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Critical Care Medicine and the 800 lb Gorilla*

Fein, I. Alan MD, MPH; Strosberg, Martin A. PhD, MPH; Fein, Alexander B. MPH, MBA

doi: 10.1097/CCM.0000000000003991
Editor's Choice

Multiplan Inc., St. Augustine, FL

Union College, Schenectady, NY

Yale University School of Medicine, New Haven, CT

*See also p. 1497.

The authors have disclosed that they do not have any potential conflicts of interest.

A scholar of military history, obviously taking his cues from Kipling’s poem “The Young British Soldier,” commented that “the high plains of Afghanistan are littered with the bleached bones of would-be conquerors.” (1) He noted that beginning with Alexander the Great, Afghanistan had been invaded with little success over 20 times in the past 2000 years, including three times by the British. One can say much the same thing about attempts to reform healthcare in the United States. Ever since Aaron and Schwartz published their seminal tract “The Painful Prescription: Rationing Hospital Care” in 1984, economists and healthcare policy makers of all stripes have been predicting the financial collapse of the U.S. healthcare system. With its disproportionately high costs, critical care has often been at the center of attention, if not controversy. This was certainly true during the cost containment years of the 1980s and 1990s, continuing into the quality movement of the early 21st century. Of course, ICU managers and directors were frequently told to contain and/or cut costs. The knee-jerk response to these demands were attempts to reduce both ICU and hospital lengths of stay. The cost of care has always been the 800 lb gorilla lurking in the corner of the ICU. The results were disappointing at best. Reductions in lengths of stay often resulted in premature discharges, increased numbers of readmissions, and increases in postdischarge mortality. Complicating matters even further has been the challenge of identifying and quantifying the cost of critical care in the first place. Peter Drucker and W. Edwards Deming, the high priests of management and the quality movement, are reputed to have said, you cannot manage that which you cannot measure. Although both of these masters of management would disavow such a simplistic notion, it remains an unavoidable demand for those on the front lines of critical care units.

A 2015 review article by Halpern et al (2) attempted to assess national ICU costs and resource utilization—this effort was akin to invading Afghanistan. As they noted, “this review walks the reader though the maze of arcane datasets and costing calculations for CCM in the US. An understanding of the valuable data on ICU beds and use in the HCRIS and AHA national hospital databases and the broad outlines of the CCM costing methodologies is necessary for the intensivist to fully appreciate the subtleties of studies that address national ICU bed supply, occupancy rates, and ICU costs. With this background of national benchmarks, and in concert with the increasing focus on CCM administrative issues, we believe the intensivist, and even the hospital administrator, will be better suited to interact with each other and have a starting point for CCM resource discussions.” They estimated that ICU costs for 2010 were approximately $108 billion, but could be significantly greater. Furthermore, this only included “CCM services rendered in an ICU setting … CCM costs associated with CCM services administered outside the typical ICU setting (i.e., Post Anesthesia Care Unit, Emergency Department) are not captured. Second, physician charges for CCM services even in the ICU are not included. Finally, the main use parameter is ICU days, thus, the fixed costs of unoccupied ICU beds may not be fully included. Costs may be 2 to 3 times these estimates, and even then this only accounts for inpatient ICU care. Post-discharge resource utilization by ICU survivors is another matter entirely.”

In a landmark 2009 article, Jencks et al (3) underscored the idea that hospital readmissions are not only a measure of hospital performance but also of the performance of the healthcare system. The factors associated with potentially preventable readmissions and postacute care spending are complex including lack of transition planning, socioeconomic status, insurance status, reimbursement arrangements, lack of alternatives to emergency department (ED). There is now a burgeoning body of literature documenting interventions to prevent hospital readmissions and reduce resource utilization. Many of the interventions were implemented in response to a major public policy initiative by Medicare: the Hospital Readmissions Reduction Program (HRRP). The objective of the HRRP is to reduce hospital readmissions following hospitalization for common medical conditions through the imposition of financial penalties. Unfortunately, reducing readmissions has proved to be no less problematic than reducing lengths of stay.

Gupta et al (4) studied heart failure admissions and found that “among fee-for-service Medicare beneficiaries discharged after heart failure hospitalizations, implementation of the HRRP was temporally associated with a reduction in 30-day and 1-year readmissions but an increase in 30-day and 1-year mortality. If confirmed, this finding may require reconsideration of the HRRP in heart failure.” Examining New York State patients pre- and post-HRRP implementation, McGarry et al (5) concluded “our findings suggest that while readmissions have decreased in New York State, these declines may not be directly attributable to HRRP penalties. The policy did produce significant potentially unintended effects in the form of greater post-discharge ED utilization among facilities facing proportionally larger penalties.” Even more distressing was the study of more than 115,000 Medicare patients with heart failure that found the implementation of the HRRP was temporally associated with a reduction in 30-day and 1-year readmissions but had the unintended consequence of increasing 30-day and 1-year mortality rates (6). Furthermore, in a study of nearly 700,000 patients admitted to ICUs in the United Kingdom which appeared in this journal last year, Maharaj et al (7) found that readmission rates of survivors had a poor correlation with postdischarge mortality and was a poor indicator of ICU performance.

The critical care community has long acknowledged that the population treated in the ICU is a major component of the problem. But it also has recognized that this population presents unique challenges. For example, the Society of Critical Care Medicine (SCCM) Stakeholders Conference (8) identified postintensive care syndrome as a defining characteristic of this population. Significantly, the SCCM conference included stakeholders from the rehabilitation, outpatient, and community care settings. The 2012 Report found great uncertainty on the best approaches for providing post-ICU care. Not surprisingly, further research was recommended. At this point, it appears that the law of unintended consequences rears its ugly head. Attempts to reduce lengths of stay can result in increased long-term mortality, increased rates of readmissions, and generally worse outcomes in terms of quality and costs. The HRRP has a decidedly mixed track record, especially when compared with care in Organization for Economic Co-operation and Development countries such as Canada, Scotland, the Netherlands, and the United Kingdom. And finally, given the nature of our peculiar healthcare system in the United States, it is virtually impossible to get a firm grasp on true healthcare costs. What we do know is that the costs of caring for the critically ill cannot be confined to the inpatient ICU population. Post ICU care must be part of the equation. One way of dealing with the 800 lb cost gorilla is to avoid it entirely: instead of engaging in complex financial shenanigans to decipher and elucidate costs, resource utilization can serve as a proxy for financial costs.

In this issue of Critical Care Medicine, Hirschberg et al (9) provide a unique look into this important aspect of the ICU patient trajectory. They rightly point out that “every year, more Americans survive an ICU admission, often with new or worsening disease, physical morbidities and ongoing health care needs. The first years following hospital discharge are especially costly for ICU survivor families. Among survivors of sepsis, an ICU stay is associated with increased hospital readmission and higher healthcare utilization compared to sepsis survivors without an ICU admission. The window between ICU discharge to one year is a time where preventative interventions have the potential to improve patient-centered outcomes.” To this end, they retrospectively identified 4,074 ICU survivors admitted to 17 ICUs at Intermountain Healthcare (IHC) hospitals during the calendar year 2012. IHC is a vertically integrated healthcare system operating 23 hospitals and 185 clinics in Utah and Idaho. The first ICU admission of 2012 was used as the index admission. They defined the post-ICU period as the 12 months after initial discharge, and the pre-ICU period as 13 months to 1 month before the index ICU admission to exclude deterioration leading to ICU admission. Resource utilization was defined as “all inpatient, ED, outpatient, physical and occupational therapy (PT, OT), and cognitive therapy visits. Cognitive therapy, PT, and OT visits were categorized separately from other outpatient visits. PT and OT visits on the same day were counted as a single visit.”

The results of the study by Hirschberg et al (9) are important yet unsurprising: ICU admission is associated with increased resource utilization by the survivors, including hospital readmissions, outpatient visits, and ED visits and admissions. This is entirely consistent with nationwide studies of ICU patients in Europe and Canada. In fact, a recent study in Scotland demonstrated that ICU survivorship is associated with higher 5-year mortality and hospital resource use than hospital control subjects, representing a substantial burden on individuals, caregivers, and society (10). A similar national study in the Netherlands examined the records of 56,760 ICU patients and 75,232 controls, finding that ICU patients have three to five times higher healthcare costs per day alive compared with a control population. They concluded that their findings could be used to optimize the healthcare trajectories of ICU patients after discharge (11).

Similarly, the IHC study of resource utilization among ICU survivors will be used to support an effort to build an “ICU aftercare and recovery infrastructure.” Given what we know about the extent of nationwide variation in ICU resource utilization from sources such as the Dartmouth Atlas (12), this makes a great deal of sense. The infrastructure must correspond to the needs of the IHC population, which is certainly different from the rest of the county not only because of demographic factors but also because it is served by an integrated healthcare system. As a highly regarded integrated healthcare system with advanced capacity to collect data and track patients, IHC is in an advantageous position to use and refine its policy-relevant research to inform the design of its interventions. Given the unique organizational structure of IHC as an integrated healthcare provider, one can only wonder and speculate what the magnitude of costs and resource utilization are elsewhere throughout the nation where this level of integration and accountability do not exist.

Finally, as recognized by the authors, there are factors affecting utilization that are beyond the control of any one institution. Insurance coverage and reimbursement methods remain important variables that can only be addressed at the national level.

We will look forward to seeing what further research will be conducted and how IHC will attack the problem. This certainly demonstrates, at the very least, the need for serious public policy reform at the national level.

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1. Moore R, Lennon M. The Wars of the Green Berets: Amazing Stories From Vietnam to the Present. 2007New York, Simon and Schuster.
2. Halpern NA, Pastores SM. Critical care medicine beds, use, occupancy, and costs in the United States: A methodological review. Crit Care Med 2015; 43:2452–2459
3. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med 2009; 360:1418–1428
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11. van Beusekom I, Bakhshi-Raiez F, de Keizer NF, et al. Healthcare costs of ICU survivors are higher before and after ICU admission compared to a population based control group: A descriptive study combining healthcare insurance data and data from a Dutch national quality registry. J Crit Care 2018; 44:345–351
12. Dartmouth Atlas Health Care: Post-Acute Care. 2019. Accessed July 29, 2019

cost; outcomes; patient trajectory; postintensive care unit discharge; resource utilization

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