some patients,

when given information about relatively poor life

expectancy and quality of life, choose not to

undergo temporary lifesaving treatment. For example, cancer patients, relying on populationbased outcome studies, sometimes choose not to

submit to active cancer therapy. For the most

part, prognostic indexes, stratified by disease and

severity of illness, do not exist for most other common chronic conditions (158).

Physicians have demonstrated dramatically

divergent predictions of life expectancy for patients with “end-stage” diseases (177). In the absence of data on acute or chronic outcome, physicians can offer only imprecise, qualitative

assessments, i.e., survival is “unlikely,” “unusual,”

or “possible,” rather than the quantitative assessments, which have probability ranges attached,

i.e., “1O to 20 percent chance of one year survival”

(277).

A fundamental dilemma is that the rare miraculous recovery does occasionally occur. Describing the dismal outcomes of 18 patients treated in

an ICU for acute renal failure after rupture of an

abdominal aneurysm, Morgan was one of the first

ICU specialists to note the problem of high-cost,

low-yield ICU care (162). The patients were elderly (mean age 65.2 years), with a high incidence

of obesity, chronic pulmonary disease, and arteriosclerotic heart disease. Despite energetic clinical efforts and dramatically high cost per patient,

17 out of 18 died. Looked at another way, however, one survived and was able to return to his

previous functional level. A retrospective review

of clinical records in these cases did not permit

success or failure of treatment to be predicted by

any means other than actual trial.
8.

Foregoing Life - Sustaining

Treatment
8.

Foregoing Life-Sustaining Treatment

INTRODUCTION

Chapter 7 described the various, interrelated

factors that help produce an environment in which

excessive intensive care unit (ICU) care is sometimes provided. The ICU treatment imperative is

now being moderated by two relatively recent developments.

First, there has been increasing recognition of

the emotional torment for the patient, the family,

physician, and the hospital staff, of seemingly

endless ICU stays that ultimately end with the

death of the patient (243,247,278). A growing

humanistic concern for the patient and his family

supports the need to preserve the dignity of a dying patient, and may require earlier cessation of

active life-support (18).

Second, there has been a growing recognition

that the high costs of treating the most severely

ill ICU patients may be too high, particularly if

they obviously limit the resources available to

treat moderately sick patients who are more likely

to benefit from intensive care (54,247).

These two developments were explicitly recognized by experts in critical care medicine at the

Critical Care Consensus Development Conference

convened by the National Institutes of Health

(NIH). The Consensus statement on Critical Care

Medicine concludes:

It is not medically appropriate to devote limited

ICU resources to patients without reasonable

prospect of significant recovery when patients

who need those services, and who have a significant prospect of recovery from acute] y life-threatening disease or injury, are being turned away for

want of capacity. It is inappropriate to maintain

ICU management of a patient whose prognosis

has resolved to one of persistent vegetative state,

and is similarly inappropriate to employ ICU

resources where no purpose will be served but a

prolongation of the natural process of death (176).

The NIH statement is significant not only because it recognizes the futility of ICU care in some

situations but also because it acknowledges that

ICU care is, in fact, already being rationed to

some extent.

A full discussion of the difficult medical, ethical, and legal issues involved in deciding to forego

life-sustaining treatment either because of the desire to permit death with dignity or because of

a need to ration ICU resources is clearly beyond

the scope of this case study. Readers are referred

to the recently published report on this subject

by the President’s Commission for the Study of

Ethical Problems in Medicine and Biomedical and

Behavioral Research (191). In this chapter, a few

issues of particular relevance to ICUs are briefly

discussed.

THE NATURAL PROCESS OF DEATH

ICUs are uniquely capable of interfering with

the natural process of death, since respirators and

other ICU technologies are able to sustain vital

functions long after the patient has any chance

of recovery. As a consequence of these lifesaving technologies and the moral considerations involved in their use, many people today die “ICU

deaths” rather than natural deaths (135). For example, once a patient has been placed on a respirator, death may occur only when the physician

steps in and discontinues its use. Indeed, some

ICUs are developing policies and procedures for

“terminal weaning” off of a respirator, which provide for the withdrawal of a respirator in a humane

and efficient manner for the acknowledged purpose of permitting the patient to die (94).

67
68 ● Health Case Study 28:: ]ntensive Care Units: Costs, Outcome, and Decisionmaking

As chapter 7 pointed out, in some situations,

such as when the patient’s prognosis and wishes

concerning treatment are not initially known,

there may be greater moral justification for permitting a death by withdrawing life-sustaining

treatment, than for passively allowing death to

occur by withholding ICU care in the first place.

The ability of ICU technologies to intervene in

the natural death process is also evident in patients suffering from a severe, debilitating, chronic

illness who can survive their acute illness but who

can never improve beyond their original unsatisfactory functional status.

In the past, pneumonia was known as “the old

man’s friend, ” because it often provided a relatively quick and painless death for those facing

years of disability (170). Medical technology,

however, has largely removed this escape hatch.

As a result, extremely elderly patients and patients

with a severe chronic illness frequently survive

their ICU stays, often at a great expense, only to

be restored, at best, to their previous state of ill

health. Similarly, patients who suffer a devastating injury and illness that in the past would have

been fatal are now frequently saved by excellent

medical skills and modern ICU technology, only

to exist in a permanent state of profound physical or mental impairment (51).

FUNDAMENTAL ETHICAL, MORAL, AND LEGAL CONSIDERATIONS

For certain categories of patients, there has been

considerable discussion in medical circles about

the extent to which physicians and hospitals should

be obligated initially to provide and then to continue ICU care. Many ICU physicians have taken

the position, for example, that a necessary prerequisite to admission to an ICU is the potential

salvageability of the patient (51,176,200,238).

Some feel that in cases where the patient is clearly

moribund and has no chance of improving, the

physician’s duty is to make the patient comfortable and not to impose intensive care (51,152).

Although patients’ families may attempt to pressure physicians into using the ICU, the physician

and the institution probably would be on safe

legal ground in denying such care, assuming the

facts of the case sustain their position and that

the decisionmaking process was reasonable (51).

A more difficult situation arises when a patient

is terminally or irreparably ill, but is considered

to have a chance of surviving the present acute

deterioration (51). In such situations, the fundamental decision on whether to use life-sustaining technology should, if possible, be made by

the patients after they have been fully informed

of their options and understand their implications

(191). A terminally ill patient’s right to forego or

discontinue life-sustaining treatment has been

established, and is usually protected by the constitutional right to privacy (191). An immediate

problem is that the term “terminal” is not a standard technical term with clear and precise criteria

for its definition (12). Physicians may not agree

on when an illness is terminal, and some do not

even use the term.

In addition, as noted in chapter 7, critically ill

patients are frequently not competent to make an

informed decision. This is particularly true of ICU

patients who suffer subtle alterations of consciousness and develop psychological reactions to their

illness or to the ICU itself. If the patient’s incapacity to consent is temporary, the decision to

forego the use of life-sustaining treatment may

have to be postponed. If the condition is permanent, however, the question arises as to who

should make the decision on the patient’s behalf

and on what basis (151).

The President’s Commission recommended that

when a patient lacks the capacity to make a decision—a common ICU occurrence—a surrogate

decisionmaker should be designated. Ordinarily,

this will be the patient’s next-of-kin (191). Problems arise when family members disagree, are

themselves incapable of good decisionmaking, or

demonstrate family interests that conflict with the

patient’s interest (191). In many instances, an incapacitated patient may have no family or even
Ch. 8–Foregoing Life-Sustaining Treatment ● 69

close friends who can act as a surrogate on making decisions about life-sustaining treatment.

At times, there maybe a fundamental disagreement between physicians and the patient’s nextof-kin on the appropriate treatment for an incompetent, seriously ill patient. When such disagreements cannot be resolved through discussion

or through a hospital-based forum such as an

ethics committee, or when the patient is a ward

of the State, the issue may have to be resolved

in court. Sometimes, a physician may agree with

a surrogate’s decision to forego life-sustaining

treatment, but, nevertheless, seek a judicial ruling for fear of criminal prosecution or civil liability

(191). It should be emphasized that cases which

mandate specific procedures for determining

whether to continue medical treatment for an incapacitated patient have been decided by State

courts. Therefore, these court-ordered remedies,

which sometimes have differed in significant

ways, apply only to the State in which the case

was brought, unless courts in other States specifically adopt the same analysis. A discussion of

the decisionmaking procedures mandated or approved by the courts in situations where a patient

cannot choose for himself is beyond the scope of

this case study.

It should be noted, moreover, that there is legal

confusion even over when a patient ought to be

considered terminally ill and over what constitutes

“medical” treatment. A New Jersey appeals court,

for example, overruled a trial judge’s decision that

would have permitted removal of a life-sustaining

feeding tube from an 84-year-old woman considered to be terminally ill but not facing imminent

death (241). The appeals court found that removal

of a feeding tube would have inflicted new suffering from dehydration and starvation on the patient. The court found that the State has a “substantial and overriding” interest in preserving the

lives of patients who are not moribund. It also

seems to have found a legal difference between

“nourishment” and “medical treatment .“ “We hold

only that when nutrition will continue the life of

a patient who is neither comatose, brain dead, nor

vegetative, and whose death is not irreversibly imminent, its discontinuance cannot be permitted

on the theory of a patient’s right to privacy, or,

indeed, on any other basis. ”1 A New Jersey Supreme Court review of this finding is pending.

The California appellate court decision in the

criminal case of People v. Nejdl and Barber, in

which homicide charges were brought against

physicians who withdrew nutrition in the form

of intravenous fluids and nasogastric feedings

from a comatose patient, significantly departs

from the reasoning used by the New Jersey Appeals Court in the case cited above. The California case did not distinguish between “ordinary”

and “extraordinary” care and instead defined the

concept of “proportionate treatment .“ The court

wrote:

Proportionate treatment is that which . . . has

at least a reasonable chance of providing benefits

to the patient, which benefits outweigh the burdens attendant to the treatment. Thus, even if a

proposed course of treatment might be extremely

painful or intrusive, it would still be proportionate

treatment if the prognosis was for complete cure

or significant improvement in the patient’s condition.z

The reasoning of the New Jersey Appeals Court

decision, which has been appealed to the State Supreme Court, and that of the California Appeals

Court would appear to be irreconcilable. Thus,

considerable legal uncertainty remains over precisely which medical therapies, if any, are considered routine or ordinary and in which clinical

situations they must be provided. Treatments

might be considered mandatory for some patients

but not for others. Weaning a terminal patient

who is brain dead off a respirator would appear

to be permissible, for example, but removing a

feeding tube or intravenous line might not. Likewise, physicians might be legally required to provide different treatment for patients who are seriously ill and have no chance for sustained recovery

than for patients who are permanently comatose

or who face imminent death.

ISee lrJ re Ccmmy, 188 N.]. Super. 523, 532 (ch. Div. 1983).

‘See Neil Leonard Barber, Robert Joseph Nedjl v. Superior Court

of the State of California for the County of Los Angeles; Court of

Appeals of the State of California, Second Appellate District, Civil

No. 60350; Oct. 12, 1983.

25-338 0 - 84 - 6
70 ● Health Case Study 28: ]ntensive Care Units: Costs, Outcome, and Decisionmaking

The use of life-sustaining technology has also

been questioned for the patient who is not terminally ill but who finds the quality of life unacceptable and without any reasonable chance for

improvement (51,225). Judgments about quality

of life obviously reflect the values and biases of

the person making the judgment (152) and therefore are relevant only if they represent the views

of the patient (148). While some courts have ventured into this area (26), there is much less legal

precedent on which to guide physicians about the

obligation to provide ICU care for such patients,

particularly where the patients are incompetent

to decide for themselves (170). Because it took

years for even the current level of consensus to

develop regarding the possibility of foregoing care

for terminally ill patients, one should expect a

similar evolutionary process on the issue of foregoing life-sustaining care for those with an unacceptable quality of life.

Beginning with the enactment of the California Natural Death Act in 1976, 15 States and the

District of Columbia have enacted statutory authorization for competent individuals to write an

“advance directive” which directs their physicians

to forego life-sustaining treatment under circumstances in which they are both incompetent and

suffering from a terminal condition (273). A “proxy

directive” designates a surrogate of the patient’s

choice to make decisions for the patient if he or

she is unable to do so; it maybe accompanied by

an “instruction directive” which specifies the type

of care the person wants to receive. In addition,

42 States have enacted “durable power of attorney” statutes, which provide authority to appoint

a proxy to act after a person becomes incompetent. Although developed in the context of property law, these statutes may be used to provide

legal authority for an advance directive.

There are a number of unresolved issues about

how advance directives should be drafted, given

legal effect, and used in clinical practice. Nevertheless, the President’s Commission recommended

their use as a way of honoring patient self-determination (191) 0

PROCEDURES FOR REVIEW OF DECISIONMAKING

The models of decisionmaking procedures for

incompetent patients derived from court opinions

are quite different. The New Jersey Supreme

Court in the Quinlan3 case invoked the presence

of hospital “ethics committees” to provide consultation to an incompetent patient’s guardian and

specifically rejected judicial review of such decisions (191). By contrast, the Supreme Judicial

Court of Massachusetts in the Saikewicz 4 case appeared to explicitly reject the New Jersey method

of decisionmaking and instead has established

judicial review of these decisions as the rule rather

than the exception (191). However, in followup

decisions, the Massachusetts court has seemingly

modified its Saikewicz opinion such that only certain categories of cases would appear to require

judicial review, such as when the family or the

family and doctors are in disagreement or when

31n re Quinlan, 70 N.J. 10, 35sA. 2d 647, 699, cert. denied, 429

U.S. 422 (1976).

4

Superintendent of Belchertown State School v. Saikewicz, 370

N.E. 2cI 417,434-3s (Mass. 1977).

the physicians needs, but cannot otherwise obtain, consent to a course of treatment when the

patient is a ward of the State (272).

The President’s Commission recommended that

resorting to courts should be reserved for occasions when adjudication is clearly required by

State law or when concerned parties have disagreements over matters of substantial importance

that they cannot resolve. The Commission stated

that ethics committees and other institutional responses can function more rapidly and sensitively

than judicial review (191).

As was noted earlier, relatively few hospitals

have such ethics committees, and those in existence serve various functions, ranging from formulating policy and guidelines and serving as a

forum for considering difficult ethical problems,

to consulting on prognosis in individual cases and,

finally, to reviewing or even making treatment

decisions (191). Because of the lack of general experience with ethics committees, the Commission
Ch. 8—Foregoing Life-Sustaining Treatment ● 71

called for additional evaluation of various forms

of formal and informal institutionally based committees before general adoption in all hospitals

(191).

It should be noted that over the past 15 years,

Institutional Review Boards (IRBs) have been set

up to review in advance the ethical considerations

of specific research involving human subjects. Although initially controversial, IRBs are now generally accepted in the biomedical research community (191).

RATIONING ICU CARE

Up to now, discussion of withholding and

withdrawing ICU care has focused primarily on

the perceived or actual interests of the patient.

However, the NIH panel has acknowledged the

fact that patients who might benefit from treatment in an ICU are denied admission because beds

are occupied by patients who do not have a reasonable prospect of “significant” recovery. Early

analysts recognized that a few individuals consumed a dramatically disproportionate share of

ICU resources and suggested that those resources

be increased so as to avoid difficult choices about

access (162). The President’s Commission advised

against limitations on access to life-sustaining care

as an initial part of any cost-containment strategy (191). It argued, instead, that the first step

should be the control of “small ticket” tests and

treatments, such as routine blood test and X-rays,

which are believed by some to be less cost effective than more dramatic forms of therapy (153),

and which can be discussed in relatively dispassionate terms. Unfortunately, because marginal

costs of ancillary services are much less than average costs, cutbacks on these services are not likely

to have a major impact on hospital costs (1).

In addition, the care of a typical high-cost ICU

patient is, to a large extent, an accumulation of

small ticket items. While some efficiencies in ICU

care can be achieved (227), the fact remains that

the decision to initiate and continue ICU care for

patients for whom recovery is unlikely, but possible, is one of the major causes of the increasing

proportion of the Nation’s health costs accounted

IRBs or ethics committees have been identified

in the so-called “Baby Doe” controversy, as a possible approach to aiding decisionmaking about

determining medical treatment for severely handicapped newborns. While the situation of severely

handicapped newborns is somewhat different

from that of seriously ill adults, in part because

it involves consideration of parental rights and

obligations, it may be that the Baby Doe controversy will generate a heightened general interest

in the role of ethics committees.

for by ICUs. Despite current efforts to make

health care more efficient, it seems clear that further attempts at cost-containment will encounter

the reality that a large amount of medical care

is consumed by patients with highly unfavorable

prognoses (219).

“It is a basic tenet of our society that we will

not give up a life to save dollars, even a great

many dollars” (111). Yet, to some extent, this

“lifesaving imperative” is a myth, since society’s

devotion to saving lives is greatest where the

threat is to identifiable individuals, such as trapped “

miners or the victims of catastrophic disease.

Society, however, accepts the loss of many “statistical” lives (111), whether from the results of

toxic waste or inadequate preventive health care.

Physicians usually follow the same lifesaving

imperative. Many health professionals, lawyers,

and philosophers have warned that while society

may choose to limit medical treatments for economic reasons, it is not appropriate for physicians

to do it for individual patients (17,83,152,266).

They argue that the doctor-patient relationship

requires an absolute commitment to do everything

possible for the individual patient, regardless of

the effect on society’s resources.

However, most physicians by training and

practice accept the fact that there are limits to the

resources that society can expend on any one individual, and in some circumstances they act as

society’s agent in balancing the needs of their patient against the needs of other patients and so-
72 ● Health Case Study 28:: Intensive Care Units: Costs, Outcome, and Decisionmaking

ciety as a whole. For example, a patient with intractable gastrointestinal hemorrhage does not

receive limitless supplies of blood (152). At some

point, a physician makes a decision, sometimes

implicitly, that society's interest in having a supply

of blood available for the community outweighs

the patient’s need for continued transfusions. The

threshold for the decision to discontinue transfusions obviously varies, depending on factors such

as the patient’s underlying medical problem, age,

and perceived life expectancy and the physician’s

point of view.

In less dire circumstances, physicians commonly

weigh the value of a marginal benefit to their patients against the general cost to society. An example is the support of preventive health screening based on population-related, cost-effectiveness

data. For instance, differences in the recommended intervals for screening for cervical cancer through use of the PAP test (103) are essentially based on different views of how many

missed cases are acceptable on a cost-effectiveness

calculation. Physicians who choose one standard

over others do so with an implicit acceptance that

there is some level of risk that is acceptable for

an individual patient.

Physicians in health maintenance organizations

(HMOs) may practice a somewhat different style

of medicine, based on the reality of a fixed pool

of resources. HMOs face “either-or” choices and

must decide whether particular treatments, such

as for catastrophic diseases, are better investments

than others, such as for prenatal care (111). While

the constraint of limited resources is imposed externally, HMO physicians, perhaps unconsciously,

may alter their decisionmaking for individual patients in accordance with the reality of limited

resources. While the HMO may exclude or limit

certain benefits explicity in its contract with

subscribers, it also counts on physicians to practice “cost-effective” medicine, often at a small but

measurable risk to certain individual patients (22).

The clear bias in ICU decisionmaking is to initiate and continue ICU care even when it is extremely unlikely that the patient will benefit from

such care. Nevertheless, because of limited ICU

resources, decisions are made every day to curtail the care provided to individual ICU patients

and to restrict access to ICUs. In public hospitals,

difficult decisions to ration limited ICU beds have

become commonplace (186). Even in nonpublic

hospitals, rationing of ICU resources has occurred,

particularly where there has been a shortage of

nurses (220,230).

Up to now, shortages in ICU capacity to treat

patients who might benefit from intensive care

have resulted primarily from internal hospital

decisions on allocation of beds and other resources

between the ICU and general floors, and not from

external economic restraints. As discussed in

chapter 6, that will no longer be the case, however, under the Medicare’s DRG hospital payment

system. In the next few years, therefore, much

more attention will have to be given to how ICU

care should be rationed.

EXPLICIT OR IMPLICIT RATIONING OF ICU CARE?

Explicit Rationing

Provision of ICU care can involve both explicit

and implicit forms of rationing. Explicit rationing of medical care generally involves direct administrative decisions on such issues as exclusion

of certain types of services from insurance coverage, limitations on the availability of specific

methods of care, preauthorized and concurrent

review and approval for expensive treatments and

procedures, required intervals between provision

of specified services, and limitations on total

benefits (159). In the context of the ICU, explicit

rationing might include the establishment of medical criteria for treatment based on predictors of

outcome for ICU care as they become available.

In addition to predominately medical considerations, factors such as life expectancy, family role,

and social contribution could also be formally

considered (196), although the experience of al-
Ch. 8—Foregoing Life-Sustaining Treatment ● 73

locating rare renal dialysis machines and selecting

patients for kidney transplants in the 1960s on the

basis of social factors was nearly intolerable to

those involved (2,14) and might not be acceptable to society.

The ethical considerations of how to decide

who should receive lifesaving treatment and who

should not has received attention by bioethicists

(13). It is relevant here to note that to avoid explicit rationing for lifesaving treatments, health

planners and policymakers have tended either to

approve facilities or financing mechanisms that

will assure treatment for nearly everyone with a

particular illness, e.g. end-stage renal disease, or

they make a decision not to facilitate treatment

for anyone suffering from a certain condition, e.g.

patients needing heart transplants (111) except

perhaps on an experimental basis (122). Since

ICUs are not disease-specific, explicit rationing on

the basis of disease would not seem to be an

appropriate means of limiting ICU care.

Explicit rationing of ICU care might also include

limits on covered benefits beyond a certain amount,

or in certain clinical situations, where patients

could have to bear the costs of ICU care directly.

Currently, most patients have insurance coverage for most ICU costs. Many without coverage

have been subsidized. In public hospitals, rationing of limited ICU beds has been based largely

on a combination of medical factors, such as

likelihood of successful intervention, and demographic factors, such as age, and not on considerations of ability to pay (186). There is the real question of whether society would tolerate explicit

denial of “life and death” ICU care on the basis

of insurance coverage or personal wealth. In recent years, Congress has considered several proposals for national health insurance that would

extend coverage to everyone for catastrophic illness in order to avoid denial of care on the one

hand and the possibility of extreme financial hardship and bankruptcy on the other (72).

Implicit Rationing

Implicit rationing involves limitations on the

resources available to health care providers, such

as fixed budgets and restrictions on sites of care

or hospital beds (159). These limitations are implicit because they do not specify what services

should be provided to whom or what assessments

physicians should make. Instead, they achieve

their effect by placing greater pressures on physicians and hospitals to make hard allocation

choices. Simple reliance on the price mechanism

can also be a rationing device, since everyone’s

ability to pay is limited at some point; for almost

all resources in our society, price does “ration”

access to goods and services. Cost-based payment

for insured medical services has been a notable

exception. The new DRG payment system for

Medicare is a form of implicit rationing since the

total payments allowed under the system are

fixed, regardless of the level of services provided.

Other forms of payment limits could also require rationing. Indeed, because many people lack

insurance altogether or have less than full-cost,

open-ended coverage, implicit rationing occurs for

many medical services today, particularly nonhospital care. It would be possible to limit total

social spending on ICUs (or anything else) through

the implicit rationing device of patient cost-sharing, which does not require administrative decisions. Such price-based allocation of resources can

be troublesome, however, when applied to catastrophic medical care for a variety of reasons (see

111).

The cost of care for the sickest patients in the

ICU is currently being subsidized to a great extent by those who are not as ill, and by the hospital. DRG fixed payments, which are not adjusted according to the severity of the illness, will

often make high-cost Medicare ICU patients significant financial “losers” for the hospital. In this

situation, physicians will likely feel institutional

pressures not only to alter the style of ICU care

they provide to reduce costs, but also to reconsider the thresholds for withholding and withdrawing ICU care from specific individuals. In addition, hospitals may limit or even reduce the

number of ICU beds, thus reducing access for patients who would have received higher cost ICU

care. This form of implicit rationing of ICU care

raises a number of questions:

● What protections will patients require to

avoid arbitrary decisionmaking to limit care?

Will certain categories of patients, such as the

elderly, the retarded, or otherwise chronically
74 ● Health Case Study 28:: ]ntensive Care Units: Costs, Outcome, and Decisionmaking

●

●

dependent persons who might benefit from

ICU care, be systematically excluded on

purely economic considerations?

Will the potential threats of criminal prosecution and malpractice suits act as a sufficient

countervailing force to the new incentives

that DRGs will bring? More specifically, will

there be a fundamental conflict between

traditional malpractice standards and new

norms of practice that may involve limiting

care more strictly? Malpractice law has traditionally judged the behavior of medical care

providers almost exclusively by the customary practice of their peers, rather than by an

independently determined standard of socially appropriate care (22). Malpractice law

generally does not recognize varying styles

of care to suit varying available resources.

It remains to be seen whether courts will recognize limited available resources as a factor in determining negligence. In fact, hospitals and physicians may have new incentives

not to treat very sick ICU-type patients in

the first place, not only because of the directly negative economic consequences, but

also because it may place them in legal jeopardy under existing malpractice standards.

Once care has been initiated, the primary

responsibility of the provider is to meet a

high standard of care that may not be reimbursed sufficiently under the DRG payment

scheme. Hospitals may decide systematically

to avoid the responsibility in the first place by

diverting and transferring patients elsewhere.

Will society tolerate different levels of ICU

care based on willingness and ability to pay?

Medicare will prohibit hospitals for the most

part from seeking direct payments from its

patients above the allowable DRG payments

(Social Security Act Amendments of 1983,

Public Law 98-21). Can a Medicare patient

in a life or death situation be denied the continued ICU care he or she desires and is willing to pay for personally, primarily through

private insurance, because Medicare prohibits patient payments above the DRG

limit? If not, it is likely that different types

of ICUs will develop, based largely on the

ability to pay.

● Finally, what procedures should be used to

assist ICU decisionmaking in an era in which

at least some patients become financial

“losers” for the hospital? A number of procedural safeguards have been proposed to

protect the interest of patients who have insufficient capacity to make particular decisions on their own behalf, including: 1) naming an appropriate surrogate to act on the

patient’s wishes or in the patient’s interest;

2) establishing administrative arrangements,

such as ethics committees for review and consultation of different decisions; and 3) permitting advance directives, such as living

wills, through which people designate someone to make health care decisions on their

behalf, and/or give instructions about their

care (191). While initially proposed in the

context of protecting the interests of incompetent patients, these or other procedural

safeguards also appear necessary to protect

the interests of competent patients who might

otherwise be rationed out of the ICU. ICU

decisionmaking has been difficult when there

was no theoretical conflict between the interests of patient, physician, and institution.

Under a prospective payment system, patients,

physicians, and hospitals may have different

interests.
9 ❑

Conclusions and

Possible Future Steps
9

Conclusions and Possible Future Step;

Until passage of the Social Security Act Amendments of 1983 (Public Law 98-21), intensive care

unit (ICU) expansion was able to proceed without major consideration of costs because of the

favorable payment environment. Indeed, tightened section 223 limits on costs of routine hospital beds in 1979 and 1980 may have even stimulated ICU expansion. It would seem clear that

Medicare’s inpatient hospital prospective diagnosis-related group (DRG) payment system will

cause hospital administrators and ICU directors

to look differently at the costs of ICU care. Unfortunately, they will find no easy solutions to

the cost problem, particularly if Medicare allows

only relatively low rates of annual spending increases.

Under DRG payment, some savings may be

generated by better organization and management

of ICUs, perhaps by centralizing separate ICUs

into larger, more general ICUs (212). Arguably,

additional savings may be gained by substituting

lower paid health personnel for nurses or physicians to provide certain ICU functions (162,212).

There may be new efforts to find cost-saving technologies that can substitute for expensive ICU

labor. One ICU, for example, has demonstrated

a significantly decreased ICU length of stay, attributable in part to the use of computer-assisted

decision algorithms (227).

In addition, it maybe possible in the near future

to predict more accurately which monitored patients do not need to be in the ICU at all. Intermediate care units or other arrangements could

be developed to care for these patients, probably,

at a somewhat lower cost (141).

At the same time, however, it is now being recognized that some ICU patients are discharged

prematurely from the ICU. One can argue that

longer stays in the ICU for these patients would

not only represent a more appropriate use of the

ICU but also might even save the hospital money

by reducing the costs of subsequently treating for

these prematurely discharged patients (246).

Nevertheless, the fact remains that relatively

few ICU patients are responsible for a substantial portion of ICU costs. This case study has attempted to demonstrate the clinical, moral, legal,

and economic factors which currently make it difficult to decide not to treat even those patients

who show little promise of benefiting from ICU

care. The high-cost subgroup is spread among all

ages, diagnostic groups, and disability classes (40).

There are as yet no demographic identifiers or accepted general prognostic indicators which permit systematic exclusion of any of the high-cost

group from ICU care. Public programs, private

insurers, perhaps the public at large, but almost

certainly hospital managers and providers, will

face increasingly difficult decisions about who

should be given ICU care and in what manner.

The process of ICU decisionmaking will become

even more important when economics may dictate curtailing or even denying care to seriously

ill patients.

A number of steps might improve the environment for intensive care decisionmaking:

Research on developing accurate predictors

of survival for patients with acute and

chronic illnesses could be expanded in order

to permit better informed decisions based on

the likelihood of short- and long-term survival. Since the results of outcome data will

always be incomplete and subject to differing interpretations, especially in relation to

an individual patient, hospitals might consider formalizing an institutional “prognosis

committee” whose function would be to advise physicians, families, and patients on the

likely survival with ICU care in individual

situations. Such a committee or hospital

function, perhaps utilizing a routinely updated national data base, obviously could

also provide a similar function for non-ICU

patients.

The suitability of the current DRG method

of payment for ICUs should be tested. If, in

fact, the DRG scheme takes insufficient ac77
7$ ● Health Case Study 28: Intensive Care Units: Costs, Outcome, and Decisionmaking

●

●

●

count of severity of illness, it is likely that

some hospitals and, consequently, some ICU

patients may face a degree of rationing that

Congress did not envision.

The legal system, including legislators and

the courts, may need to recognize the possible conflict between malpractice standards

which assume quality of care that meets national expert criteria, and a decisionmaking

environment in which resources may be severely limited. At the same time, it must be

kept in mind that the threat of both malpractice suits and criminal prosecution may

become an even more important protection

against arbitrary or unfair denial and termination of ICU care.

Health professionals who are involved in

making decisions regarding critically ill patients might benefit from more education on

medical ethics and relevant legal procedures

and obligations. In recent years, the journal

Critical Care Medicine, published by the

Society of Critical Care Medicine, has included articles and editorials on specific ethical and legal issues. Likewise, new textbooks

on critical care medicine (224) have devoted

chapters to specific ethical and legal issues

that frequently arise in the ICU. More formal education at the graduate and postgraduate level for all health professionals who

work with critically ill patients might be considered.

The actual decisionmaking process for critically ill patients may need greater attention.

At a time when the interests of the ICU patient, physician, and hospital were theoretically the same, i.e., under a full-cost reimbursement system, the need for formal rules

and procedures for life and death decisions

might not have been necessary. Even so,

many hospitals found the need to establish

formal procedures for “Do Not Resuscitate”

orders. With a payment system that sets the

interests of at least some very sick ICU patients against the immediate financial interests of the hospital, however, it may be

necessary to impose additional formal protections on the decisionmaking process. Hospitals might explore formalizing decisionmaking committees or mandating second

opinions to lessen the burden on individuals

faced with excruciatingly difficult choices

about terminating life-support. Hospitals

could consider formally separating the ICU

triage function from the direct patient care

function, particularly with regard to the ICU

Medical Director, in order to minimize potential conflicts of interest. More generally,

society will need to decide how it wishes conflicts over decisions on terminating lifesupport to be resolved—in courts, through

formal hospital committees such as ethics

committees, through government-imposed

utilization review procedures which can follow fixed rules and-regulations, or other,

haps more decentralized, mechanisms.

per-
Appendixes
Appendix Am —Acknowledgments and

Health Program Advisory Committee

ACKNOWLEDGMENTS

The development of this case study was greatly aided by the advice of a number of people. The author

and OTA staff would like to express their appreciation to the Medical Technology and Costs of the Medicare

Program Advisory Panel, to the Health Program Advisory Committee, and especially to the following individuals:

Randy Bovbjerg Richard Lieberman

The Urban Institute SysteMetrics

Washington, DC Bethesda, MD

Martha Brooks Joanne Lynn

Springfield, VA Cliften, VA

Mark Chassin John E. Marshall

The Rand Corp. National Center for Health Services Research

J. Richard Crout Michael McMullan

National Institutes of Health Health Care Financing Administration

Palmer Dearing Lois P. Myers

Blue Cross/Blue Shield Association University of California, San Francisco

Patricia Donovan Joseph Onek

Was h Onek, Klein, & Farr ../ ,

Betty Draper Washington, DC

The George Washington University Joseph E. Parrillo

School of Medicine -

Mark Goodhart

American Hospital Assoc

Andria Grenedier

Alexandria, VA

Ake Grenvik

University Health Center

Stephanie Hadley

National Institutes of Health

Steven A. Schroeder

ation University of California, San Francisco

Douglas Wagner

The George Washington University

School of Medicine

of Pittsburgh Donald A. Young

Prospective Payment Assessment Commission

National Institutes of Health Rebekah Zanditan

William Knaus Takoma Park, MD

The George Washington University

School of Medicine

81
82 ● Health Case Study 28:: Intensive Care Units: Costs, Outcome, and Decisionmaking

HEALTH PROGRAM ADVISORY COMMITTEE

Sidney S. Lee, Committee Chair

President, Milbank Memorial Fund

New York, NY

Stuart H. Altman*

Dean

Florence Heller School

Brandeis University

Waltham, MA

H. David Banta

Deputy Director

Pan American Health Organization

Washington, DC

Carroll L. Estes**

Chair

Department of Social and Behavioral Sciences

School of Nursing

University of California, San Francisco

San Francisco, CA

Rashi Fein

Professor

Department of Social Medicine and Health Policy

Harvard Medical School

Boston, MA

Harvey V. Fineberg

Dean

School of Public Health

Harvard University

Boston, MA

Melvin A. Glasser***

Director

Health Security Action Council

Committee for National Health Insurance

Washington, DC

Patricia King

Professor

Georgetown Law Center

Washington, DC

Joyce C. Lashof

Dean

School of Public Health

University of California, Berkeley

Berkeley, CA

Alexander Leaf

Professor of Medicine

Harvard Medical School

Massachusetts General Hospital

Boston, MA

Margaret Mahoney 

President

The Commonwealth Fund

New York, NY

Frederick Mosteller

Professor and Chair

Department of Health Policy and Management

School of Public Health

Harvard University

Boston, MA

Norton Nelson

Professor

Department of Environmental Medicine

New York University Medical School

New York, NY

Robert Oseasohn

Associate Dean

University of Texas, San Antonio

San Antonio, TX

Nora Piore

Senior Advisor

The Commonwealth Fund

New York, NY

Mitchell Rabkin’

President

Beth Israel Hospital

Boston, MA

● Until April 1983.

● ’Until March 1984.

● ** Until October 1983.

● ***Until August 1983.
App. A—Acknowledgments and Health Program Advisory Committee • 83

Dorothy P. Rice

Regents Lecturer

Department of Social and Behavior Sciences

School of Nursing

University of California, San Francisco

San Francisco, CA

Richard K. Riegelman

Associate Professor

George Washington University

School of Medicine

Washington, DC

Walter L. Robb

Vice President and General Manager

Medical Systems Operations

General Electric

Milwaukee, W1

Frederick C. Robbins

President

Institute of Medicine

Washington, DC

Rosemary Stevens

Professor

Department of History and Sociology of Science

University of Pennsylvania

Philadelphia, PA
Appendix B.—Cost Estimates

As emphasized in chapter 3, there are significant

technical problems in estimating the actual or even the

relative costliness of intensive care unit (ICU) care, It

is essential to recognize some of the most important

data problems that have had to be confronted. First,

only charge data is generally available. Assumptions

about the relation of charge to cost have been made

separately for room and board and for ancillary services. Second, national data on the amount of inpatient

ICU care provided is available for Medicare, but not

for the general population. In addition, there are concerns about the reliability of the MEDPAR data base

(254). The national estimates have necessarily had to

build up from this Medicare data base.

Third, standardized national data exists for ICU

beds but not for ICU days. Usually, bed occupancy

rates in ICUs are comparable to hospital bed occupancy rates in general. We assume, then, that the proportion of ICU days to total hospital days is nearly the

same as ICU beds to total hospital beds.

Fourth, the relevant data bases combine ICU and

coronary care unit (CCU) care. No attempt, therefore,

is made to distinguish ICU and CCU costs. Furthermore, the assumptions underlying cost estimating for

ICU and CCU care may not hold for other types of

special units, such as pediatric, neonatal, and burn

ICUs. A data base for intermediate care units is simply

not available at all. Therefore, the estimates presented

here are for adult ICU/CCU costs which understate

the costs of more broadly defined special care units.

As was noted in chapter 2, adult ICU/CCU beds in

1982 made up 5.9 percent of hospital beds, while separate pediatric, neonatal, and burn ICUs together

made up another 1 percent of beds.

Definition 1—8 to 10 percent: The percentage of

hospital costs represented by the direct and indirect

cost of running the ICU, as reflected in charges for ICU

room and board. The Health Care Financing Administration (HCFA) has analyzed the use of and charges

for accommodation and ancillary services in short-stay

hospitals for Medicare beneficiaries based on a 20-

percent sample of Medicare beneficiaries—the MEDPAR data base (112). In 1980, HCFA’S sample showed

that charges for ICU/CCU care constituted 7 percent

of total hospital charges. Since Medicare patients’ utilization of ICUs is roughly in the same proportion as

non-Medicare patients (see ch, 4), we assume then that

about 7 percent of all hospital charges were for

ICU/CCU room and board charges. As discussed in

chapter 3, charges generally underestimate actual costs

of operating ICUs. In one careful study from a single

hospital, the hospital charge for special care room and

board was found to be only 65 percent of the marginal

cost of maintaining the bed. In contrast, the marginal

cost for general floor beds was less than the established

charge by approximately one-third (110). Thus, based

on this and other anecdotal reports, one can conservatively estimate that ICU/CCU costs represented 8 to

10 percent of hospital costs in 1980. The proportion

of hospital beds devoted to intensive care has, however, increased since 1980. It is likely that the proportion of ICU bed days has increased as well. Therefore,

today, the estimate would be at the high end of the

8- to 10-percent range or even slightly higher.

Definition 2—14 to 17 percent: The percentage of

total hospital costs consumed by patients when in the

ICU. This includes room and board and ancillary

services.

Method A: The simple approach to this estimate is

to double the room and board charges—room and

board makes up about 50 percent of total hospital

charges—and then make a charge-to-cost adjustment.

As noted in chapter 3, in general, hospitals mark up

costs for ancillary services by almost a third to determine charges. Thus, it would not be appropriate to

simply double the cost estimate derived from the calculations in Definition 1 above. We simply do not

know precisely the appropriate charge-to-cost adjustments to make for ICU room and board charges and

for ancillary service charges. In addition, data suggest

that ICU patients use more ancillary services per day

than non-ICU patients (see ch. 3). The extent of this

additional utilization is not precisely known.

If one assumes that the markup for the ancillary

services and the markdown for ICU room and board

were roughly the same and that ICU patients use the

same amount of ancillary services as non-ICU patients—conservative assumptions—the estimate for

percentage of hospital costs consumed by patients

when in the ICU would be 14 percent, relying on the

MEDPAR data for 1980 presented above. If it is assumed

that ICU patients used 20 percent more ancillary services than non-ICU patients, the estimate rises to 15 percent. The recent expansion in ICU beds since 1980

might add another 1 to 2 percent. The estimated range,

then, is 14 to 17 percent.

Method B: Louise Russell provided a method for

estimating the total costs of ICU care by relating the

percentage of the total hospital beds that were ICU/

CCU beds to the relative costs per day in an ICU and

in a general hospital ward (205). This method assumed

that days of care are proportional to the number of

beds. Russell also used a 3:1 ratio for relative costliness

of an ICU day compared to a regular bed day. Her

method, when applied to 1976 American Hospital

Association (AHA) bed data, provides a conservative

84
App. B—Cost Estimates ● 85

estimate that adult ICU/CCU costs represented about

13 percent of total hospital costs at that time. Updating

for 1982 AHA data that 5.9 percent of beds in nonFederal, short-term hospitals are ICU or CCU beds

would give an estimate of about 1S percent, assuming

the same 3:1 cost ratio.

As noted in the discussion under Method A above,

critical assumptions are used to generate the 3:1 relative costliness ratio, i.e., that the markup for ancillary services is roughly comparable to the markdown

for ICU room and board, and that ICU patients use

ancillary services in the same proportion as non-ICU

patients. The 3:1 ratio may well be too conservative.

A 3.5:1 ratio would give an overall estimate of about

17 percent, using Russell’s method. Russell herself

using 1979 AHA bed data estimated that almost 20 percent of all hospital costs are accounted for by intensive care (206). This estimate included costs of neonatal

and, presumably, pediatric ICU and burn unit beds.

Thus, our estimates of percentage cost, 15 to 17 percent, using Russell’s method, is consistent with her own

estimate. This estimate also agrees with the estimate

calculated according to Method A above.

Definition 3—28 to 34 percent: The total hospital

costs for patients who spend any time in the ICU.

Some authors have utilized this concept to demonstrate

the high proportion of total hospital costs accounted

for by intensive care patients (175). This calculation

is relatively easy to obtain from hospital accounting

reports. Reports from two large hospital ICUS show

that approximately 50 percent of the total hospital

costs incurred by ICU patients occurs when patients

are on regular medical floors (54,175). Similarly, HCFA’S

MEDPAR data demonstrates that the average room

and board charge for routine bed stay and for an ICU/

CCU bed stay were roughly the same (112). Therefore,

a user of both an ICU/CCU bed and a regular bed

would have charges two times the charge of the ICU/

CCU stay. If by Definition 2, it was estimated that 14

to 17 percent of total hospital costs are incurred by

patients while in the ICU, then about twice that percentage—between 28 to 34 percent of hospital costs—

probably is expended on patients who spend any time

during their hospitalization in the ICU or CCU. The

estimate agrees with the findings in one large community hospital in which patients spending any time in

the ICU represented 9.5 percent of total hospital admissions and, yet, incurred nearly 30 percent of total

hospital charges (175). Unfortunately, while relatively

easy to calculate, this cost definition is not very relevant to consideration of ICUS as a separate technology.

Definition 4—cannot be estimated: The incremental

cost generated by ICUS above the cost that a hospital

would have to absorb for treating ICU-type patients

if the ICU did not exist. This definition tests whether

the ICU is a cost generator independent of the patients

it treats. Certainly, some amount of the fixed ICU costs

would be saved if the ICU did not exist. However,

some of these costs, e.g., depreciation of ICU equipment, would be generated in any case since the costs

would be transferred to regular medical and surgical

floors. To the extent that efficiencies are achievable

by aggregating equipment and personnel in separate

areas, an initial impetus to development of ICUS, ICUS

conceivably could reduce hospital costs. In fact, the

scant data available suggests that costs of running a

conventional medical floor did not decrease with development of the ICU (97).

Experts in provision of ICU care maintain that some

patients require ICU care to have a chance at survival

(50). The sickest ICU patients simply would not survive without the coordinated and concentrated care

provided in the ICU. For practical and ethical reasons

that were discussed in chapter 5, this hypothesis cannot be directly tested. To the extent that these experts

are correct, ICUS do generate a large incremental cost

to the hospital, but with substantial benefits to survivors. These very sick patients may consume as much

as 40 to 50 percent of ICU costs in some institutions

(54,175).

ICUS, however, also generate increased incremental

costs for patients who are likely to survive hospitalization whether they are cared for in the ICU or not.

Griner followed the experience of patients admitted to

a general hospital with the diagnosis of acute pulmonary edema for the year before and the year after

the opening of an ICU (98). While the mortality rate

of 8 percent did not change, the average hospital bill

for patients admitted during the year after opening of

the ICU was 46 percent greater than for those admitted the year before (99). His sample size, unfortunately, was quite small.

Griner’s study is essentially the only one of its kind

which gives an estimate of the incremental cost of an

ICU for treating similar patients with similar medical

outcomes. Difficulties from generalizing the results of

this study for the purposes of this case study include:

1) the patient population studied represents a small

subpopulation of ICU patients; 2) the study is a decade old; and 3) the observational period of ICU care

was the first year of its operation, a period during

which care may be the least efficiently provided.

In 1981, Cromwell’s group (49) attempted to isolate

the role of various factors which might explain variations in inpatient charges using a complex regression

equation. One finding was that both hospital routine

and ICU bed stays were significant explainers of ancillary use. They found that ICU bed days are associ25-338 0 - 84 - 7
86 ● Health cue Stucfy 28: Intensive care Units: Costs, Outcome, and Decisionmaking

ated with a greater use of ancillary services than routine bed days. Using the regression, they found that

ICU days on average cost about 56 percent more in

ancillary services than regular days, holding case mix,

surgery, insurance status, and other variables constant.

While the case mix measure used (diagnosis and urgency of admission) may not be a precise measure of

severity of illness, the regression did confirm that the

ICU days are associated with additional costs in ancillary services above those that can be explained by patient characteristics. Again, it is possible that very sick,

“ICU-type” patients would have greater ancillary services used for their care regardless of their bed location.

The 56-percent increment, however, is substantial and,

at least, suggests that the ICU itself may have been

partly responsible for the greater use of ancillary

services.

Griner’s and Cromwell’s work together suggest that

ICUS generate incremental hospital costs both in additional direct ICU costs and in greater use of ancillary services to achieve similar outcomes as care on

regular medical and surgical floors. An estimate of the

amount of this cost cannot be provided.
—

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