QUALITY ASSURANCE AND COST-EFFECTIVENESS
INTRODUCTION
While structural standards of intensive care units (ICUs) in industrialised countries are mostly well
established, many interesting developments are taking place in quality improvement of ICU processes
and in outcome research.
The last few years have brought about powerful instruments for measuring outcome (result) quality.
The area of process quality - how the available structures should be implemented and managed to
achieve optimal results - has so far received the least attention, but processes will certainly be a major
focus of interest during the coming years. How processes are done have a direct impact on the
outcome of care, thus the quality of processes affect patient outcomes.
Why is that so?
An ever-expanding spectrum of highly developed medical care is paralleled by a constantly increasing
demand for its sophisticated services. On the other hand resources are clearly becoming limited and
society is neither ready nor able to meet the huge costs of this development. These two major forces
affect the practice of modern medicine.
Some measures to prevent the drifting apart of these clinical struggles are to control the use of
resources, improve the efficiency of patient care, and improve processes that impact patient outcomes.
This process is known as quality improvement. Maintaining or improving the performance of our ICUs
without further increasing the immense costs can form the 'chain' of quality improvement that prevents
these forces from drifting apart completely.
Let us assume that there is pressure on the critical care services in your area resulting in transfers and
cancellation of elective surgery because of a shortage of nursing staff. You want to prove that your ICU
performs well, provides cost-effective care, and deserves additional funding. Immediately you are
confronted with quality and cost issues and questions such as :
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How do we define quality at our institution?
Which processes are important? (Smooth processes have a beneficial effect on costs as
you will learn in the cost section)
How do we measure cost? What methods are available?
How do we determine cost-effectiveness and enable it to be a meaningful concept for
clinicians at the bedside?
1/ HOW TO DEFINE AND UNDERSTAND QUALITY WITHIN THE ICU?
Understanding quality
Hospitals are extremely complex organisations and so are intensive care units. Due to their complex
organisation, multidisciplinary functioning, the large workforce, and the technology costs involved,
ICUs can be a reflection of the overall healthcare situation.
For decades physicians have assumed that they had a social mandate to judge the quality of care.
Now we are drawn into discussions with people and agencies who would not have dared to contest the
doctor's leading role a few years ago. We also have to struggle with a completely new vocabulary
associated with the quality improvement process.
T HINK
Perhaps understanding more about the process of quality improvement will reduce the
anger, frustration and disinterest associated with its implementation. Why are many
physicians angry, frustrated or uninterested when confronted with the tasks of formal
quality improvement?
Let us become familiar with some of the terms and methods of thinking around quality matters.
How to define quality
You may get academic definitions for 'Quality'. They are all not very helpful in your daily work. The
simplest definition says that quality always compares outcomes (results of care) with objectives
(intended outcome of care). Quality assessment is, in principle, nothing more than a comparison of
an observed situation with an expected or planned one.
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It is important to note that quality always describes a relationship. There is no
such thing as absolute quality.
You will find further information about the definition of quality in the following references.
T HINK
Imagine a certain medical result (outcome). Then think of two different settings: one
where the result is satisfactory and one where the same result is insufficient. It is the
differences between these two that provide opportunities for improvement.
he quality circle
Any assessment or management of quality is done in a circular way, which some prefer to call the
audit process or the quality circle.
1. A relevant problem is identified and specified.
2. A standard, preferably an accurately measurable one, is set.
3. Quantitative data, relevant to the problem, are collected.
4. Comparisons between measurements and the objectives are made.
5. Findings are implemented and turned into management decisions.
From here on the quality circle starts anew. New, hopefully higher standards and new objectives are
set and structures and processes are refined in order to reach the goals.
This scheme appears simple enough but is quite often not followed. The most frequent error is to
mistake active collection of data for real quality assessment. Mere collection of numbers without being
able to compare them with standards is a futile statistical exercise. The result is a 'data graveyard'.
Taking as an example the problem of accidental extubation (an often cited quality indicator), what
are the five steps of the quality circle you need to undertake to ensure full quality assessment?
Go to your ICU and look for examples of ongoing data collection aimed at
quality improvement. Check whether the quality circle is really being closed
correctly or whether mere data sampling is practised.
Structures, processes and outcomes
According to Donabedian's theories, overall quality in medicine comprises three areas: structures,
processes and results. This is the most frequently used terminology. Other terminologies exist which
are imported from the industrial world. One for instance uses the terms 'Input', 'Thruput' and 'Output'
instead of structures, processes and outcomes. Of course the meaning is the same. Within the ICU
setting the classical areas may be described as follows.
Structural quality
Structural quality describes the resources available in your unit for patient care.
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ICU design
Rooms
Organisation and management resources
Equipment
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Staffing resources e.g. nurses, physicians, respiratory therapists and pharmacists
Educational resources and competency
Funding
Structural quality is clearly defined in many countries. Quality standards can be set by national health
authorities, regulatory agencies, or intensive care societies.
Find out what structural regulations exist for ICUs in your country. Assess the
structural quality of your own ICU. Find out whether it is in accordance with
regulations in your country. Also compare your structures with international
recommendations.
Process quality
Process quality assesses events that happen over the course of hospitalisation from admission to
discharge. It comprises all factors involved in the dynamic of delivering patient care. It is namely the
sum of all events, including how things are being done (processes), misunderstandings, omissions,
timing and effectiveness of communication. Also, whether or not guidelines are observed is another
element of process quality. You can find more information about the use and misuse of process data in
the following reference.
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Timing and communication are the key elements of processes. If you identify a
situation where timing or communication was an issue you can be sure to face a
problem of process quality.
There are a number of major elements of process quality in an ICU. For practical purposes we have
grouped them as follows:
Related to individual patient care
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Do-not-resuscitate and withdrawal of care policies
End of life care
Related to the care of groups of patients
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Admission, triage and discharge policies, appropriateness of care
Case-mix: type of admission, severity scores, number of organ system failures,
comorbidities
Workload: assessment (by Therapeutic Intervention Scoring System (TISS) or similar tools)
Related to the management of the unit
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General objectives of the unit
Communication issues
Method used for detecting the number and severity of adverse events
Nursing turnover and staff satisfaction
Guidelines in general, implementation and compliance with guidelines
Cost and utilisation management processes: use of expensive drugs, nutritional services
Implementation of quality improvement activities
Methods to assess staff competency and certification
Multidisciplinary team availability for patient care
Miscellaneous
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Relationship with other services
Relationship with patients families
Outcome quality
Outcome quality describes what the ICU has produced by utilising its structures and by applying its
processes. Traditionally ICU mortality has been most frequently used as an outcome measure.
Increasingly other outcomes are also being considered.
Typical outcome parameters of intensive care are :
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Mortality in the ICU
Mortality at hospital discharge and at 6 or 12 months
Quality of life and functional status at 6 or 12 months
Severity adjusted mortality rates (SMRs)
ICU readmission rate
Nosocomial events (nosocomial infections, accidental extubations, decubitus ulcers)
Number and severity of adverse events/incidents/errors
Financial outcomes: ICU and hospital costs
Complications
Patient and family satisfaction
You can find out more about SMRs in the PACT module on Clinical outcome
.
T HINK
Why would many specialists consider ICU mortality to be a crude and insufficient
outcome parameter ?
T HINK
How could you assess long term outcomes of ICU survivors ?
Managing quality - In the table below, you can see that the best instrument to assess and control
structural quality is standards, but guidelines and indicators are also useful.
Main
instruments
for assessing
and
controlling
quality
Relative
importance of
management
tools with
respect to the
three quality
areas:
'Structures',
'Processes'
and 'Results'.
Speak the same language. Be sure all in your group mean the same thing when
you talk about quality and use specific terminology. Do not get lost in struggles
over definitions. First agree on the terms you want to use.
Seven quality attributes of healthcare
Donabedian also proposed seven attributes of a healthcare system that would define its quality :
For further discussion about issues of efficacy, effectiveness and efficiency, see the PACT module on
Health technology assessment
Any comprehensive approach to quality will have to include these factors to some degree.
2/ HOW TO ASSESS THE PERFORMANCE OF YOUR ICU?
The goal of an ICU is to help patients with acute critical illness survive. In order to do that an ICU must
admit those who will benefit from intensive care and not allow in those who will have no benefit. In
addition, the ICU is expected to 'perform' well, which means to do its work as successfully,
expeditiously and efficiently as possible.
Measuring performance is defined as a quantitative method of tracking progress towards a goal. There
is no established way of measuring ICU performance. At best, the performance of an ICU can be
appraised indirectly. We must resort to the use of indicators of process quality as surrogate measures
reflecting overall performance.
Another way to look at performance of a unit is to evaluate its management processes and the
managerial skills of the team leaders. Assessment then includes communication skills, timing of
services, conflict resolution, staff satisfaction, leadership and unit culture in general. Examining
organisational problems and potential means of improvement is a start to understanding the
performance of your ICU.
Vertical versus horizontal comparison
How is this done? You can either compare what your unit has achieved last year with what it did in
earlier years. This describes 'vertical' comparison. In such an internal quality assessment, the question
is asked whether the unit is performing better or worse than in the past. First of all, there are no known
direct measures of ICU performance. You thus have to use proxy measurements. Using disease
severity measures (like SAPS II or APACHE) and severity adjusted outcomes would seem the way to
go, but several confounding factors like changes in your case-mix or pre-ICU treatment may impact on
the analysis. You can find further information about SAPS II and APACHE in the PACT module on
Clinical outcome .
Horizontal comparison involves comparing the performance of one ICU with another and is a difficult
task. The most worthwhile comparisons would be among units in similar hospitals with a similar casemix. A high performance ICU, for example, would have lower observed, than expected, mortality.
A NECDOTE
In the past, Florence Nightingale was frustrated with the obvious inadequacies of
medical record-keeping and the impossibility of comparing hospital performance:
'... in scarcely an instance have I been able to obtain hospital records fit for any
purposes of comparison. If they could be obtained... they would show subscribers how
their money was being spent, what amount of good was really being done with it, or
whether the money was not doing mischief rather than good...'
Benchmarking
You may also wish to compare your unit's performance with your neighbouring unit. This is an example
of a 'horizontal' approach. One method used in the horizontal approach is known as 'benchmarking'.
What is a benchmark?
The expression is borrowed from the business and industrial world. It means to compare your business
or your service with the best competitor around. Benchmarking in the ICU world means to look for
yardsticks with which to measure your unit's performance. Your hospital administrator might have a
slightly different view on benchmarking. He probably understands benchmarking as looking for ICUs
with lower costs than yours.
Look around in your hospital neighbourhood for other ICUs you could compare with
your own unit. Discuss with your unit director whether he/she agrees.
Comparing the performance of one ICU with another is an even more difficult task. An often-cited
study of 1982 (see reference below) made comparisons between intensive care in the USA and
France and found some important differences. American ICUs admitted older patients and resorted
more frequently to invasive monitoring than their French counterparts. Severity of illness, observed
mortality and therapies applied were however extremely similar. There was no case-mix adjustment.
Comparing the performance of two separate ICUs may be misleading if there are no
adjustments made for different case-mix.
Go to your unit and find out what kind of performance assessment is done. Discuss this
with your unit director and become active in the process.
Comparison over time
An example of a time sensitive process is weaning from mechanical ventilation. The following graph
shows the average length of mechanical ventilation in a typical European medical-surgical ICU.
Patients ventilated for less than 24 hours were excluded. In this unit mechanical ventilation in the early
80s lasted about 10 days. Fifteen years later the same task was fulfilled in only five days. Be assured
that the pathologies remained the same and that the patients' mean age increased somewhat.
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'Off ventilator days' is a suitable marker of ICU process quality.
What is your interpretation of these observations on ventilator days?
The benchmarks used are not other units, but previous years within the same unit. By comparing
these, the unit is able to judge how efficiently it masters the task of 'mechanical ventilation'. In this
particular unit, the ventilator days were significantly reduced in the mid 80s and again in the early 90s.
The first reduction probably reflects the introduction of new ventilator technology (electronic devices
with improved spontaneous breathing options), the second drop probably depicts the increasing
clinical knowledge of staff about applying spontaneous, pressure supported modes. Also mastering
non-invasive ventilatory techniques has an effect.
T HINK
about the meaning of a shorter ventilation time, assuming the overall mortality in these
ventilated patients remains the same.
Why is monitoring of the duration of mechanical ventilation ('off ventilator days') a worthwhile
quality indicator in the ICU ?
Efficacy, effectiveness & efficiency
We can learn something else from the above example. It shows us the difference
between effectivenessand efficiency. The effectiveness of mechanical ventilation in terms of saving
the lives of a certain percentage of the patients remained the same, whereas the efficiency of
ventilation in terms of performing it in an expeditious way was very much improved.
Let's say two ICUs have the same effectiveness in terms of the numbers of patients who survive.
However, unit 1 may be more efficient in terms of admitting, managing and discharging its patients
than unit 2.
It is known that 'efficient' ICUs distinguish themselves by better communication culture, strong
multiprofessional leadership and solid conflict solving approaches.
The 'EFF' terminology
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Efficacy: does it work in principle?
Effectiveness: does it work in the real world?
Efficiency: is it worth doing?
Efficacy
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Efficacy is like life in a zoo. Food and shelter are provided, every detail of life is clearly defined
and organised.
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Many excellent clinical papers published in the literature are efficacy studies. They address
well-defined scientific questions in an extremely controlled and standardised way.
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Effectiveness
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Effectiveness describes real life in the wild; full of surprises. Nothing is predictable or taken for
granted.
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Efficiency
Efficiency looks at effectiveness from an additional economic viewpoint.
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Clinical studies mostly describe well-defined standardised situations with clear inclusion and
exclusion criteria. If, by comparing therapy A with therapy B a difference is found in favour of
one regimen, the usual recommendation will be to introduce this method into daily clinical
practice. Quite often the application in the real world of intensive care will fail to produce the
expected difference.
What appears to be a clearly advantageous therapy in controlled clinical studies
may not work in daily practice. What the controlled study describes is efficacy,
what we observe in the ICU is effectiveness.
Working with indicators
As shown in Task 1
, indicators are surrogate measures to address quality issues of any service
organisation like an ICU. An indicator never covers all aspects of a service, but if well chosen, it points
to an important direction and allows robust assumptions to be made on the overall performance.
Indicators are especially powerful tools in assessing processes and outcomes.
On the following screens you will find a list of indicators. All have been successfully used for quality
management in intensive care units. For reasons of transparency they have been roughly grouped.
Some indicators are used as examples throughout this module.
If you want to start working with indicators: START SMALL! Do not begin by
using more than a few indicators. Do not select a field your unit is already good
at. Start working on your weaknesses. Carefully select indicators to study that
most directly impact the area of concern identified.
Indicators addressing medical outcomes
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ICU mortality
Hospital mortality, 30 day mortality
Indicators addressing logistic outcomes
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Length of stay (LOS) in the ICU
Hospital LOS
Indicators addressing adverse and unforeseen events
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Risk assessment
Incident, accident and error reporting
Procedure-related and other complications
Readmission rate
Indicators addressing process quality (timing and communication)
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Duration of ventilator weaning, off ventilator days
Transport/transfer times
Timing of selected services
Medical decision making, laboratory use
Indicators addressing economic outcomes
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ICU per diem and total costs
Hospital costs
Nosocomial infection rate
Drug use monitoring, pharmacy
Patient and family perceived outcomes
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Patient (customer) satisfaction, family satisfaction
Quality of life, quality adjusted life years (QALYs)
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Patient preferences, families' expectations
End of life care
Staff related results
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Employee satisfaction, ICU burn-out phenomenon
Nursing care, nursing workload
Guidelines (generation, edition, maintenance)
Auditing techniques
Managerial issues
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Admission policy, access to ICU, discharge decisions
Research activities
Communication, interprofessional relationships
Recruitment of organ donors, avoiding refusal
Reporting of incidents or adverse events (medical errors)
Prevalence - Many surveys have shown that preventable errors are a major source of mortality and
morbidity in hospitals. It appears that consequent application of available medical knowledge would
bring about far more quality improvement than the continuous search for ever newer and better
therapies. Surprisingly, medical errors are not viewed as the most important problems by physicians.
Choose neutral terms - Situations where bad rules were applied or where the good rules were not
used should preferably be called 'incident' or 'event'. No one really likes to report his failures. The word
'error' is burdened with a portion of guilt and is unsuited for unemotional discussions about adverse
events. We therefore prefer to use the neutral term 'incident'.
How to monitor incidents - In any quality system, reporting routines for undesirable results or for
processes drifting out of control are key elements upon which management decisions are based.
Screening for adverse occurrences is a well-documented method of quality control in hospitals.
However, it is far from being widely implemented in the ICU world. In order to initiate successful
incident monitoring you should proceed simultaneously on two tracks: develop a blame-free unit
culture that is open to discussion of failures without looking for culprits and, set up a formal incident
reporting and recording system.
What incident reporting does for you - It provides you with a 'fingerprint' of your unit. It allows you to
tap the collective knowledge of your team about faulty processes. It identifies areas where you can
improve safety. It allows for an open and unemotional discussion on preventable mistakes. And most
importantly it will help to prevent injury to your patients and improve clinical practice.
Suggested elements of an incident monitoring system
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Streamlined documentation
Anonymous recording (no culprits)
Self reporting
Compulsory participation
Include narrative of event
Include events without patient damage (near miss)
Regular and quick evaluation
Reporting of deviations to all caregivers
Linked to management decisions
Continuous planning
Start small
What you shouldn't do - Do not ask: 'Who was it?', ask 'Who knows how to avoid this next time?' Do
not record names of staff members involved. Do not sanction or publicly blame anyone.
What you should do - Create a blame-free culture and examine 'what is going on here' and seek
solutions to problems identified.
Errors may be looked at either in a legal way (court case) or under quality aspects. What is the
difference between the legal world and quality improvement programmes in dealing with errors?
Find out in your unit whether there exists an incident reporting system. If yes,
compare it with the elements suggested above. If no, go to your leadership team
boss and try to convince him/her to plan and introduce voluntary incident
reporting.
A few countries, most prominently Australia, have succeeded in establishing nationwide incident
reporting systems for intensive care. They have standardised their reporting and filing system. This
also allows detection of rare events and risks, which a local reporting system would be unable to
uncover. Further, it permits benchmarking to some degree.
Cause-effect approach
One way of addressing problems of unsatisfactory ICU processes is by undertaking a process analysis
using the 'fishbone' diagram. This is also called the 'cause-effect' diagram.
The 'Fishbone' diagram
'Bones' = major categories
How it works
State the process problem you want to assess and put it down as the 'head' of the fish (the place
where the fish starts to rot), then prepare 'bones' reflecting major cause categories usually the four
shown here, but you are free to choose others.
Then have a formal session with team representatives from all levels and collect their input and note it
down on appropriate 'bones' or sub-bones. Don't discuss possible solutions at that stage; just accept
every statement in order to pinpoint the causes for the problem. It is important to maintain a nonhierarchical style during such a session. If the chief of service patronises the session, subordinates will
not dare to speak up and much valuable knowledge will be lost for the analysis.
Later, have someone sum up the findings and turn them into management decisions. Implement those
and do not fail to assess the effect, hopefully an improvement later on. This 'cause-effect' approach
also serves to detect specific areas to target for improvement, rather than a 'shotgun' approach to
problem solving.
A NECDOTE
In an ICU, there was a general impression that patients with acute myocardial
infarction were not cared for in an expeditious way. Coronary lysis appeared to be
generally too long and too varied. Coronary lysis using an i.v. thrombolytic drug just
took too long. Members of all services involved and from all function levels sat together
and everyone stated what he or she knew about delays in coronary lysis. All the
information resulted in the cause-effect diagram on the next screen.
Below is an example how a complex time sensitive process in the ICU - coronary lysis - was analysed
using the cause-effect diagram.
In the above analysis many factors contributing to delays were indeed identified. By grouping them
along different 'bones', major branches responsible for delays were graphically depicted. While
communications, people and rules/methods appeared equally important, structural deficits played no
role in this specific ICU. A thorough analysis of the problem showed that the process was not only
taking too much time on average but also that there was much variation.
Go to your unit and select one process the team feels is running
unsatisfactorily. Form an ad hoc group with members from all levels and
professional backgrounds. Have one single session where everyone gives his
views, why process XY is running poorly. Depict the collected team knowledge
in a fishbone diagram.
T HINK
The above is probably the fingerprint of an ICU in a wealthy country, enjoying a good
structural quality. Imagine an ICU in a developing country and guess how structural
factors could be causes for delays.
Why is the so called 'door-to-needle' time a valuable indicator of process quality?
Go through the list of process indicators (see Task 2, Working with Indicators)
for your ICU and select those which appear the most useful to you. Discuss the
indicators in your group, suggest a rating and be prepared to discuss and
defend your choice. If you wish, add other processes. Be careful to study
processes that most directly impact the areas of concern identified.
Working with guidelines
The example above dealing with improving timing of acute coronary care depicts how we can
successfully work with guidelines. 'Guidelines' or 'clinical practice guidelines' are explicit, normally
written rules, telling the team how a specific clinical situation has to be addressed. Guidelines are used
for diagnostic, therapeutic and prophylactic tasks and the combination of all. At best, guidelines are
evidence-based and help clinicians to directly apply the result of sound research at the bedside.
Guidelines delineate the framework within which the process has to run. Guidelines are stricter than
general unit policies (e.g. admission policy) and softer than directives for specific tasks (e.g.
application of an inhalation treatment).
There are two aspects to the use of guidelines: their development and their implementation.
Development of guidelines
What do you do when a procedure in your unit needs to be regulated? You can take the rules from a
renowned textbook, from a state-of-the-art article or you copy them from a model unit in your
neighbourhood. Also professional societies regularly publish guidelines.
On the other hand you can also sit down together with your team and work something out on your
own.
You may think that it is not important as to how it is done, but surprisingly, it matters a lot. The table
below shows that guidelines developed internally, prompted by a specific learning situation or crisis are
highly respected.
However recommendations generated outside the unit, even if widely published, have relatively little
impact. Involvement of the entire patient care team is essential to establish buy-in into the process.
Implementation of guidelines
It is not enough to generate guidelines, they must be implemented, enforced, and studied for
compliance and patient outcomes. The best results are achieved by using a teaching/coaching
approach.
T HINK
Adhering to clear guidelines and rules is an important element of good practice in the
ICU. Think of ways to strengthen the framework of guidelines in your unit.
Why do you think having guidelines developed inside the unit has the highest impact on daily
practice within the unit ?
3/ FUNDAMENTALS OF ECONOMIC ANALYSIS AND COST ASSESSMENT
Why is costing an important issue in the ICU?
The costs of treating severely ill patients in ICUs are known to be high. Costs for medical care make
up an important percentage in any western government's budget, but also the average citizen's tight
household budget is increasingly affected. Inevitably the question arises as to what society and its
members are willing to pay and what they are getting in return. Financial restraints presently lead to
an increasing pressure on hospitals to prove that their expenses are justified.
The field of intensive care in particular is no exception. On the contrary, due to their complex
organisation, their multidisciplinary functioning, the large workforce and the technology costs involved,
ICUs can be viewed as a kind of model service, reflecting the overall healthcare situation in an
accentuated way.
In the United States, ICUs are consuming up to 30% of hospital budgets, and around 10% in
European countries. For most western countries it is also true to say that intensive care consumes 1%
of the gross national product (GNP). No wonder politicians and health economists are becoming
increasingly aware of ICU costs.
Estimate what percentage of your hospital budget is spent for ICU. Then go to
your hospital administration and try to find out the true figure. Also find out how
much money is spent in absolute numbers.
Be aware that costing models for intensive care not only differ from country to
country but also between hospitals. So don't be satisfied just with the total costs
of intensive care. Have explained to you how they are calculated.
What is costing anyway?
Costing basically tells you where the money goes. It does not tell you where the money comes from.
Costing by itself does not save any money. Neither does costing alone tell you anything about quality.
Costing basically has two components: the quantity of the resource used and the price of that
resource.
It is impossible to describe costs as a whole. We need to differentiate. One has to address this task in
two ways :
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Are the costs fixed or variable?
Are the costs direct or indirect?
This appears complicated at first sight but makes sense as soon as we take a closer look.
Fixed costs and variable costs
Total costs include fixed and variable costs. Fixed costs, or total fixed costs consist of those that are
not influenced by the activity level when observed over a certain time. This reflects the cost of the
structural quality of a department as stated above in the quality section. Variable costs are those that
are influenced by the process of delivering patient care. These are costs that can potentially be
controlled.
Direct costs and indirect costs
This is another view of cost elements. Here we look at whether costs can be fully attributed to a
specific cost object. These are direct costs and in the ICU the cost object would be the patient.
Indirect costs (or overheads) are costs that are shared and are not attributable to a single object.
Generally, direct costs can be viewed as patient related costs whereas indirect costs are non patient
related.
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In the ICU direct costs are directly related to the care of an individual patient.
Indirect costs are not related to individual patient care.
When calculating the total costs, indirect costs are broken down and allocated to the cost objects
using certain rules. Direct and indirect costs are then added. There are many allocation methods for
indirect costs. The exactitude is much lower as with direct costs and considerable arbitrariness is
commonly included.
The following items are the most important contributors of direct and indirect costs in your ICU:
The table above only shows you how costs of ICU services can theoretically be attributed to a cost
object, in our case the ICU patient. Whether this is indeed done or not is quite another matter. In most
ICUs the costs are not really broken down in a very detailed way. Variable and direct costs are those
that are most amenable to target for cost containment and efficient use of resources.
Go to your ICU and find out how the direct costs are attributed. Find out those
which are not collected. Find out by which model indirect costs are allocated to
your unit.
Here the four cost types together :
T HINK
ICU physicians today are expected to help to manage costs. Consider in which field
the ICU director and his/her staff are indeed able to influence costs.
Which type of costs, do you think has a larger proportion in the ICU: the fixed costs or the
variable costs? Explain your answer.
Don't mix up costs with charges. Costs describe the actual expenses needed to
treat a patient. Charges are what the patient finds on his bill, and this can vary
widely between institutions. Still many clinical publications fail to make this
differentiation and this can create challenges to do comparison of financial
outcomes.
Look through several clinical papers where costs are mentioned. Look carefully
whether the costing method is described. Can you find papers where charges
(billing to the patient) were used instead of costs?
4/ HOW TO ASSESS COSTS AND DETERMINE COST-EFFECTIVENESS?
Assessing costs
From what we saw in Task 3, costing appears quite straightforward: you just collect the four different
cost types and sum them up. This gives you the total costs of either cost object you care to analyze.
This can be costs per individual patient, costs per patient day or costs of running the unit over a certain
time (e.g. one year). Having done that you will be ready for benchmarking your costs (see also Task
2
).
Despite what method is used, the important aspect here is that a
A pessimistic note
comprehensive assessment of costs requires an assessment of all
aspects of care. All too often, clinicians and decision makers focus on
the direct costs of a particular intervention, therapy, or programme
and neglect the important indirect costs that ensue. For example, a
strong emphasis is placed upon the costs of pharmaceuticals and
devices without looking at the other associated resources, including
the cost of storage, labour, laboratory costs (e.g. aminoglycoside
levels), and even the cost of complications, adverse events, or sideeffects.
Notwithstanding the many efforts of national and international
agencies, costing in intensive care is still far from being constant and
standardised. Cost models used in different studies or countries are
inconsistent regarding inclusion of many cost elements into their
calculations. Comparison of ICU costs on a national or even an
international level is far from being a reality, but remains a remote
goal. The author in the reference below wrote in despair: 'Cost
comparison across different intensive care units is impossible as long
as there is no fixed standard method of costing'. However, a new
method of international cost comparison has just been described. It is
called the International Programme for resource use in Critical care.
It is an ongoing research trial approved by the ESICM and the article
describing the methodology has recently been submitted to the
Intensive Care Medicine journal.
How it is done
Basically there are two methods of costing: bottom up or top down. In addition to these basic
approaches there are also techniques to estimate costs with the use of resource and cost proxies (e.g.
nursing workload assessment, weighted hospital days).
Cost collecting
concepts
Bottom up means that costs are recorded at the cost object level, this is, in our setting, the ICU
patient. Any item (drugs, disposables) or service (delivered at the bedside or as remote support
services) is recorded and given a cost tag. Collection of data can be done online in the unit or
retrospectively based on the patient's file. Data collection is cumbersome, labour intensive and tends
to be incomplete when indirect costs are concerned. On the other hand bottom up costing would
ideally allow assessment of costs real time for any single patient or for specific diagnostic groups.
Top down costing consists in taking the total hospital costs and allocating them to the level of the
respective services. By definition, top down costing can only be done retrospectively. Top down
approaches are mostly used for allocating indirect costs like heating, housekeeping or capital costs.
This type of costing is unable to measure costs to individual patients.
Alternative approaches (costing by surrogate cost markers) - Instead of attempting costing in the
ways shown above, many hospitals resort to proxy cost models. The burdensome data collection is
then overcome by putting forfeited cost/price tags on surrogate markers of ICU costs, often multiplying
them by time factors. Cost markers in use can be 'weighted ICU days', severity scores, nursing
workload scores, therapeutic activity scores (TISS) or DRGs.
A recent approach - A UK group has generated a top down model based on six clearly defined cost
blocks (capital equipment, building costs, non-clinical support services, clinical support services,
consumables, staff costs). To generate the model, thorough bottom up cost assessment had to be
done. See reference below for further information.
Comparing bottom
up and top down
costing
To determine cost-effectiveness
Again we enter an area unfamiliar to most physicians. Basically we wish to know what is the effect of
putting money and effort into the care of our patients. It goes without saying that we generally hope
that something beneficial will be the result. Before we enter deeper into this matter we ought to clarify
some terminology regarding costs and its effects. There are several comparative terms in use to
describe the relation of input to output. It is helpful to differentiate between them.
N OTE
N OTE
Cost-effectiveness compares input and output of a system. It tells you what you
get in return for your costs.
There are four different types of studies dealing with cost issues: cost-benefit
studies (CB) which compare money spent with money earned; costeffectiveness analyses (CE) which compare costs with a non monetary result;
cost-utility studies (CU) which compare cost and effect against quality of life
measures and finally, cost-minimisation studies (CM) which only compare the
financial input, the costs of measure A (therapeutic, diagnostic or prophylactic)
with the costs of measure B.
Relative cost-effectiveness
Cost-effectiveness refers to the joint clinical and economic impact of any particular therapy,
intervention, or programme. By definition, cost-effectiveness requires a comparison between two or
more alternatives to achieve a particular clinical outcome. Hence, relative cost-effectiveness compares
costs and effects of one measure (therapeutic, diagnostic or preventive) with those of at least one
other. In a cost-effectiveness analysis, the comparison is expressed as a numerical cost-effectiveness
ratio, which provides a summary measure of resources expended per unit of outcome or benefit that is
yielded. Hence a lower cost-effectiveness ratio of one alternative would imply that this is the more
cost-effective measure, for fewer resources would need to be expended to yield the same level of
benefit.
The relation between costs and effectiveness can be illustrated in the schematic graph below,
called the cost-effectiveness plane. It puts costs for a therapy and an alternative (e.g. no therapy)
into relation with the health effects achieved (e.g. mortality).
Intensivists are increasingly being asked to demonstrate whether therapies are beneficial. Due to the
evident budget restraints new therapies are increasingly judged by their cost-effectiveness. No one will
argue that intensive care saves lives. But what about new therapies that are so expensive that funding
becomes difficult? New interventions cannot be introduced without some indication of their cost or
cost-effectiveness (see the first reference below). New costs have to be justified. Society wants to
know the balance between healthcare benefit and the costs it has to pay.
A recent example of a very thorough cost-effectiveness analysis in intensive care patients is the
PROWESS study on drotrecogin in severe sepsis.
In this context we are only interested in the cost-effectiveness aspect of this paper: clearly the treated
patients were all clustered in the 'more costly, more effective' quadrant. Analysis then assessed what
the average costs were and how wide the results were scattered. The additional costs per patient
varied within a wide range as depicted by the elliptic area on the graphic below.
Costs per additional life saved were $ 160 000, which means that on an average this sum had to be
spent to make one additional patient survive who wouldn't live otherwise.
T HINK
about an expensive therapy currently in use within your unit for which costeffectiveness studies do not exist. How useful would a cost-effectiveness study have
been?
What does cost-effectiveness analysis do?
It informs us in a deeper way about the balance between costs and effects of a new therapy. By itself it
is not the tool with which to make decisions. But it helps decision makers to look at effectiveness
matters in a more transparent and explicit way.
5/ PRIORITISATION OF RESOURCES IN THE ICU
The increasingly difficult dilemma between growing demand and limited resources has already been
addressed in the introduction. The suggested way to go is quality improvement in the sense of making
better and more efficient use of our resources.
However even the very best quality improvement programme will eventually reach limits: when the
demand for intensive care services can no longer be matched by merely perfecting it within the set
financial restraints.
Who is interested in cost containment?
Depending on one's point of view the answers may be different.
Are the patient and his family interested?
Patients and their families want the best available care. If anything can be done it has to be done in
their opinion. This is especially true for healthcare systems where insurance companies or national
health services cover the costs and the patients are not billed directly.
Are the doctors and nurses interested?
Healthcare professional are trained to treat their patients to the best of their knowledge and skills. They
try to achieve optimal outcomes. They want to provide state-of-the-art care. They want their patients to
benefit from the most recent advances of medical science in an unrestricted way.
Is society in general interested?
Society in general is not interested in individual outcomes. Healthcare is just one among other
important concerns. Health politics are driven by harsh economic realities. Health agencies will be
interested in statistical health outcomes for society as a whole, or for major groups. Governments will
prefer to put the money there where as many citizens as possible will get the most health benefit.
Ironically, as healthcare professionals we belong to all three of the above groups. We are at the same
time healthcare consumers, healthcare producers and taxpayers.
Should intensive care be rationed?
Maybe this question on rationing is put the wrong way, because hidden and even overt rationing has
been practised for years. Only the general public has not been aware of this common practice.
Economists and governments tell us, that the available funding for intensive care is clearly limited. We
can no longer expect the generous allocation of resources we received decades ago. This means that
we have to make the best possible use of the structures available to us.
Let's assume intensive care would become a scarce good like water in the desert. Strategies will have
to be developed as to how to distribute the available care by rules acceptable to all.
To address the topic of rationing, two of Donabedian's seven attributes of healthcare quality have to be
considered: Acceptability and Equity (see
).
Acceptability - It means what is acceptable with respect to outcome, resource utilisation and imposed
suffering? Are the rules of rationing acceptable to society in general? Society has to accept that some
of its members will die earlier or suffer more when funding for certain fields of healthcare is limited.
Equity - This means fairness between persons and institutions of a healthcare system. Aspects of
equity in the field of intensive care are: equal access to ICU care for everyone; explicit and fair
admission and discharge rules; no implicit (informal) rationing and no discrimination for subgroups.
Based on personal experience, give examples of inequity (unfairness) in ICU care?
Restricting access
One strategy of rationing is to restrict access to the ICU. Basically, the duty of an ICU is to admit those
patients who can benefit from its services. We should not admit those for whom it brings no advantage.
Patients too sick or too healthy to benefit from the ICU should not be admitted. Also patients who
refuse ICU care should stay out. While this sounds straightforward, things are more difficult in daily
practice:




In some organisation models the intensive care physician is not sufficiently involved in the
decision to admit.
Also, in most cases it is impossible to tell early on whether a specific patient will indeed
benefit from an admission.
Often admission decisions are made with the momentarily available resources in mind. The
same patient is admitted if there is enough bed space or refused if there is not.
Explicit admission rules are often missing.
To advance the strategy of restricting access, the intensivist needs to be in a position allowing him
'fore checking' (assessment prior to ICU admission) in the emergency room, the OR or other
neighbourhood services. He should develop an admission policy based on the principles of equity.
Admissions should be refused for those unable to benefit (the dying and the too healthy).
Limiting life-sustaining treatments
Once the patient has been admitted, another strategy to make best use of the available resources
could be to restrict the level of life-sustaining treatments or their duration for specified groups of
patients. Again explicit rules, whenever possible evidence based, should be applied. It is helpful to
identify clinical situations where invasive and aggressive therapy is not beneficial and should be
replaced by palliative care.
An example of limiting the level of life-sustaining treatments is to refrain from intubation and
mechanical ventilation in certain groups of patients. Typical groups would be patients with end stage
cystic fibrosis or patients with end stage COPD.
An example of limiting the duration of life-sustaining treatments would be the group of the very
elderly patients, those above 85 years. While age by itself is not a sufficient reason for refusing
admission, an aggressive therapy trial can be limited to a certain time frame. If, within this time span,
the patient is unable to benefit from the attempted therapy but deteriorates instead, efforts would be
reduced. Very elderly patients are usually focused on a quality of life acceptable to them, but they do
not want their suffering prolonged. This approach might be fair and acceptable to all. Again, if lifesustaining treatments are to be limited because of resources available, the rules have to be explicit,
fair and acceptable to all parties involved.
Recognising futility
Futility in the ICU means that our efforts have no chance of helping the patient survive. The patients
who do not survive generate most costs in ICUs. Within their stay the last days of their lives are the
costliest.
If we could sufficiently tell the survivors apart from the nonsurvivors, we could drastically economise
our resources and spare the nonsurvivors and their families much suffering.
The problem lies with our insufficient prognostic tools. Even the most sophisticated severity scores
only give us probabilities. If a SAPS II score predicts a hospital mortality of 95% for Mr X, his chance of
surviving and leaving the hospital alive is still 5%. The more accurate clinical severity scores become
for individual prognosis the more helpful they will become for recognising futility in individual patients.
One strategy might be to compare expected mortality calculated with actual mortality observed.
Another strategy therefore to prioritise ICU resources is to identify futility as early as possible. Scoring
and outcomes research are called upon to provide such tools.
You can find further information about futility in the PACT module on Ethics
.
CONCLUSION
In this module we had the opportunity to explore the unfamiliar territories of quality assessment and
costing. We learned to appreciate relations between quality and costs. We also received an insight into
cost-effectiveness analysis. The years ahead will bring increasing financial restraints to hospital
medicine. If, as healthcare professionals we want to participate actively in the inevitable public
discussion and make a stand for our patients, we have to know the basics of costing, quality control
and cost-effectiveness analysis.
PATIENT CHALLENGES
A 45-year-old lady was admitted seven days ago to your hospital for moderate pancreatitis,
most likely due to gallstones.. There were no signs of infection. She had previously been healthy,
except for being slightly overweight and hypercholesterolaemic. She had been eating until the day of
admission. She was initially treated on a medical ward where she had an uneventful early course.
On day two her physicians decided to start her on total parenteral nutrition (TPN). A left subclavian
venous catheter was placed and its correct position documented by chest X-ray. She received nil by
mouth and her stomach was drained by nasogastric tube. She received parenteral antibiotics.
The signs of pancreatitis subsided on day four and she was without pain and had no nausea. TPN was
continued.
Learning issues
PACT module on Pancreatitis
On day five her left arm became reddened, oedematous and painful and she developed a fever. The
next evening she was shivering, hypotensive and confused. The nurses' notes on the ward clearly
described her deterioration; a reddened puncture site of the central venous line was also noted. The
resident on night duty ordered a fever medication and a mild sedative.
In the morning of day seven the patient is in septic shock and gets rushed to your ICU.
Learning issues
Relevant markers of ICU performance (1)
Relevant markers of ICU performance (2)
Approaches to describing overall performance of an ICU
Analysing performance in the ICU
Analysing the way this patient has been managed so far, what are your concerns or comments?
Were the right things done at the right time? Give reasons for your answer.
Learning issues
PACT module on Nutrition
Working with guidelines
N OTE
A good quality indicator has to:
 Address a relevant issue
 Evaluate a frequent situation
 Ask simple questions
 Give clear answers
 Be easy to assess
After admission to your ICU several blood cultures are drawn and the CVP line is removed and
cultured. The patient is volume resuscitated, but also needs vasopressors. She shows signs of the
early stages of respiratory failure and you start her on face mask CPAP. Her urinary output is reduced.
An arterial line and a PA catheter are placed and repeat haemodynamic measurements are performed.
In the evening she has to be intubated because of a developing ARDS.
Obviously as this patient is now in septic shock, the resources required to treat her will be
considerable. Poor prior management led to this situation.
Learning issues
PACT module on Severe infection
PACT module on Sepsis and MODS
What measures would you propose to lessen the likelihood of a case like this
recurring? How are the costs related to quality?
Learning
issues
Process quality
Cost-effectiveness
The next day your patient is in full blown septic shock and ARDS, renal failure is an imminent threat.
Her blood cultures reveal that she has S. aureus sepsis.
Over the next two shifts the patient requires continual care by at least two nurses and the physicians.
A vast amount of drugs and disposables is used and many diagnostic procedures are performed.
The resources required to care for this patient are considerable. You discuss the cost implications with
your colleagues.
What do you think is the most expensive cost element in the care of this patient?
Learning issues
Direct costs
How much, on average, does it cost to care for this kind of critically ill patient?
Learning issues
Assessing costs
You investigate the matter of the patient's painful swollen arm more thoroughly. Suspecting a vascular
problem you do an improvised phlebography of her left arm. The phlebogram of her left brachial vein is
shown below. The contrast in the subclavian vein is missing because it is completely occluded by a
thrombosis. Instead, a web of smaller veins bypassing the obstruction is visible.
The phlebogram confirms your suspicion of a septic subclavian thrombosis. The vein is completely
occluded, the venous blood flows through a convolute of smaller veins.
You wonder whether there are alternative technologies available to reduce the risk of septic subclavian
thrombosis. The director of the ICU tells you that there are newer CVP lines, coated with either
antiseptic agents or even antibiotics, which have been shown to reduce the risk of the adverse event
you encountered.
What issues do you have to consider in comparing the relative cost-effectiveness of different
central venous technologies?
Learning issues
Relative cost-effectiveness
After four weeks of concerted effort and care by the ICU team, the patient survives and is well enough
to be discharged to the general ward. Your team feels they did an excellent job as this critically ill
woman with multisystem disease survived her ICU course. The team is further encouraged by her
husband's strong belief that had she been in the hospital in the neighbouring town, she would not have
survived.
You are intrigued by the thought that your unit may indeed perform better than your neighbouring ICU.
Is there any way of assessing this?
Learning issues
PACT module on Clinical outcome
Indicators of process quality
Benchmarking
On the general ward, your former patient is asked to complete a customer satisfaction questionnaire
with respect to the care she has received. She responds that she simply cannot remember much about
her stay, but that her family tells her she was well cared for.
In your view, what is the value of assessing patient satisfaction in ICU patients?
N OTE
In most
aspects ICU
patients are
NOT
'customers':
They almost
always lack
choices that
are available
in the typical
customer
relationship
and in
addition, they
lack
information
and
background
knowledge
about their
therapy and
course of
illness.
A few weeks later you admit an 80-year-old man who is not as fortunate as your first patient. He
also has severe sepsis following ruptured colonic cancer.
He requires full ventilatory and renal support (continuous venovenous haemofiltration: CVVHF) and
needs a minimum of twenty nursing hours per day.
After three weeks, it becomes clear to the team that he will likely not survive his illness. Emphasis is
placed on palliative care and withdrawal of support.
Learning issues
PACT module on Acute renal failure
How would you ensure the highest quality end of life care for this patient?
N OTE
Learning issues
PACT module on Ethics
Clearly a doctor's
primary
responsibility is to
his patient. Even
when the physician
believes that chances
of successful therapy
are low he should
favour treatment.
There are though
situations in the ICU
where survival can
no longer be in the
best interest of the
patient, his family
and society in
general.
How would you go about addressing the cost-effectiveness of the care provided for this particular
patient?
Learning issues
Cost-effectiveness
N OTE
Formal assessment of cost-effectiveness is difficult for these particular cases in view of the
fact that the outcomes and the qualitative aspects of caring for the dying patient are hard
to quantify and thus, traditional cost-effectiveness ratios may fail to capture the 'value' of
the care that is provided.
Your patient dies just over three weeks after admission.
During the team's regular quality session there was a discussion about this patient's care. Some team
members thought that his death had been prolonged by the administration of futile therapy. In addition,
by performing this exercise of futility, valuable resources were not available for other patients who
could have benefited.
The decisions to limit care and to focus on palliation had been informal and vague. Team members
were frustrated that the unit was lacking a real explicit concept for making DNR orders (do not
resuscitate).
Following the team discussion you decide to assess and present a programme for improving the care
provided to the dying patient in the ICU (end of life care).
Learning issues
Recognising futility
What do you require for this programme to succeed?
Learning issues
Process quality
You present your draft proposals at the next team meeting, where there is broad, in principle,
agreement. You further discuss with the team a more formal approach to quality management.
You recall the case of the first patient who was partially a victim of questionable decisions and
dangerous events (parenteral nutrition when not indicated, CVP line with severe adverse effects).
There is a common feeling within the team that things could improve and 'something should be done to
remedy the situation'.
You are keen to use the momentum generated by the two cases to promote an enhanced quality
culture within the team. You are interested in developing a quality improvement programme,
specifically targeted to assessing and improving process quality in the ICU.
How would you set up such a programme and how can you help it to succeed?
Learning issues
Incident reporting
Working with guidelines
On reflection, what we have learned with these two cases is that process quality has much more to do with
day-to-day patient care than we think. We saw that debatable therapeutic decisions and poor performance of
invasive skills drive complications and costs.
We have realised that process quality means applying good rules and/or avoiding bad rules. Poor process
quality not only makes the patient suffer unnecessarily, it is also very costly.
Our traditional concept, that good quality is expensive and poor quality is cheap fails in view of the above
example: Poor processes are costly and smooth processes save money.
Learning
issues
Theory on costing
Q1. Which of the following quality assessment tools are suited for critically ill patients ?
A. A mailed questionnaire to assess patient satisfaction
True
False
B. Routine analysis of standardised mortality ratios (SMRs)
True
False
C. An incident/accident reporting system
True
False
D. A formal complaints management system
True
False
E. A regular appropriateness review of all admissions
True
False
A. Both expressions mean the same thing
True
False
B. Nursing costs refer to the money required to pay them (labour costs)
True
False
C. Costs are all the consumables together
True
False
D. Charges are what the patient finds on his bill
True
False
E. ICU Costs describe only the money spent in activities directly related to cases
True
False
True
False
Q2. Consider these statements regarding 'costs' and 'charges'
Q3. Consider the following cost items. Do they describe direct costs ?
A. Disinfectants used for the unit
B. Heating costs
True
False
C. i.v. antibiotics
True
False
D. Costs for physiotherapy
True
False
E. Pulmonary artery catheters
True
False
A. Top down costing accurately measures the cost per individual patient
True
False
B. Charges on the patient's bill accurately reflect costs
True
False
C. Bottom up costing is simple and accurate
True
False
D. Use of nursing activity scores is an example of costing by proxy models
True
False
E. Top down costing allows comparisons between institutions
True
False
A. Cost-effectiveness analysis tells us where to allocate money
True
False
B. Quality adjusted life years (QALYs) are simple to calculate
True
False
C. Relative cost-effectiveness is the comparison of different therapies with their costs and
outcomes
True
False
D. Opportunity costs means what it costs, when an available procedure is not applied
True
False
E. Costs per survivor is the most important denominator of cost-effectiveness in intensive
care
True
False
Q4. Read and consider the following statements on costing methods
Q5. Which of the following statements on cost-effectiveness are true and which are false ?