ICU rationing linked to shortage of resources

Older patients, fewer beds strain system

Although all health care institutions and specialties are challenged by simultaneously rising costs and lack of financial resources, the problem is particularly acute in critical care, say experts.

"It is both a combination of money shrinking and possibilities getting bigger, so that we both have less money — yet every day there are new things you can do with patients in the ICU [intensive care unit]," says Mitchell Levy, MD, FCCM, FCCP, medical director of the intensive care unit at Rhode Island Hospital in Providence and the chair and principal investigator of the Values, Ethics, and Rationing in Critical Care (VERICC) Task Force.

"We are getting into more sophisticated technologies allowing for more diagnosis, but not necessarily better diagnosis; new sophisticated therapeutic interventions and drugs, not necessarily with better outcomes, but they are becoming more available. Families are uncertain about how to make decisions and how aggressive to be. We have both inadequate conversations with families and no guidelines on how to apply limits reasonably at the bedside. You add all of that up and, unfortunately, you get a bad combination," he explains.

Below are just some of the factors influencing the critical care crisis:1,2,3

• Overall, total health care spending grew seven times faster that the overall economy in 2001, with hospital costs accounting for more than half the total. Expenditures for health care represent nearly one-seventh of the nation’s gross domestic product, with intensive care usage alone accounting for $142 billion, or approximately 1% of the gross domestic product.

• Compounding the problem, in the year 2000, the percentage of the U.S. population older than 65 grew to nearly 12.5%. Among that group, the fastest accelerating segment were those ages 80 and older — the same segment of the population that requires the most expensive medical care.

• Though there is a growing demand for hospital services, particularly critical care, there is a shrinking supply of critical care beds. Between 1995 and 2001, the number of beds per ICU dropped by some 20%. And 62% of all hospital emergency departments are full or overflowing.

• One-third of U.S. hospitals are losing money every day. Another one-third is barely solvent.

• ICU services account for 20% of all hospital costs incurred in the United States and approximately 50% of the total is the cost of staffing ICUs.

• Each year, 4.4 million patients are admitted to intensive care units. The cost of one ICU day is four times that of a regular hospital bed day.

• Improved technology has increased the number of surgeries performed on previously untreatable patients by 28%. Increasing demand for critical care is exceeding the current availability of ICU beds.

• During the period of 1995-2001, the average number of beds per ICU decreased by 20%, from 15.6 to 12.5 beds per unit — often due to cost constraints, staff shortages, and other administrative complications.

• ICUs are often marginal or money-losing operations, primarily due to outlier cases — those patients that stay in the ICU for six days or more. Up to 67% of ICU costs are spent on outlier cases, though they make up only 10% of ICU patients.

References

1. Levit K, et al. Trends in U.S. healthcare spending, 2001. Health Affairs (January/February 2003); 154-164.

2. Health Care Costs. Fact Sheet. AHRQ Publication No. 02-P033, Sept. 2002. Agency for Healthcare Quality and Research, Rockville, MD.

3. The Lewin Group. Emergency Department Overload: A Growing Crisis. The Lewin Group Analysis of AHA ED and Hospital Capacity Survey; 2002.