Costs and cost-effectiveness of a tele-ICU program

ICU mortality rates tend to be high and ICU care is very expensive. Evidence suggests that ICU staffed with intensivists achieve better outcomes than those staffed by other types of physicians. A national shortage of intensivists has lead to the development of tele-ICU programs which allow intensivists to remotely care for patients in several ICUs simultaneously. This paper investigates the cost-effectiveness of a tele-ICU program from the health care system perspective.

Based on sample size computations, data were collected on 4142 ICU patients (half in the pre-tele-ICU period and half in the post-tele-ICU period) in 6 ICUs part of a large non-profit health care system in the Gulf Coast region. Clinical outcomes and the Simplified Acute Physiology Score II (SAPS) were obtained by chart reviews. Financial outcomes were computed using the proprietary cost-accounting system. Average daily costs, costs per case, and costs per patient were computed. We used OLS regression with a log transformation for patient costs as the dependent variable to investigate differences in patient costs between the pre- and post-tele-ICU period. The regression reflected the 6 (hospital) x 5 (SAPS quintile) x 2 (pre-post) factorial design where main effects and joint effects are entered cumulatively. Since a previous study (Thomas et al 2009) found that mortality in the sickest 20% of patients was the only clinical outcome affected by the tele-ICU, we computed the cost-effectiveness ratio of the tele-ICU program in decreasing mortality in this group.

The average daily costs and the cost per case increased on average 16% and 31% respectively after implementation of the tele-ICU ($5,216, $31,417) from the period before implementation of the Tele-ICU ($4,500, $24,050). The average cost per patient also increased from $20,222 in the pre-period to $25,813 in the post-period. Patients in the sickest quintiles, the 4th and the 5th SAPS quintiles, experienced the greatest difference in costs, $7,781 and $6,613 respectively. Regression analysis indicated that total patient costs differed by hospital (p<0.0001), SAPS quintile (p<0.0001), and tele-ICU (p < 0.0001). In the sickest quintile (5th SAPS quintile), the cost for a 10% reduction in mortality was $5,280.

Widespread implementation of tele-ICU programs is premature, as they considerably increase costs with no clear improvement in clinical outcomes. If tele-ICU programs are adopted at all, tele-ICU monitoring should be restricted to the sickest patients as it has the potential to reduce mortality at an acceptable cost in this specific group of patients.