Regionalization of Critical Care Medicine Could Achieve Better Outcomes at Reduced Costs
From 1993 to 1995, researchers at IHC Care, an integrated, multi-hospital, nonprofit health care system in Utah, examined the delivery of critical care medicine in a multi-hospital system and developed analytic models to determine the potential impact of regionalization.
- At IHC, the severity of illness in intensive care units (ICU) is increasing, with implications for hospital costs and length of stay.
- The larger hospitals within the system are already using an informal system of triage for different levels of critical care, especially in specific disease groups, such as head injuries; however, patient transfer is not always based on severity of illness, for reasons that are not yet understood.
- Smaller hospitals within the system with very low volumes of ICU patients and lesser severity levels had worse patient outcomes than other facilities.
- Reorganizing critical care could be a major factor in improving care for critically ill patients at IHC.
- Improving the process of health care delivery influences outcomes in an intensive care unit favorably, while dramatically lowering costs.
The Robert Wood Johnson Foundation (RWJF) supported this project through a grant of $396,561.
The practice of intensive care, or critical care medicine, is labor-intensive and expensive, constituting 20 percent of all hospital costs and 1 percent of the Gross Domestic Product in 1993. Only in the past 20 years have physicians and nurses begun to dedicate themselves exclusively to critical care medicine and only in the past five years has this field been recognized as a medical sub-specialty.
Although not every hospital can afford critical care medicine, especially in rural America, the service is in great demand, largely due to treatment advances in both acute and chronic illness, the increased age of the population, and AIDS.
The standard approach to the care of the critically ill has been to expand technology and pharmacopeia to accommodate new discoveries about basic mechanisms of disease processes. While this approach has saved individual lives, it has not improved access, contained costs, or ensured appropriate matches between patient needs and services.
Regionalization of critical care medicine, an approach that has worked well in the US for perinatal care, is one strategy for addressing these issues but more information is needed so that rational guidelines can be developed for health care planners and providers.
In 1990, the Society of Critical Care Medicine developed guidelines for classifying various levels of critical care and suggested that regionalizing critical care medicine would reduce costs and improve outcomes. A year later, the American College of Critical Care Medicine established a task force on regionalization, chaired by Terry P. Clemmer, M.D., one of the principal investigators of the grant reported here.
The task force determined that although regionalization had intuitive appeal, scientific data were lacking to either support or refute its positive effects on clinical outcomes, or its cost-effectiveness.
The Foundation's interest in the project focused primarily on regionalization as a strategy for reducing health care costs. It was viewed as the ground work for further research in this area and as a complement to the SUPPORT study (ID# 020776), which described the effects of patient preference on end-of-life care, much of which is delivered in intensive care units (ICUs).
The purpose of this grant was to describe the delivery of critical care medicine in a multi-hospital system and to develop analytic models to determine the potential impact of regionalization. The investigators gathered data on 15,532 admissions to 17 ICUs within IHC Care Inc. (IHC), an integrated, nonprofit health care system in Utah, whose 24 hospitals range from small rural facilities to metropolitan teaching/research hospitals.
Admissions were categorized by disease, severity of illness, and level of care in the ICU. Patient data were then correlated with mortality, functional status, cost, and length of stay. The analysis was intended to determine whether the care setting was optimal for each patient in terms of recovery, patient monitoring, or the provision of terminal care.
Other project goals were to:
- Define the necessary data elements and establish guidelines for regionalizing critical care medicine at IHC.
- Identify which type of critically ill patients may benefit from a formal system of regionalization.
- Project the potential impact of regionalization within the IHC system.
The researchers hoped their work would prove applicable in other multi-hospital systems. In 1994, the principal investigator requested an expansion of this study to include specialized pediatrics care. Expansion was denied by the Foundation, both because the case was not viewed as sufficiently compelling and because the scope of the ongoing project was already ambitious.
Only a portion of the anticipated analytical work occurred within the study period. Data-collection time was nearly double the principal investigator's estimate, primarily because some patient charts were not readily retrievable, and there were further delays due to unanticipated methodological challenges and staff illness.
As a result, while data have been collected on the current system of critical care at IHC as well as some information about outcomes, guidelines for transferring patients within a regionalized network have not been developed yet. Nor is it known at the time of writing this report which patients will benefit most from regionalization or what impact it may have on the system.
However, the data already have proved useful in other, unanticipated ways, as the IHC system reorganizes the structure of its patient care services. The data collection and analysis are being completed with an additional $35,000 in support provided to the project by The Deseret Foundation, which is affiliated with one of the hospitals of the IHC, and by a restricted account held at The Deseret Foundation by the principal investigator.
- At IHC, the severity of illness in ICUs is increasing, with implications for hospital costs and length of stay.
- The larger hospitals within the system are already using an informal system of triage for different levels of critical care, especially in specific disease groups, such as head injuries. In general, patients are receiving an appropriate level of intensive care. However, patient transfer is not always based on severity of illness, for reasons that are not yet understood.
- Smaller hospitals within the system with very low volumes of ICU patients and lesser severity levels had worse patient outcomes than other facilities. This suggests some institutions should not maintain their own ICUs because they do not have the critical mass of critically ill patients that a hospital needs to provide quality ICU care.
- Reorganizing critical care could be a major factor in improving care for critically ill patients at IHC. This may be more easily accomplished at IHC, a single system in which an unstructured, voluntary system of referrals already occurs, than in a region served by multiple HMOs and provider networks.
- Improving the process of health care delivery influences outcomes in an intensive care unit favorably, while dramatically lowering costs. These results, which have been maintained over four years, were achieved by coupling statistical and scientific principles of standardization and quality improvement with a commitment to creating new relationships and a new culture among members of the health care delivery team.
Data collected from one critical care unit at LDS Hospital in Salt Lake City, Utah, part of the IHC system, were used in a paper on quality improvement within that unit, which has been submitted for publication to Critical Care Medicine (see the Bibliography). The findings from the intensive care regionalization study have not yet been published.
AFTER THE GRANT
The investigators continue to analyze project data with an eye towards publication. It is hoped that the analysis will allow IHC to develop criteria by disease group for transferring patients to other levels of critical care within the system in a manner that optimizes patient outcomes and system cost-effectiveness. The complexity of collecting and analyzing appropriate data may make it impractical for other regional systems to replicate this study.
GRANT DETAILS & CONTACT INFORMATION
Research on Quality and Costs in a Regional Critical Care System
IHC Care Inc. (Salt Lake City, UT)
Dates: September 1993 to December 1995
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Clemmer TP, Spuhler VJ, Oniki TA and Horn SD. "Results of a Collaborative Quality Improvement Program on Outcomes and Costs in a Tertiary Critical Care Unit." Critical Care Medicine, 27(9): 17681774, 1999. Abstract available online.
Report prepared by: James Wood
Reviewed by: Karyn Feiden
Reviewed by: Marian Bass
Program Officer: Lewis G. Sandy