Expenses and ICU

  Abstract
 

Introduction: In this era, health-care facilities have improved greatly which has increased the life expectancy of humanity, but all these costs and so the role of economic evaluations of health-care interventions has become increasingly important especially in developing countries like India. Objective: To estimate the expenses of a patient in Intensive Care Unit (ICU), disease wise expenditure and area of expenses (therapeutic and diagnostic). Materials and Methods: This prospective observational study was conducted in tertiary care hospital of private setup in Mumbai region. The inclusion criterion was admitted patients in medicine ICU (MICU) on the basis of the clinical presentation during January 2014–February 2014 (2 months). The cost of treatment included the bed charges in the hospital ICU, diagnostic cost (routine and special investigations), therapeutic cost, cost of oxygen, monitor, nebulization, ventilator, cost of drugs, and other consumables were assessed. Results: Totally fifty patients were admitted in above period to MICU. The average stay of a patient in MICU amounts to 4 days (approximated for 4.01) with the least being 1 day for unstable angina and maximum 11 days for congestive cardiac failure. Conclusion: The major shares of expenses in treatment in MICU were on medicines, and this can be reduced using generic drugs.
Keywords: Hospital stay, Intensive Care Unit cost, treatment expenses

How to cite this article:
Agrawal A, Gandhe MB, Gandhe S, Agrawal N. Study of length of stay and average cost of treatment in Medicine Intensive Care Unit at tertiary care center . J Health Res Rev 2017;4:24-9

How to cite this URL:
Agrawal A, Gandhe MB, Gandhe S, Agrawal N. Study of length of stay and average cost of treatment in Medicine Intensive Care Unit at tertiary care center . J Health Res Rev [serial online] 2017 [cited 2018 Feb 23];4:24-9. Available from: http://www.jhrr.org/text.asp?2017/4/1/24/199329

  Introduction
 

In this era, health-care facilities have improved greatly which has increased the life expectancy of humanity, but all the costs and so, the role of economic evaluation of health-care interventions has become increasingly important.[1]

Very few studies have been done with regard to the cost of treatment of patients admitted to medical Intensive Care Unit (ICU) of third world countries. In India, the concept of ICU management has come forth in the last 30 years and is yet in its budding stage. People are unaware about their role and importance with respect to critical care, and so a thought of admission at such places is responsible for chaos among caregivers.[2] If effective studies could highlight the expenditure toward the management of life-threatening conditions, then it would be helpful. The medical facilities have improved in India, however, owing to the high expenditure involved; few privileged ones can afford it.[3] To make maximum people utilize these benefits, proper analysis of high cost is to be found out.[4]
Owing to the wide spectrum of disease presentation and the availability of vast management (diagnostic and treatment) options the cost varies, making it difficult to estimate the cost of the treatment.[5] A single episode of an ICU admission imparts economic burden, so there is a need to find out the pharmacoeconomics of treatment in the developing countries.[6] Although in developed countries number of studies are done in terms of expenses they differ from the scenario. However, these previous studies can be helpful as guidelines for future studies in the third world countries. The aim of the study was to calculate and further analyze the average cost of management of a patient admitted in medicine ICU (MICU), to know which disease among the common entrants in the ICU is the costliest to treat and the area of maximum expenditure.

  Materials and Methods
 

This is a descriptive epidemiological study which was conducted in a tertiary care hospital with twenty bedded MICU in the private setup of Mumbai region. This ICU is having all modern intensive care equipment such as multiparameter monitor and five ventilators. Specialist medical staff with two full-time intensivists along with a battery of physicians, cardiologist, nephrologist, gastroenterologist, and neurophysician. The staff is well trained in handling medical emergencies. The pathology department is fully equipped with 24 h emergency facility. The radiology department inclusive of computed tomography (CT)-scan, ultrasonography, and X-ray is also 24 h functional.

All patients admitted to MICU on the basis of the clinical presentation during January 2014–February 2014 (2 months) were included in the study. All patients who suffered sudden unexplained death were excluded as well as all those who were transferred to higher cardiac center for further intervention such as angioplasty, coronary artery bypass grafting (not available at our institute). All patients who underwent the operative procedure and those who were kept for postoperative management did not form a part of the study. Newly diagnosed cases of hypertension and diabetes were not included.
A prospective estimation of the cost in the MICU was made with regards to cost of stay in the ICU (bed-charges), diagnostic cost (cost of investigations [routine], cost of special investigations [two-dimensional (2D) echo, CT scan, magnetic resonance imaging (MRI)], therapeutic cost [cost of therapeutic procedures-catheterization, central venous pressure (CVP) insertion, intubation, etc.] cost of oxygen, monitor, nebulization, ventilator, and cost of drugs and other consumables) was done for fifty patients who were included in the study.[7] These patients were regularly followed till they were transferred to the wards to know about the expenditure.
Statistical analysis

All data were plotted on Excel sheet and analyzed using software SPSS version 16.0. (SPSS Inc., Chicago, US). The numbers of patients admitted were calculated and total days of hospital stay were ascertained. The average length of hospital stay was also calculated.[8] The patient's average cost of stay is calculated by assessing the cost of stay for a particular disease (95% confidence interval).

During study duration, total seventy-five patients were admitted to the ICU of which eight patients expired, seven patients underwent operative management, three patients were kept for postoperative management, and seven patients were transferred to a higher cardiac center in view of urgent cardiac intervention. Finally, fifty patients who met the inclusion criteria were included out of which there were 31 male patients and nineteen female counterparts.
Bed charges in the hospital ICU were included in hospital indoor charges. Bed-charges also accounted for the nursing care, which includes monitoring of vitals, mouthcare, bed care, all dressings, infusion pumps, and other special care required. It amounted to Rs. 800/day whereby a 24-h check-in facility for calculation purpose was present. A nominal charge of Rs. 50 was taken as admission charge from hospital. Patients are observed in the ward for a day or two, and if they continue to show signs of improvement then they are discharged home and asked for regular follow-up visits with the physician and treatment is continued on an outpatient basis unless exacerbation takes place.
Oxygen is provided through a central oxygenation facility, which costs Rs. 400/day. Monitoring of continuous electrocardiogram, saturation and blood pressure monitoring costs Rs. 250/day while nebulization charges are Rs. 250/day and Rs. 1800/day was the charge for ventilator.

With evidence-based medicine in vogue, the diagnosis has to be justified, and clinical diagnosis alone no longer holds true, so every patient has to undergo investigations as per the clinical judgment to confirm the diagnosis. Every patient underwent a battery of investigations routine (complete blood count, liver function test, kidney function test, lipid profile, creatinine kinase muscle and brain [CK-MB]) to special investigations such as echo, CT scan, and MRI as per the requirement.

For all patients in the ICU, food was provided every second hourly by the hospital as per the guidance of the physician and the dietician. The relatives of the patient as per the treatment modality prescribed bought drugs. This variable varied as per the medical diagnosis, patient response and the timely complications developing.

Therapeutic procedures were differed with the presentation of the patient. However, this included-catheterization, CVP line, intubation and intravenous line. In case of myocardial infarction (MI) that constitutes maximum patients (30%) in the study, the routine investigations were same as any other condition reported in the ICU, additional investigations were 2D echo to know the cardiac status in terms of ejection fraction and electrocardiograms with the cardiac enzymes CK-MB (which increased the diagnostic costs). In the treatment modality thrombolysis with costly medicines like injectable streptokinase (Rs. 4000) or injectable urokinase (Rs. 9000) and the need for injectable nicorandil as well as injectable glycoprotein IIa and IIIb inhibitors and low molecular weight, heparin accounted for the high therapeutic costs.

Unstable angina (20%) is an admission in ICU more for observation purpose than for therapeutic purpose owing to chest pain. As compared to MI costly treatment modality like thrombolysis is not required. Although frequent electrocardiogram and low molecular weight heparin form a part of diagnosis and treatment, respectively.

Congestive cardiac failure (CCF) patients were 12% of the entrants in ICU. Here, high costs could be attributed to the need of therapeutic procedures like CVP line, catheterization besides nebulisation. Arterial blood gas (ABG) is required to assess if respiratory failure is also present. Out of six patients, two required ventilator support owing to the hypoxemic respiratory failure in the setting of pulmonary edema in which they were bought. However, once the fluid was driven out of the body with the help of diuretics and fluid restriction the ventilator support was withdrawn off quickly in comparison to chronic obstructive pulmonary disease (COPD) patients were ventilator has to be removed off slowly requiring longer duration and so high costs in turn. Frequent X-rays are required to judge the degree of congestion. 2D-echo is must in these patients to know about dilated cardiomyopathy, valvular lesion as well as the ejection fraction.

The stay of asthma patient in ICU is less. Nebulization is the only important cost additive factor here. Costly investigations, as well as therapeutic procedures, are not required accounting for low costs compared to the other diseases. These patients on the treatment of infection improve very fast and can be quickly taken out of the ICU care.

Four patients of organophosphorus poisoning (OP) are included in the study due to common presentation in an agricultural country like India. Out of four patients, 3 (75%) did require ventilator for 3–4 days in view of respiratory paralysis and failure contributed mainly to factors such as increased secretions, pulmonary edema, and there is always danger of aspiration pneumonia and secondary chest infection most common being ventilator-associated pneumonia. Out of the three cases of OP poisoning, ventilator-associated pneumonia occurred in one case. Blood investigation-pseudocholinesterase level is a must in these cases to decide removal of ventilator support besides improvement of the patient clinically. Frequent ABG is required to know about the respiratory failure component. The longer stay in ICU and costly antibiotics add to the cost of treatment.

COPD patients are usually elderly and require ventilator support; frequent ABG analysis, as well as X-ray are, must along with the nebulization that contribute to the cost. In spite of being respiratory condition, 2D echo along with CVP line are must to know the cardiac status in view of cardiomegaly, right ventricular dilatation to estimate the degree of cor-pulmonale and also to estimate if there is fluid overload due to poor cardiac status. Medications required here are costly which includes broad-spectrum antibiotics, bronchodilators, and corticosteroids.

In case of cerebrovascular accident (CVA), it is the requisition of CT-scan which adds up to the investigation charges. Besides the routine treatment, it is the physiotherapy, which is the major modality for cost as well as treatment. Out of five patients, only one underwent MRI-angiography for posterior circulation stroke to know the exact lesion.

  Results
 

The study had 31 male patients and 19 female patients who were selected randomly as per the inclusion criteria. The youngest patient was of 22 years and the eldest of 86 years with mean age being 60 years [Figure 1].

Figure 1: Age distribution pattern of patients admitted to Intensive Care Unit

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