Citation Information :
Chacko B, Peter JV. Approach to Intensive Care Costing and Provision of Cost-effective Care. Indian J Crit Care Med 2023; 27 (12):876-887.
Intensive care unit (ICU) service is resource-intense, finite, and valuable. The outcome of critically ill patients has improved because of a better understanding of disease pathology, technological developments, and newer treatment modalities. These improvements have however come at a price, with ICUs contributing significantly to health budgets. Several costing tools are used to assess cost. Accurate assessment has been hampered by the lack of standardized methodology and the heterogeneity of ICUs. In a costing exercise, the level of disaggregation (micro-costing vs gross-costing) and the method of costing (top-down vs bottom-up) need to be considered. Intensive care unit costing also needs to be viewed from the perspective of stakeholders. While all stakeholders aim to provide quality health care, objectives may vary. For the public health care provider, the focus is on optimizing expenditure; for the private health care provider it is bottomline; for a patient, it is affordability; for an insurance service provider, it is minimizing payout; and for the regulator, it is ensuring quality standards and fair pricing. The field of health economics deals with the application of the principles of cost-minimization, cost-effectiveness, cost-utility, and cost-benefit to identify treatments that result in the best outcome at the lowest cost, without limiting resources to other competing interests. In the ICU setting, studies on the efficient use of available resources, and interventions that reduce cost and minimize avoidable cost, would not only translate to cost savings, lives saved, and quality-adjusted life years gained but also enable policymakers to better allocate health care resources.
Djeundje VB, Haberman S, Bajekal M, Lu J. The slowdown in mortality improvement rates 2011–2017: A multi-country analysis. Eur Actuar J 2022;12(2):839–878. DOI: https://doi.org/10.1007/s13385-022-00318-0.
Brown GC. Living too long: The current focus of medical research on increasing the quantity, rather than the quality, of life is damaging our health and harming the economy. EMBO Rep 2015;16(2):137–141. DOI: 10.15252/embr.201439518.
Dondorp AM, Iyer SS, Schultz MJ. Critical care in resource-restricted settings. JAMA 2016;315(8):753–754. DOI: 10.1001/jama.2016.0976.
Dondorp AM, Haniffa R. Critical care and severe sepsis in resource poor settings. Trans R Soc Trop Med Hyg 2014;108(8):453–454. DOI: 10.1093/trstmh/tru099.
Seidel J, Whiting P, Edbrooke D. The costs of intensive care. Contin Educ Anaesth Crit Care Pain 2006;6(4):160–163. DOI: 10.1093/bjaceaccp/mkl030.
Jayaram R, Ramakrishnan N. Cost of intensive care in India. Indian J Crit Care Med 2008;12(2):55–61. DOI: 10.4103/0972-5229.42558.
Adhikari NK, Fowler RA, Bhagwanjee S, Rubenfeld GD. Critical care and the global burden of critical illness in adults. Lancet 2010;376(9749):1339–1346. DOI: 10.1016/S0140-6736(10)60446-1.
Halpern NA, Pastores SM, Greenstein RJ. Critical care medicine in the United States 1985–2000: An analysis of bed numbers, use, and costs. Crit Care Med 2004;32(6):1254–1259. DOI: 10.1097/01.ccm.0000128577.31689.4c.
van Zyl-Smit R, Burch V, Willcox P. The need for appropriate critical care service provision at non-tertiary hospitals in South Africa. S Afr Med J 2007;97(4):268, 270, 272. PMID: 17446951.
Rungta N, Zirpe KG, Dixit SB, Mehta Y, Chaudhry D, Govil D, et al. Indian Society of critical care medicine experts committee consensus statement on ICU planning and designing, 2020. Indian J Crit Care Med 2020;24(Suppl 1):S43–S60. DOI: 10.5005/jp-journals-10071-G23185.
The World Bank. Current health expenditure (% of GDP). The World Bank 2023. Available from: https://data.worldbank.org/indicator/SH.XPD.CHEX.GD.ZS.
The Economic Times. India's disproportionately tiny health budget: A national security concern?. The Economic Times, 2023. Available from: https://economictimes.indiatimes.com/industry/healthcare/biotech/healthcare/indias-disproportionately-tiny-health-budget-a-national-security-concern/articleshow/49603121.cms.
The Times of India. ‘Covid ICU costs equal to 7-month pay for average Indian.’ The Times of India, 2021. Available from: https://timesofindia.indiatimes.com/india/covid-icu-costs-equal-to-7-month-pay-for-average-indian/articleshow/84600389.cms.
Newsweek 90. India's cost of Covid ICU care treatment equals 16 months of pay for day laborers. Newsweek 90, 2021. Available from: https://www.newsweek.com/indias-cost-covid-icu-care-treatment-equals-16-months-pay-day-laborers-1613113.
Murthy S, Adhikari NK. Global health care of the critically ill in low-resource settings. Ann Am Thorac Soc 2013;10(5):509–513. DOI: 10.1513/AnnalsATS.201307-246OT.
Hicks P, Huckson S, Fenney E, Leggett I, Pilcher D, Litton E. The financial cost of intensive care in Australia: A multicentre registry study. Med J Aust 2019;211(7):324–325. DOI: 10.5694/mja2.50309.
Mahomed S, Mahomed OH. Cost of intensive care services at a central hospital in South Africa. S Afr Med J 2018;109(1):35–39. DOI: 10.7196/SAMJ.2018.v109i1.13268.
Hung TM, Van Hao N, Yen LM, McBride A, Dat VQ, van Doorn HR, et al. Direct medical costs of tetanus, dengue, and sepsis patients in an intensive care unit in Vietnam. Front Public Health 2022;10:893200. DOI: 10.3389/fpubh.2022.893200.
Parikh CR, Karnad DR. Quality, cost, and outcome of intensive care in a public hospital in Bombay, India. Crit Care Med 1999;27(9):1754–1759. DOI: 10.1097/00003246-199909000-00009.
Shweta K, Kumar S, Gupta AK, Jindal SK, Kumar A. Economic analysis of costs associated with a Respiratory Intensive Care Unit in a tertiary care teaching hospital in Northern India. Indian J Crit Care Med 2013;17(2):76–81. DOI: 10.4103/0972-5229.114822.
Kulkarni AP, Divatia JV. A prospective audit of costs of intensive care in cancer patients in India. Indian J Crit Care Med 2013;17(5):292–297. DOI: 10.4103/0972-5229.120321.
Thomas K, Peter JV, Christina J, Jagadish AR, Rajan A, Lionel P, et al. Cost-utility in medical intensive care patients. Rationalizing ongoing care and timing of discharge from intensive care. Ann Am Thorac Soc 2015;12(7):1058–1065. DOI: 10.1513/AnnalsATS.201411-527OC.
Singh T, Sk Pillai J, Sahoo MC. How much does it cost for a surgical ICU bed in a public hospital in India. Risk Manag Healthc Policy 2021;14:4149–4154. DOI: 10.2147/RMHP.S324551.
Peter JV, Thomas K, Jeyaseelan L, Yadav B, Sudarsan TI, Christina J, et al. Cost of intensive care in India. Int J Technol Assess Health Care 2016;32(4):241–245. DOI: 10.1017/S0266462316000398.
Cox HL, Laupland KB, Manns BJ. Economic evaluation in critical care medicine. J Crit Care 2006;21(2):117–124. DOI: 10.1016/j.jcrc.2006.02.003.
News Medical Life Sciences. What is the role of regulatory bodies in healthcare? News-Medical.net, 2021. Available from: https://www.news-medical.net/health/What-is-the-Role-of-Regulatory-Bodies-in-Healthcare.aspx.
Roberts RR, Frutos PW, Ciavarella GG, Gussow LM, Mensah EK, Kampe LM, et al. Distribution of variable vs fixed costs of hospital care. JAMA 1999;281(7):644–649. DOI: 10.1001/jama.281.7.644.
The Balance. What is opportunity cost? The Balance, 2022. Available from: https://www.thebalancemoney.com/what-is-opportunity-cost-357200.
Olivera MJ. Opportunity cost and COVID-19: A perspective from health economics. Med J Islam Repub Iran 2020;34:177. DOI: 10.47176/mjiri.34.177.
Hübner C, Ried W, Flessa S. Assessing the opportunity costs of patients with multidrug-resistant organisms in hospitals. Eur J Health Econ 2018;19(7):1009–1017. DOI: 10.1007/s10198-017-0949-8.
Abu Al-Saad N, Skedgel C, Nortje J. Principles of resource allocation in critical care. BJA Educ 2017;17(12):390–395. DOI: https://doi.org/10.1093/bjaed/mkx029.
Špacírová Z, Epstein D, García-Mochón L, Rovira J, Olry de Labry Lima A, Espín J. A general framework for classifying costing methods for economic evaluation of health care. Eur J Health Econ 2020;21(4): 529–542. DOI: 10.1007/s10198-019-01157-9.
Tan SS, Rutten FFH, van Ineveld BM, Redekop WK, Hakkaart-van Roijen L. Comparing methodologies for the cost estimation of hospital services. Eur J Health Econ 2009;10(1):39–45. DOI: 10.1007/s10198-008-0101-x.
Niñerola A, Hernández-Lara AB, Sánchez-Rebull MV. Improving healthcare performance through activity-based costing and time-driven activity-based costing. Int J Health Plann Manage 2021;36(6):2079–2093. DOI: 10.1002/hpm.3304.
Mastrogianni M, Galanis P, Kaitelidou D, Konstantinou E, Fildissis G, Katsoulas T. Factors affecting adult intensive care units costs by using the bottom-up and top-down costing methodology in OECD countries: A systematic review. Intensive Crit Care Nurs 2021;66:103080. DOI: 10.1016/j.iccn.2021.103080.
Ricci de Araújo T, Papathanassoglou E, Gonçalves Menegueti M, Grespan Bonacim CA, Lessa do Valle Dallora ME, de Carvalho Jericó M, et al. Critical care nursing service costs: Comparison of the top-down versus bottom-up micro-costing approach in Brazil. J Nurs Manag 2021;29(6):1778–1784. DOI: 10.1111/jonm.13313.
Tan SS, Bakker J, Hoogendoorn ME, Kapila A, Martin J, Pezzi A, et al. Direct cost analysis of intensive care unit stay in four European countries: Applying a standardized costing methodology. Value Health 2012;15(1):81–86. DOI: 10.1016/j.jval.2011.09.007.
Wilcox ME, Vaughan K, Chong CAKY, Neumann PJ, Bell CM. Cost-effectiveness studies in the ICU: A systematic review. Crit Care Med 2019;47(8):1011–1017. DOI: 10.1097/CCM.0000000000003768.
Richards BF, Fleming JB, Shannon CN, Walters BC, Harrigan MR. Safety and cost effectiveness of step-down unit admission following elective neurointerventional procedures. J Neurointerventional Surg 2012;4(5):390–392. DOI: 10.1136/neurintsurg-2011-010058.
Bassin BS, Haas NL, Sefa N, Medlin R, Peterson TA, Gunnerson K, et al. Cost-effectiveness of an Emergency Department-Based Intensive Care Unit. JAMA Netw Open 2022;5(9):e2233649. DOI: 10.1001/jamanetworkopen.2022.33649.
Seneff MG, Wagner D, Thompson D, Honeycutt C, Silver MR. The impact of long-term acute-care facilities on the outcome and cost of care for patients undergoing prolonged mechanical ventilation. Crit Care Med 2000;28(2):342–350. DOI: 10.1097/00003246-200002000-00009.
Stevens K, McCabe C, Jones C, Ashcroft J, Harvey S, Rowan K, et al. The incremental cost effectiveness of withdrawing pulmonary artery catheters from routine use in critical care. Appl Health Econ Health Policy 2005;4(4):257–264. DOI: 10.2165/00148365-200504040-00008.
Westwood M, Ramaekers B, Whiting P, Tomini F, Joore M, Armstrong N, et al. Procalcitonin testing to guide antibiotic therapy for the treatment of sepsis in intensive care settings and for suspected bacterial infection in emergency department settings: A systematic review and cost-effectiveness analysis. Health Technol Assess 2015;19(96):v–xxv, 1–236. DOI: 10.3310/hta19960.
Pliakos EE, Andreatos N, Shehadeh F, Ziakas PD, Mylonakis E. The Cost-effectiveness of rapid diagnostic testing for the diagnosis of bloodstream infections with or without antimicrobial stewardship. Clin Microbiol Rev 2018;31(3):e00095–e000117. DOI: 10.1128/CMR.00095-17.
Scott J, Waite S, Napolitano A. Restricting daily chest radiography in the intensive care unit: Implementing evidence-based medicine to decrease utilizationt. J Am Coll Radiol 2021;18(3 Pt A):354–360. DOI: 10.1016/j.jacr.2020.05.035.
Chen J, Sun D, Yang W, Liu M, Zhang S, Peng J, et al. Clinical and economic outcomes of telemedicine programs in the intensive care unit: A systematic review and meta-analysis. J Intensive Care Med 2018;33(7):383–393. DOI: 10.1177/0885066617726942.
Hamel MB, Phillips RS, Davis RB, Teno J, Connors AF, Desbiens N, et al. Outcomes and cost-effectiveness of ventilator support and aggressive care for patients with acute respiratory failure due to pneumonia or acute respiratory distress syndrome. Am J Med 2000;109(8):614–620. DOI: 10.1016/s0002-9343(00)00591-x.
Mayer SA, Copeland D, Bernardini GL, Boden-Albala B, Lennihan L, Kossoff S, et al. Cost and outcome of mechanical ventilation for life-threatening stroke. Stroke 2000;31(10):2346–2353. DOI: 10.1161/01.str.31.10.2346.
Cooke CR, Kahn JM, Watkins TR, Hudson LD, Rubenfeld GD. Cost-effectiveness of implementing low-tidal volume ventilation in patients with acute lung injury. Chest 2009;136(1):79–88. DOI: 10.1378/chest.08-2123.
Rotta BP, da Silva JM, Fu C, Goulardins JB, Pires-Neto R de C, Tanaka C. Relationship between availability of physiotherapy services and ICU costs. J Bras Pneumol 2018;44(3):184–189. DOI: 10.1590/S1806-37562017000000196.
Hamel MB, Phillips RS, Davis RB, Desbiens N, Connors AF, Teno JM, et al. Outcomes and cost-effectiveness of initiating dialysis and continuing aggressive care in seriously ill hospitalized adults. SUPPORT Investigators. Study to understand prognoses and preferences for outcomes and risks of treatments. Ann Intern Med 1997;127(3): 195–202. DOI: 10.7326/0003-4819-127-3-199708010-00003.
Desai AA, Baras J, Berk BB, Nakajima A, Garber AM, Owens D, et al. Management of acute kidney injury in the intensive care unit: A cost-effectiveness analysis of daily vs alternate-day hemodialysis. Arch Intern Med 2008;168(16):1761–1767. DOI: 10.1001/archinte.168. 16.1761.
Jones AE, Troyer JL, Kline JA. Cost-effectiveness of an emergency department-based early sepsis resuscitation protocol. Crit Care Med 2011;39(6):1306–1312. DOI: 10.1097/CCM.0b013e31821201be.
Noritomi DT, Ranzani OT, Monteiro MB, Ferreira EM, Santos SR, Leibel F, et al. Implementation of a multifaceted sepsis education program in an emerging country setting: Clinical outcomes and cost-effectiveness in a long-term follow-up study. Intensive Care Med 2014;40(2):182–191. DOI: 10.1007/s00134-013-3131-5.
Manns BJ, Lee H, Doig CJ, Johnson D, Donaldson C. An economic evaluation of activated protein C treatment for severe sepsis. N Engl J Med 2002;347(13):993–1000. DOI: 10.1056/NEJMsa020969.
Socal MP, Cordeiro T, Anderson GF, Bai G. Estimating savings opportunities from therapeutic substitutions of high-cost generic medications. JAMA Netw Open 2022;5(11):e2239868. DOI: 10.1001/jamanetworkopen.2022.39868.
Rosenthal VD, Udwadia FE, Kumar S, Poojary A, Sankar R, Orellano PW, et al. Clinical impact and cost-effectiveness of split-septum and single-use prefilled flushing device vs 3-way stopcock on central line-associated bloodstream infection rates in India: A randomized clinical trial conducted by the International Nosocomial Infection Control Consortium (INICC). Am J Infect Control 2015;43(10):1040–1045. DOI: 10.1016/j.ajic.2015.05.042.
Siddiqui UT, Tahir MZ, Shamim MS, Enam SA. Clinical outcome and cost effectiveness of early tracheostomy in isolated severe head injury patients. Surg Neurol Int 2015;6:65. DOI: 10.4103/2152-7806.155757.
Herritt B, Chaudhuri D, Thavorn K, Kubelik D, Kyeremanteng K. Early vs. late tracheostomy in intensive care settings: Impact on ICU and hospital costs. J Crit Care 2018;44:285–288. DOI: 10.1016/j.jcrc.2017.11.037.
Kyeremanteng K, Gagnon LP, Thavorn K, Heyland D, D'Egidio G. The impact of palliative care consultation in the ICU on length of stay: A systematic review and cost evaluation. J Intensive Care Med 2018;33(6):346–353. DOI: 10.1177/0885066616664329.
Peek GJ, Mugford M, Tiruvoipati R, Wilson A, Allen E, Thalanany MM, et al. Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): A multicentre randomised controlled trial. Lancet Lond Engl 2009;374(9698):1351–1363. DOI: 10.1016/S0140-6736(09)61069-2.
Park M, Mendes PV, Zampieri FG, Azevedo LCP, Costa ELV, Antoniali F, et al. The economic effect of extracorporeal membrane oxygenation to support adults with severe respiratory failure in Brazil: A hypothetical analysis. Rev Bras Ter Intensiva 2014;26(3):253–262. DOI: 10.5935/0103-507X.20140036.
Smith KJ, Pesce RR. Pulmonary artery catheterization in exacerbations of COPD requiring mechanical ventilation: A cost-effectiveness analysis. Respir Care 1994;39(10):961–967. PMID: 10146114.
Chacko B, Thomas K, David T, Paul H, Jeyaseelan L, Peter JV. Attributable cost of a nosocomial infection in the intensive care unit: A prospective cohort study. World J Crit Care Med 2017;6(1):79–84. DOI: 10.5492/wjccm.v6.i1.79.
Dziegielewski C, Skead C, Canturk T, Webber C, Fernando SM, Thompson LH, et al. Delirium and associated length of stay and costs in critically ill patients. Crit Care Res Pract 2021;2021:6612187. DOI: 10.1155/2021/6612187.
Bagshaw SM, Tran DT, Opgenorth D, Wang X, Zuege DJ, Ingolfsson A, et al. Assessment of costs of avoidable delays in intensive care unit discharge. JAMA Netw Open 2020;3(8):e2013913. DOI: 10.1001/jamanetworkopen.2020.13913.
Sud S, Mittmann N, Cook DJ, Geerts W, Chan B, Dodek P, et al. Screening and prevention of venous thromboembolism in critically ill patients: A decision analysis and economic evaluation. Am J Respir Crit Care Med 2011;184(11):1289–1298. DOI: 10.1164/rccm.201106-1059OC.
Cox CE, Carson SS, Govert JA, Chelluri L, Sanders GD. An economic evaluation of prolonged mechanical ventilation. Crit Care Med 2007;35(8):1918–1927. DOI: 10.1097/01.CCM.0000275391.35834.10.
De Cock E, Krueger WA, Sorensen S, Baker T, Hardewig J, Duttagupta S, et al. Cost-effectiveness of linezolid vs vancomycin in suspected methicillin-resistant Staphylococcus aureus nosocomial pneumonia in Germany. Infection 2009;37(2):123–132. DOI: 10.1007/s15010-008-8046-7.
Heyland DK, Konopad E, Noseworthy TW, Johnston R, Gafni A. Is it “worthwhile” to continue treating patients with a prolonged stay (>14 days) in the ICU? An economic evaluation. Chest 1998;114(1):192–198. DOI: 10.1378/chest.114.1.192.
Sznajder M, Aegerter P, Launois R, Merliere Y, Guidet B, CubRea. A cost-effectiveness analysis of stays in intensive care units. Intensive Care Med 2001;27(1):146–153. DOI: 10.1007/s001340000760.
Graf J, Wagner J, Graf C, Koch KC, Janssens U. Five-year survival, quality of life, and individual costs of 303 consecutive medical intensive care patients–A cost-utility analysis. Crit Care Med 2005;33(3):547–555. DOI: 10.1097/01.ccm.0000155990.35290.03.
van Mastrigt GA, Heijmans J, Severens JL, Fransen EJ, Roekaerts P, Voss G, et al. Short-stay intensive care after coronary artery bypass surgery: Randomized clinical trial on safety and cost-effectiveness. Crit Care Med 2006;34(1):65–75. DOI: 10.1097/01.ccm.0000191266.72652.fa.
Ridley S, Morris S. Cost effectiveness of adult intensive care in the UK. Anaesthesia 2007;62(6):547–554. DOI: 10.1111/j.1365-2044.2007.04997.x.
Graf J, Mühlhoff C, Doig GS, Reinartz S, Bode K, Dujardin R, et al. Health care costs, long-term survival, and quality of life following intensive care unit admission after cardiac arrest. Crit Care 2008;12(4):R92. DOI: 10.1186/cc6963.
Linko R, Suojaranta-Ylinen R, Karlsson S, Ruokonen E, Varpula T, Pettilä V, et al. One-year mortality, quality of life and predicted life-time cost-utility in critically ill patients with acute respiratory failure. Crit Care 2010;14(2):R60. DOI: 10.1186/cc8957.
Cubro H, Somun-Kapetanovic R, Thiery G, Talmor D, Gajic O. Cost effectiveness of intensive care in a low resource setting: A prospective cohort of medical critically ill patients. World J Crit Care Med 2016;5(2):150–164. DOI: 10.5492/wjccm.v5.i2.150.