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102 PART 1: An Overview of the Approach to and Organization of Critical Care

2.8 activities of daily living 6 months following hospital discharge. This with acceptable quality of life is not an appropriate use of resources.
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is significantly higher than functional limitations for survivors of short- Clinicians should also remain cognizant of ways to decrease costs in this
term mechanical ventilation. There is some improvement by 12 months, patient population.
but this is impacted by some degree of survival bias, in that patients with Alternative sites of care for CCI patients can reduce hospital costs.
the highest number of limitations in ADLs at 6 months are less likely to These cost savings are largely related to lower-intensity nursing. In
survive to 1 year. In fact, when trajectories are followed, significantly one study, CCI patients were randomized to receive continued care in
more patients will die or experience declines in physical function than an acute ICU versus further management in a specialized multidisci-
will improve. Cognitive limitation is another important factor for long- plinary unit in the same hospital. Hospital mortality did not differ
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term survivors of CCI. In a study of patients admitted to a ventilator between the two groups, but mean hospital costs per survivor in the
weaning unit, 68% of 6-month survivors were delirious or comatose at specialized unit were $109,220 compared with $138,434 in the ICU
the time of follow-up. The high degree of physical and cognitive limita- (p = 0.0005). Economic analyses of the cost implications of transferring
tions for CCI patients at long-term follow-up reflect both the severity of CCI patients to external facilities such as LTAC hospitals are challeng-
the original insults or injury and development of new complications in ing because of selection bias involved with LTAC transfer decisions.
a vulnerable population. 59 However, a recent study of Medicare patients suggested that transfer to
While functional limitations can be profound, overall health-related an LTAC hospital is associated with longer hospitalization and higher
quality of life is not as closely linked to functional limitations as many Medicare payments, adjusting for propensity factors associated with
people would believe. Patients who have experienced near-death events LTAC transfer. Another recent analysis confirmed that LTAC transfer
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can be satisfied with living with physical limitations when death is the results in higher Medicare payments for the episode of acute care, but
obvious alternative. 60,61 This is especially true in the elderly, for whom when considering time spent in skilled nursing facilities and acute
physical limitations were often present before their critical illness. hospital readmissions, LTAC transfer is associated with lower overall
Quality-of-life assessments in cognitively intact survivors of CCI reflect health care costs. The societal cost issues related to postacute care
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this phenomenon of adaptation. Depending on the setting, between remain complex, but the potential cost savings for individual hospitals
50% and 80% of survivors report their quality of life to be fair, good, will remain a major factor driving transfers of CCI patients to LTAC
or excellent. 62,63 In fact, in at least one study, quality-of-life outcomes hospitals until payments are bundled and shared between referring and
for cognitively intact survivors did not differ significantly from those receiving institutions.
of other ICU patients. It should be remembered, however, that the The most effective approach to reducing costs for CCI patients is to
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majority of patients in these studies did not survive to 1 year in a cogni- prevent complications in the acute phase that can lead to prolonged
tively intact state. For the majority of patients who die within the year, organ failure and CCI. This is likely to begin with early appropriate
their terminal courses are characterized by long periods of invasive and resuscitation and antibiotic coverage for severe sepsis; lung-protective
institutionalized care, with accompanying symptoms of discomfort and ventilation for ARDS; protocols for reducing central line–associated
emotional distress. bloodstream infections, ventilator-associated pneumonia, and other nos-
■ COSTS ocomial infections; delirium prevention; and early mobility protocols.

The growing burden of CCI has significant cost implications for health COMMUNICATION OF OUTCOMES
care systems. Annual hospital costs for CCI patients in the United States
is expected to rise to as high as $64 billion by 2020. Patients who The poor long-term survival and functional outcomes of CCI patients
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require more than 7 days of mechanical ventilation consume as much are well documented, yet clinicians either remain unaware or are reluc-
as 37% of ICU resources, and 21% of ICU resources are consumed tant to communicate expected outcomes to surrogate decision makers.
after the seventh day of mechanical ventilation. In the United States, In focus group studies, families of CCI patients express a desire to hear
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public programs (Medicare [45%] and Medicaid [20%]) pay for the prognoses for long-term survival and function, yet only 7% of families
majority of hospitalizations for CCI. Median hospital days per Medicare receive information about 1-year survival, and 20% receive informa-
patient undergoing mechanical ventilation for at least 4 days and a tion about expected function. These limitations in communication
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receiving a tracheostomy was 25 days, and average Medicare costs were between clinicians and decision makers result in significant discordance
$105,000 per stay. However, index hospital costs account for only part in expectations of outcome (Table 14-4). 68
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of the total costs for an episode of care for a CCI patient. Forty-six per- One of the barriers to communication of prognosis is uncertainty
cent of Medicare patients with CCI are transferred to LTAC hospitals. on the part of clinicians and worries about being wrong. This issue
The total median length of stay (hospital and LTAC) for those patients is particularly relevant in CCI since patients have survived the worst
is 66 days, and total median Medicare costs for the entire episode are part of their acute illness, which can provide a sense of improvement
over $150,000. for clinicians and families alike. Additionally, much of the long-term
These high costs attract the attention of hospital administrators, mortality is related to new problems that occur after the patient leaves
third-party payers, and patient and family advocates. Given the overall the acute ICU. In order to facilitate understanding and communica-
poor outcomes for many of these patients, clinicians often wonder about tion of long-term prognosis in CCI, investigators have developed and
the appropriateness of some of these expenditures. A cost-effectiveness validated a prediction model for 1-year survival from CCI. 16,58 Mortality
analysis comparing ongoing care for a typical 65-year-old CCI patient increases with cumulative presence of risk factors measured on day 21
compared to patients who had life-sustaining therapies withdrawn by of ventilation including advanced age, low platelet count, and continued
day 14 of mechanical ventilation conservatively estimated added costs requirement for renal replacement therapy or vasopressors (Table 14-5).
to be approximately $144,000, or $82,000 per quality-adjusted life year Similar models are being developed using variables measured on day
(QALY). Costs were most sensitive to age ($206,000 per QALY gained 10 and 14 of mechanical ventilation so that long-term prognoses can
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for an 85-year-old) and prognosis ($61,000 per QALY gained for patients be discussed earlier in the course of CCI. Importantly, an objective
with <50% probability of death at 1 year). This economic analysis places assessment of prognosis will only help if time is taken to communicate
cost-effectiveness of continued care for younger CCI patients with better the information and facilitate decision making that is centered on a
prognoses within the range of other medical interventions. In most soci- patient’s values. Multiple interventions are being studied to enhance this
eties, costs should not drive medical decision making, and most health process of assessment and communication of outcomes for CCI patients.
care systems adapt to costly outliers. However, clinicians and surrogate A written brochure describing CCI and its outcomes has been devel-
decision makers should use good judgment in recognizing that contin- oped and validated, and is available through the Society of Critical Care
ued aggressive care in individual patients who are unlikely to survive Medicine. Additionally, an electronic decision aid that assists clinicians
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