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Incremental Charges and Benefits

Ian L. Cohen, MD, FCCP, FCCM; James Lambrinos, PhD; I. Alan Fein, MD

JAMA. 1993;269(8):1025-1029.

Abstract
Objective.
—To evaluate the cost-effectiveness of prolonged mechanical ventilation in patients 80 years of age and older in the intensive care unit (ICU).

Design.
—A retrospective review of consecutive ICU patients requiring 3 or more days of mechanical ventilation. Cost-effectiveness analysis was performed by assessing incremental hospital charges from hospital billing records; charges were then related to years of life saved. A telephone survey was used to follow up hospital survivors for a minimum of 4 years after discharge.

Setting.
—A 20-bed medical-surgical ICU in a 420-bed, tertiary-care community teaching hospital.

Patients.
—The study included all patients aged 80 years or older taken from a comprehensive database of all patients admitted to the ICU requiring mechanical ventilation from April 1,1985, through October 31, 1987 (n=512). Of 59 potential candidates, 45 were found to have complete billing records and were the subject of further analysis.

Results.
—Of the 45 patients in the group under analysis, 10 survived to leave the hospital. Of these, two were alive and one could not be located at the time of follow-up. The charge per year of life saved is estimated to be between $51 854 and $75 090 in 1985-1987 dollars. Of 22 patients whose age in years plus duration of mechanical ventilation in days totaled 100 or greater, only two survived hospitalization and neither was alive at follow-up. The cost per year of life saved in this subset of patients was $181 308 in 1985-1987 dollars. One of these patients was discharged to a nursing home and died there 4.5 years later, after multiple hospital readmissions. The other patient died at home 2 months after hospital discharge.

Conclusion.
—Based on hospital charges and life expectancy, the cost-effectiveness of prolonged mechanical ventilation in ICU patients age 80 years and over was poor in our population when the combination of age and duration of mechanical ventilation exceeded 100. Further studies using this type of analysis may prove valuable in both clinical and administrative decision-making processes.

(JAMA. 1993;269:1025-1029)

Author Affiliations
From the Departments of Surgery and Medicine, Albany (NY) Medical College (Drs Cohen and Fein); and the Graduate Management Institute, Union College, Schenectady, NY (Dr Lambrinos).

Footnotes
Presented in part at the 57th Annual Meeting of the American College of Chest Physicians, San Francisco, Calif, November 7, 1991.

Reprint requests to Department of Surgery, A-162, Albany Medical College, 47 New Scotland Ave, Albany, NY 12208 (Dr Cohen).

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