Cost of Chronic Critically Ill Patients to the Healthcare System: A Single-center Experience from a Developing Country
Süleyman Yıldırım, Yusuf Durmaz, Yosun Şan, İmren Taşkıran, Burcu A Cinleti, Cenk Kirakli
Citation Information :
Yıldırım S, Durmaz Y, Şan Y, Taşkıran İ, Cinleti BA, Kirakli C. Cost of Chronic Critically Ill Patients to the Healthcare System: A Single-center Experience from a Developing Country. Indian J Crit Care Med 2021; 25 (5):519-523.
Background: An increasing number of patients become chronic critically ill (CCI) and dependent on long-term therapies in the intensive care unit (ICU). Mortality and healthcare costs increase in these patients. In order to deal with this problem, the magnitude and risk factors for CCI must first be determined. Therefore, we aimed at evaluating the incidence cost and risk factors for CCI in our ICU.
Materials and methods: This retrospective cohort study was compiled by recruiting patients admitted to our ICU between January 1, 2017, and December 31, 2018. Patients with an ICU stay of more than 21 days were defined as CCI. Patients who did not survive in the first 21 days were excluded from the study because it could be not known whether these patients would progress to CCI. During the study period, 1,166 patients were followed up, and 475 (40%) of them were excluded and 691 patients were included in the final analyses.
Results: During the study period, 691 patients were included in the study and 152 of them (22%) were CCI. Age, acute physiology and chronic health evaluation (APACHE)-2 score, length of stay, and daily costs were higher in patients with CCI. The cost for a patient with CCI is sixfold that of a patient without CCI. ICU mortality was 47% in patients without CCI and 54% in the CCI patients (p < 0.001).
Conclusion: CCI affects an increasing number of patients and leads to increased mortality rates and cost. Prolonged duration in ICU may cause complications such as secondary infections, sepsis episodes, and acute renal injury. The treatment of these complications may lead to increased mortality and cost.
Carson SS, Bach PB. The epidemiology and costs of chronic critical illness. Crit Care Clin 2002;18(3):461–476. DOI: 10.1016/s0749-0704(02)00015-5.
Loss SH, Marchese CB, Boniatti MM, Wawrzeniak IC, Oliveira RP, Nunes LN, et al. Prediction of chronic critical illness in a general intensive care unit. Rev Assoc Med Bras 2013;59(3):241–247. DOI: 10.1016/j.ramb.2012.12.002.
Loss SH, De Oliveira RP, Maccari JG, Savi A, Boniatti MM, Hetzel MP, et al. The reality of patients requiring prolonged mechanical ventilation: a multicenter study. Rev Bras Ter Intensiva 2015;27(1):26–35. DOI: 10.5935/0103-507X.20150006.
Loss SH, Nunes DSL, Franzosi OS, Salazar GS, Teixeira C, Vieira SRR. Chronic critical illness: are we saving patients or creating victims? Rev Bras Ter Intensiva 2017;29(1):87–95. DOI: 10.5935/0103-507X.20170013.
Bigatello LM, Stelfox HT, Berra L, Schmidt U, Gettings EM. Outcome of patients undergoing prolonged mechanical ventilation after critical illness. Crit Care Med 2007;35(11):2491–2497. DOI: 10.1097/01.CCM.0000287589.16724.B2.
Estenssoro E, Reina R, Canales HS, Saenz MG, Gonzalez FE, Aprea MM, et al. The distinct clinical profile of chronically critically ill patients: a cohort study. Crit Care 2006;10(3):1–9. DOI: 10.1186/cc4941.
Gould C V., Rothenberg R, Steinberg JP. Antibiotic resistance in long-term acute care hospitals: the perfect storm. Infect Control Hosp Epidemiol 2006;27(9):920–925. DOI: 10.1086/507280.
Kalb TH, Lorin S. Infection in the chronically critically ill: unique risk profile in a newly defined population. Crit Care Clin 2002;18(3):529–552. DOI: 10.1016/s0749-0704(02)00009-x.
Cabrera-Cancio MR. Infections and the compromised immune status in the chronically critically ill patient: prevention strategies. Respir Care 2012;57(6):979–990. DOI: 10.4187/respcare.01621.
Kahn JM, Le T, Angus DC, Cox CE, Hough CL, White DB, et al. The epidemiology of chronic critical illness in the United States. Crit Care Med 2015;43(2):282–287. DOI: 10.1097/CCM.0000000000000710.
Zilberberg MD, De Wit M, Pirone JR, Shorr AF. Growth in adult prolonged acute mechanical ventilation: implications for healthcare delivery. Crit Care Med 2008;36(5):1451–1455. DOI: 10.1097/CCM.0b013e3181691a49.
Kao KC, Hu HC, Fu JY, Hsieh MJ, Wu YK, Chen YC, et al. Renal replacement therapy in prolonged mechanical ventilation patients with renal failure in Taiwan. J Crit Care 2011;26(6):600–607. DOI: 10.1016/j.jcrc.2011.03.005.
Marchioni A, Tonelli R, Sdanganelli A, Gozzi F, Musarò L, Fantini R, et al. Prevalence and development of chronic critical illness in acute patients admitted to a respiratory intensive care setting. Pulmonology 2020;26(3):151–158. DOI: 10.1016/j.pulmoe.2019.09.006.
Jeffcote T, Foong M, Gold G, Glassford N, Robbins R, Iwashyna TJ, et al. Patient characteristics, ICU-specific supports, complications, and outcomes of persistent critical illness. J Crit Care 2019;54:250–255. DOI: 10.1016/j.jcrc.2019.08.023.
Yildirim F, Karabacak H, Kaya IO. Factors affecting weaning failure in critically-ill patients undergoing emergency gastrointestinal surgery. J Crit Intensive Care 2020;11(1):8–14. DOI: 10.37678/dcybd.2020.2199.
Muzaffar SN, Gurjar M, Baronia AK, Azim A, Mishra P, Poddar B, et al. Preditores, padrão de desmame e desfecho em longo prazo de pacientes com ventilação mecânica prolongada em unidade de terapia intensiva no norte da Índia. Rev Bras Ter Intensiva 2017;29(1):23–33. DOI: 10.5935/0103-507x.20170005.
Boniatti MM, Friedman G, Castilho RK, Vieira SRR, Fialkow LA. Characteristics of chronically critically ill patients: comparing two definitions. Clinics 2011;66(4):701–704. DOI: 10.1590/s1807-59322011000400027.
Keenan SP, Sinuff T, Cook DJ, Hill NS. Which patients with acute exacerbation of chronic obstructive pulmonary disease benefit from noninvasive positive-pressure ventilation? A systematic review of the literature. Ann Intern Med 2003;138(11):861–870. DOI: 10.7326/0003-4819-138-11-200306030-00007.
Masip J, Roque M, Sánchez B, Fernández R, Subirana M, Expósito JA. Noninvasive ventilation in acute cardiogenic pulmonary edema: systematic review and meta-analysis. JAMA 2005;294(24):3124–3130. DOI: 10.1001/jama.294.24.3124.
Kulkarni A, Agarwal V. Extubation failure in intensive care unit: predictors and management. Indian J Crit Care Med 2008;12(1):1–9. DOI: 10.4103/0972-5229.40942.
Ferrer M, Sellarés J, Valencia M, Carrillo A, Gonzalez G, Badia JR, et al. Non-invasive ventilation after extubation in hypercapnic patients with chronic respiratory disorders: randomised controlled trial. Lancet 2009;374(9695):1082–1088. DOI: 10.1016/S0140-6736(09)61038-2.
Gong Y, Han X, Duan J, Huang S. Not all COPD patients benefit from prophylactic noninvasive ventilation after scheduled extubation: an exploratory study. Int J COPD 2019;14:2809–2814. DOI: 10.2147/COPD.S232339.
Marti C, John G, Konstantinides S, Combescur C, Sanchez O, Lankeit M, et al. Systemic thrombolytic therapy for acute pulmonary embolism: a systematic review and meta-analysis. Eur Heart J 2015;36(10):605–614. DOI: 10.1093/eurheartj/ehu218.
Coşkun R, Gündoğan K, Atağ E, Akbudak IH, Öztürk A, Güven M, et al. Predictors of mortality in critically ill patients with poisoning: a single center experience. Turkiye Klin J Med Sci 2013;33(5):1274–1282. DOI: 10.5336/medsci.2012-33098.
Iwashyna TJ. Patient and population – level approaches to persistent critical ıllness and prolonged ıntensive care unit stays. Crit Care Clin 2018;34(4):493–500. DOI: 10.1016/j.ccc.2018.06.001.
Damuth E, Mitchell JA, Bartock JL, Roberts BW, Trzeciak S. Long-term survival of critically ill patients treated with prolonged mechanical ventilation: a systematic review and meta-analysis. Lancet Respir Med 2015;3(7):544–553. DOI: 10.1016/S2213-2600(15)00150-2.