D DAVID PUBLISHING. Cost Analysis of an Intensive Care Unit. 1. Introduction

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1 Journal of Pharmacy and Pharmacology 2 (2014) D DAVID PUBLISHING Daria Putignano 1, Federico Fedele Di Maio 1, Valentina Orlando 1, Aniello De Nicola 2 and Enrica Menditto 1 1. Department of Pharmacy, CIRFF-Center of Pharmacoeconomics, University Federico II of Naples 80131, Italy 2. Department of Anaesthesia and Intensive Care Unit, San Leonardo Hospital, Castellammare di Stabia 80053, Italy Abstract: We proposed a retrospective cost analysis of patients hospitalized in the intensive care unit of San Leonardo Hospital (Southern-Italy), stratified for diagnostic groups at hospital admission in 2010, from National Health Service perspective. The cost analysis was performed on patients with a length of stay longer than 24 hours. Direct medical costs were estimated: hospitalization costs and surgical procedures were calculated by tariff system DRG (diagnosis related group) while device-related costs were provided by the management of the hospital pharmacy. In order to evaluate the burden of the diagnostic groups, we used two indicators proposed by Rossi C. et al.: cost per surviving patient and money loss per patient. The most frequent admission diagnoses were edema (16.4%) and left heart failure (13.9%). There was a wide variation in the mean costs per patient (from 2,777 for stroke to 7,227 for nephro-urological disease). Intracranial bleeding had the highest cost for dead and survived patients, whereas neurological diseases and COPD (chronic obstructive pulmonary disease) had the lowest costs, indicating a better efficiency. Our findings are a starting point for further investigations aimed at the exploitation of resources that are currently being absorbed by ICU (intensive care unit), in order to provide patients with the best possible healthcare. Key words: Cost-analysis, intensive care unit, economic evaluation, bottom up. 1. Introduction During the last 10 years, relevant changes in the socio-economic situation in the world have altered the structure of healthcare systems. The objective of interventions performed on healthcare system has been to contain healthcare costs without sacrificing the right to appropriate healthcare. In this context, the organizational and functional transformation of hospitals, as well as the ability to adapt to scientific and technological innovation, has assumed particular importance for complex healthcare services. A large reshaping of the public hospital network has taken place in Italy. The hospital has evolved from being a large and undifferentiated place of hospitalization to an intensive care and criticality area. The number of public hospitals, as well as the number of beds, was decreased by approximately 18% [1] between 2001 and However, this reduction was not homogeneous but depended largely on the specific Corresponding author: Daria Putignano, Pharm.D., research field: pharmacoeconomics. daria.putignano@gmail.com. wards. There was a decrease in the number of beds for wards such as general surgery, pediatrics and infectious diseases, but an increase for intensive care [1]. ICU (intensive care unit) is still one of the most resource-consuming wards in hospitals. The high expenditures for ICUs are due to costs for highly trained and experienced staff, equipment and diagnostic tests, drugs and other therapeutic interventions. Calculating costs of ICU is helpful in assessing intensity of interventions and analyzing patient characteristics, while identification of cost drivers leads to optimum utilization of resources [2]. Several studies have assessed the costs of ICUs so far. However, the cost estimations for ICU stay are heterogeneous. Potential factors influencing actual cost differences include variations in study setting (e.g., bed occupancy rate, density of acute care beds and staff composition), variations in medical practice (e.g., emergency retrievals, referral pattern and use of mechanical ventilation), the availability of healthcare resources, the hospital payment system (e.g., public/private-mix and insurance payment) and

2 502 relative and absolute prices between countries [3, 4]. There is a lack of overviews on costs of ICU in Italy. We propose a retrospective cost analysis of patients hospitalized in ICU of San Leonardo Hospital (Southern-Italy), stratified for diagnostic groups at hospital admission in 2010, from National Health Service perspective. 2. Materials and Methods 2.1 Sample Selection We performed a retrospective cost analysis. Information regarding all adult patients (older than 18 years), admitted to ICU of the Hospital San Leonardo in Castellammare di Stabia (Campania Region Southern Italy) in 2010 was retrieved. Patients were stratified for diagnostic groups at hospital admission (left and right heart failure, cardiac arrest, heart attack, stroke, chronic obstructive pulmonary disease, edema, pleural effusion, neurological failure, intestinal infarction, fibrillation, intracranial bleeding, renal pathology). Information regarding admission diagnoses was retrieved by hospital discharge records based on ICD-9-CM coding system. Patients admitted to ICU came from emergency department, medical ward, surgical ward or operating room. Demographic and clinical information of all patients (age, sex, weight, height, condition of admission to intensive care, outcome of hospitalization, length of stay, devices and surgical procedures performed) were collected anonymously in accordance with Legislative Decree 196/ Cost Analysis The cost analysis was performed on patients with a length of stay longer than 24 hours. The methodology used for the assessment of costs was the bottom-up. We preferred the bottom-up approach because it values each cost component for individual patient. This approach enables statistical analyses aimed to the detection of cost differences among patients and among cost components [5]. Direct medical costs were estimated (hospitalization, surgical procedures, devices). The costs of hospitalizations and surgical procedures were calculated based on the 24.0 version of the tariff system DRG (diagnosis related group). When more rates existed for an event, we considered the average cost weighted by frequency according to the latest available information on hospital admissions in Italy. Information on costs of the devices was provided by the management of the hospital pharmacy of San Leonardo Hospital. We excluded the variable costs of the department, such as drugs, blood and blood products, blood tests, microbiological tests, diagnostic imaging and costs of personnel. The total cost was computed by multiplying the amount of resources adsorbed by the unit cost in 2010, by using price and tariffs applied in that year. Values were expressed in Euro at the time of the analysis. The cost per patient was calculated as mean cost per patient. The means were used as central tendency parameters, expressed as a mean cost per patient. This parameter can be easily used to make projections on different populations and moreover, it is of easy use for policy makers. In order to evaluate the burden of the diagnostic groups, we chose to use two indicators proposed by Rossi et al. [6]: cost per surviving patient (total resources used/total survivors) and money loss per patient (total resources used for dead patients/total patients). These two measures were represented in a scatter plot of the efficiency of resource consumption. The analysis was conducted from the perspective of the third party payer the NHS (national healthcare service), which in Italy is in charge of financing and providing healthcare services. The analysis was carried out using Microsoft Excel Results A total of 201 patients were included in the study. Baseline characteristics for the whole study population

3 503 Table 1. Baseline characteristics of the study sample. Overall population (N = 201) Male 103 (51.2) Age, mean (SD) 69.3 (14.7) Patients over 75 years 82 (40.8) Admission in ICU from Emergency ward 98 (48.8) Medical ward 46 (22.9) ICU (other hospital) 9 (4.5) Surgical ward 24 (11.9) Operating room 24 (11.9) Length of stay in ICU, mean (SD) 10.5 (12.0) Patients with Length of stay shorter than 9 (4.5) 24 hours 24 hours Patients with Length of stay longer than 192 (95.5) 24 hours (N, %) Patients died in ICU 108 (56.3) were reported in Table 1. Mean age (SD) was 69 (14.7) years with 51.2% male enrolled in ICU of San Leonardo Hospital. Over 75 years patients represented 41.0% of total. Patients admitted to ICU came from emergency department (48.8%), medical ward (22.9%), other ICU (4.5%), surgical ward (11.9%) or operating room (11.9%). Mortality in ICU was 56.3%. The most frequent diagnostic groups were: edema (16.4%), left heart failure (13.9%) and chronic obstructive pulmonary disease (9.0%) (Fig. 1). A total amount of 192 patients (95.5%) with a length of stay longer than 24 hours was included in the cost analysis. The highest total cost was for left heart failure ( ). Average cost/patient varied widely across diseases. The mean cost per patient of treating nephro-urological disease was 7,227, whereas it was 2,777 for a stroke. Most variability was due to the difference in the length of stay. Table 2 shows cost and cost structure for each diagnostic group. Fig. 2 plots the two measures: cost per surviving patient and money loss per patient. Intracranial bleeding is the only disease with the highest cost for dead and survived patients, while neurological diseases and COPD have the lowest costs, indicating a better efficiency. 4. Discussion The need for reliable economic information on the quantity and quality of resources consumed in the ICU represents an important issue for both national and international realities. Despite the need for cost data, there are still few investigations on the real costs of Figure. 1 Most frequent diagnostic group.

4 504 Table 2. Costs, costs structure, extra days of hospitalization threshold per diagnostic group. Diagnostic group (N) Total ( ) Cost Average cost/patient ( ) Hospitalization Cost structure Consumables Nutrition Extra days of hospitalization threshold Surgical Mortality Alive Dead Procedures in ICU patients patients Left heart failure (26) 141,809 5, Edema (32) 119,958 3, COPD (17) 74,229 4, Intestinal infarction (13) 59,651 4, Cardiac arrest (13) 57,975 4, Neurological Failure (15) 56,586 3, Intracranial bleending (10) 41,336 4, Fibrillation (10) 41,215 4, Heart attack (7) 38,846 5, Right heart failure (8) 35,107 4, Stroke (10) 27,770 2, Renal pathology (3) 21,682 7, Pleural effusion (2) 10,913 5, Figure 2. Two-dimensional representation of the cost of treating different conditions in terms of cost per surviving patient and money loss per patient. ICU based on the individual patient s resource usage [7-10]. Moreover, the comparison of studies on the cost of ICU is often difficult, due to the use of varying methods of cost calculation [2, 5, 11]. Many studies

5 505 are based on ICU annual expenditures or budget, from which the costs are broken down for the number of patients and the days spent in the ICU [12-14], charges [15, 16] or cost to charge ratios [17-19] to analyze the cost of ICU care. It has been shown that in the United States ICU departments consumed 22% of total hospital costs [20]. Also, the costs of ICU departments in the Netherlands have been estimated to represent approximately 20% of the total hospital budget, with the costs per day between threefold and fivefold greater in ICU departments than in general wards [3, 18]. Studies from different European countries found mean daily costs ranging between 1,125 and 1,590 per day [9, 10, 13, 20, 22-24]. In a multicenter German study, Moerer et al. [25] reported that the mean total costs per patient and day were 791 ± 305, with 19.4% of the patients costing more than 1,000 per day and a maximum of 2,815 per patient-day (inflated to 2008). At the extreme point, the total costs per day at ICU departments in the United States were 3,221 (inflated to 2008) [26]. Evidence regarding ICU costs in Italy was showed in 2004 by GiViTI MargheritaDue Project which represented the first initiative to evaluate ICU organization and performances in Italy. More than 150 Italian ICUs participated in the project. Through the continuous collection of the data, in electronic format, relating to patients admitted to the ICU, it was possible for the first time to analyze the activities carried out in the ICU in terms of clinical outcomes and resource use. Thanks to computerized patient data management system in the ICU, the analysis of direct cost was easier. The main findings showed that the mean value of variable cost per patient was 1,715 [27]. 5. Conclusion Our findings showed that the clinical characteristics of the patients enrolled corresponded with the typical range of this department. The greatest number of patients admitted to the ICU came from emergency departments. Edema, left heart failure and COPD were the most frequent diseases of admission. These patients were very heterogeneous in terms of disease severity, length and complexity of treatment. In our cost analysis of ICU, based on bottom up approach, the direct costs (hospitalization, surgical procedures and devices) were considered. We excluded costs of the department such as drugs, blood and blood products, blood tests, microbiological tests, diagnostic imaging, the fixed costs of the department as personnel and the costs of the structure. This exclusion on the one hand represented a limitation of the study, but on the other hand made our analysis more stable, as variable costs were not included. The results showed that the total costs were widely heterogeneous among the different diagnostic groups within the ICU. The left heart failure (total cost 141,809), edema (total cost 119,958) and chronic obstructive pulmonary disease (total cost 74,229) were the most expensive diseases for ICU department. These results are similar to those already present in the scientific literature [6]. This information is important for health care providers who need to balance the costs and benefits of ICU against those of other types of health care. Another important variable factor was the outcomes. There was a marked difference in cost between survived patients and died patients within the same diagnostic group. It is clear that there are two aspects to take into account: on the one hand, an economic problem about accurate management of resources; on the other hand, ethical issues. The head ICU physician plays a key role in the continuing search for new and more effective treatments and, when possible, cost-effectiveness. This work provides some useful information to reflect upon economic costs in the ICU operating today in our country. Despite the limitations, the results can represent a starting point for further investigations aimed at the exploitation of resources absorbed by ICU to provide patients with the best

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