Page 42 - ACCCN's Critical Care Nursing

Resourcing Critical Care 19

Funding based on achieving positive patient outcomes
would be ideal, as it would ensure that critical care units TABLE 2.1 Approaches to assessing treatment options 12
were using their resources only for those patients who
were most likely to achieve positive outcomes in terms of Approach Description
morbidity and mortality, but such an ideal has not devel-
oped sufficiently to date. Funding based on health out- Benefit–risk The benefit of treatment and the inherent
risks to the patient are assessed to inform
approach
comes only does, however, raise the risk of encouraging a decision; this approach excludes
clinicians to ‘cherry-pick’ only the most ‘profitable’ or monetary costs.
‘successful’ patient groups at the expense of others. In Benefit–cost Evaluate the benefit and cost of the
private (for-profit) hospitals or countries with very poor approach decision to proceed; this approach
health systems, ‘cherry-picking’ only those patients for incorporates cost to patient and society.
whom a successful outcome is guaranteed is likely to be Implicit approach The medical practitioner provides the
more common, whereas in the public hospitals of most service and judges its appropriateness.
Western countries an educated guess/risk is often applied
to the decision as to whether a patient should enter the
critical care unit or not. suggested that if all healthcare provided were appropriate,
3
It is vital to note the very important role played by rural rationing would not be required. Defining what is
and isolated health services and, in particular, critical care ‘appropriate’ can be subjective, although not always. The
12,20
units and outreach services in these regions. Many of the RAND group suggests that there are at least three
contemporary activity-based funding formulas are diffi- approaches that can be used to assess appropriateness of
cult to apply to these settings. There are diseconomies of care (Table 2.1). These include the benefit–risk, benefit–
scale in such settings as a result of small bed numbers, cost and implicit approaches.
limited but highly skilled nurses and doctors, and unpre- The first two approaches are considered to be explicit
dictable peaks and troughs in demand, which make approaches, while the third tends to be subjective.
workforce planning and the management of call-in/over- However, all approaches have a subjective element. While
time and fatigue problems difficult for small teams to the implicit approach is considered to be subjective in
manage. The professional isolation and limited access to nature, the medical practitioner must contemplate
education, training and peer support can also create ‘benefit–risk’ and ‘benefit–cost’ considerations but should
morale problems for some members of the team. Further- also involve the patient/family in the contemplation and
more, the diseconomies and isolation require empathetic ultimate decision. What is best for the patient is not just
funding processes to recognise the difficulties unique to the opinion of the treating doctor and needs to be
regional and isolated critical care services. If such units considered in much broader terms, such as the patient’s
are to remain viable and capable of delivering levels of previous expressed wishes and the family’s opinion as
safe and effective care equivalent to those expected in de-facto patient representatives. The quality of the deci-
larger metropolitan hospitals, then additional funding sion and the quality of the expected outcome require
and support is required to compensate for the cost and many competing considerations.
tyranny of distance.
The ‘quality’ agenda in healthcare has argued for ‘best
ECONOMIC CONSIDERATIONS practice’ and ‘best outcomes’ in the provision of health
services, although it may be more pragmatic to consider
AND PRINCIPLES ‘value’ when discussing what is and what is not an appro-
One early comprehensive study of costs found that 8% priate decision in critical care. The following equation
of patients admitted to the ICU consumed 50% of expresses the concept ‘value’ simply:
resources but had a mortality rate of 70%, while 41% of Quality Benefit × Sustainability
patients received no acute interventions and consumed Value = =
×
only 10% of resources. More recent Australian studies Cost Price Suffering
14
show that, although critical care service is increasingly The quality of the outcome is a function of the benefit to
being provided to patients with a higher severity of acute be achieved and the sustainability of the benefit. The
and chronic illnesses, long-term survival outcome has benefit of critical care is associated with such factors as
improved with time, suggesting that critical care service survival, longevity and improved quality of life (e.g.
may still be cost-effective despite the changes in greater functioning capacity and less pain and anxiety).
case-mix. 15,16 The benefit is enhanced by sustainability: the longer the
benefit is maintained, the better it is. 21
An Australian study showed that in 2002, ICU patients
cost around $2670 per day or $9852 per ICU admission, Cost is separated into two components, monetary (price)
with more than two-thirds going to staff costs, one-fifth and non-monetary (suffering). Non-monetary costs
to clinical consumables and the rest to clinical support include such considerations as morbidity, mortality, pain
and capital expenditure. Nevertheless, some authors and anxiety in the individual, or broader societal costs
17
provide scenarios as examples of poor economic decision and suffering (e.g. opportunity costs to others who might
making in critical care and argue for less extreme vari- have used the resources but for the current occupants, and
ances in the types of patient ICUs choose to treat in order what other health services might have been provided but
to reduce the burden of the health dollar. 18,19 Others have for the cost of this service). 21