Advertisement

A Minority of Patients on Mechanical Ventilation Consume Disproportionate Resources

A Retrospective Cohort Study
Published:November 27, 2020DOI:https://doi.org/10.1016/j.chest.2020.11.022

      Background

      The Pareto principle states that the majority of any effect comes from a minority of the causes. This property is widely used in quality improvement science.

      Research Question

      Among patients requiring mechanical ventilation (MV), are there subgroups according to MV duration that may serve as potential nodes for high-value interventions aimed at reducing costs without compromising quality?

      Study Design and Methods

      This multicenter retrospective cohort study included approximately 780 hospitals in the Premier Research Database (2014-2018). Patients receiving MV were identified by using International Classification of Diseases, Ninth Revision, Clinical Modification, and International Classification of Diseases, Tenth Revision, codes. They were then divided into quintiles according to MV duration; their hospital costs, post-MV onset length of stay (LOS), ICU LOS, and cumulative post-MV onset hospital days per quintile were compared.

      Results

      A total of 691,961 patients were included in the analysis. Median [interquartile range] duration of MV in days by quintile was as follows: quintile 1 (Q1), 1 [1, 1]; Q2, 2 [2, 2]; Q3, 3 [3, 3]; Q4, 6 [6, 7]; and Q5, 13 [10, 19]. Median [interquartile range] post-MV onset LOS (Q1, 2 [0, 5]; Q5, 17 [12, 26]) and hospital costs (Q1, $15,671 [$9,180, $27,901]; Q5, $70,133 [$47,136, $108,032]) rose from Q1 through Q5. Patients in Q5 consumed 47.7% of all post-MV initiation hospital days among all patients requiring MV, and the mean per-patient hospital costs in Q5 exceeded the sum of costs incurred by Q1 to Q3. Adjusted marginal mean (95% CI) hospital costs rose exponentially from Q1 through Q5: Q2 vs Q1, $3,976 ($3,354, $4,598); Q3 vs Q2, $5,532 ($5,103, $5,961); Q4 vs Q3, $11,705 ($11,071, $12,339); and Q5 vs Q4, $26,416 ($25,215, $27,616).

      Interpretation

      Patients undergoing MV in the highest quintiles according to duration of MV consume a disproportionate amount of resources, as evidenced by MV duration, hospital LOS, and costs, making them a potential target for streamlining MV care.

      Key Words

      Abbreviations:

      CDI (Clostridioides difficile infection), IQR (interquartile range), LOS (length of stay), Q1 (quintile 1), SNF (skilled nursing facility), VAP (ventilator-associated pneumonia)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic and Personal
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to CHEST
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Institute for Healthcare Improvement
        • Gershengorn H.B.
        • Kocher R.
        • Factor P.
        Management strategies to effect change in intensive care units: lessons from the world of business part I. Targeting quality improvement initiatives.
        Ann Am Thorac Soc. 2014; 11: 264-269
        • The National Institute for Health Care Management (NIHCM)
        The concentration of U.S. health care spending, 2014.
        • Perspectives
        Questioning the role of the 80/20 rule for healthcare: Determining the impact for population health today.
        • Centers for Disease Control and Prevention, National Center for Health Statistics
        Health expenditures.
        • Barrett M.L.
        • Smith M.W.
        • Elixhauser A.
        • Honigman L.S.
        • Pines J.M.
        Utilization if intensive care services, 2011. HCUP Statistical Brief #185. December 2014. Agency for Healthcare Research and Quality, Rockville, MD.
        • Dasta J.F.
        • McLaughlin T.P.
        • Mody S.H.
        • et al.
        Daily cost of an intensive care unit day: the contribution of mechanical ventilation.
        Crit Care Med. 2005; 33: 1266-1271
        • Zilberberg M.D.
        • Luippold R.S.
        • Sulsky S.
        • Shorr A.F.
        Prolonged acute mechanical ventilation, hospital resource utilization and mortality in the United States.
        Crit Care Med. 2008; 36: 724-730
        • Zilberberg M.D.
        • Shorr A.F.
        Prolonged acute mechanical ventilation and hospital bed utilization in 2020 in the United States: implications for budgets, plant and personnel planning.
        BMC Health Services Res. 2008; 8: 242
        • US Department of Health and Human Services Office for Human Research Protections
        Human Subject Regulations Decision Charts.
        • Zilberberg M.D.
        • Nathanson B.H.
        • Sulham K.
        • Fan W.
        • Shorr A.F.
        A novel algorithm to analyze epidemiology and outcomes of carbapenem resistance among patients with hospital-acquired and ventilator-associated pneumonia: a retrospective cohort study.
        Chest. 2019; 155: 1119-1130
        • Zilberberg M.D.
        • Nathanson B.H.
        • Ways J.
        • Shorr M.D.
        Characteristics, hospital course, and outcomes of patients requiring prolonged acute vs. short-term mechanical ventilation in the US, 2014-2018.
        Crit Care Med. 2020; 48: 1587-1594
        • Klompas M.
        • Anderson D.
        • Trick W.
        • et al.
        • CDC Prevention Epicenters
        The preventability of ventilator-associated events. The CDC Prevention Epicenters Wake Up and Breathe Collaborative.
        Am J Respir Crit Care Med. 2015; 191: 292-301
        • Andriolo B.N.
        • Andriolo R.B.
        • Saconato H.
        • et al.
        Early versus late tracheostomy for critically ill patients.
        Cochrane Database Syst Rev. 2015; 1: CD007271
        • Vianello A.
        • Arcaro G.
        • Palmieri A.
        • et al.
        Survival and quality of life after tracheostomy for acute respiratory failure in patients with amyotrophic lateral sclerosis.
        J Crit Care. 2011; 26 (329.e7-329.e14)
        • Lanken P.N.
        • Terry P.B.
        • Delisser H.M.
        • et al.
        An official American Thoracic Society clinical policy statement: palliative care for patients with respiratory diseases and critical illnesses.
        Am J Respir Crit Care Med. 2008; 177: 912-927
        • Ruan S.Y.
        • Teng N.C.
        • Huang C.T.
        • et al.
        Dynamic changes in prognosis with elapsed time on ventilators among mechanically ventilated patients.
        Ann Am Thorac Soc. 2020; 17: 729-735
        • Vassilakopoulos T.
        • Petrof B.J.
        Ventilator-induced diaphragmatic dysfunction.
        Am J Respir Crit Care Med. 2004; 169: 336-341
        • Slutsky A.S.
        Lung injury caused by mechanical ventilation.
        Chest. 1999; 116: 9S-15S
        • Norton S.A.
        • Hogan L.A.
        • Holloway R.G.
        • Temkin-Greener H.
        • Buckley M.J.
        • Quill T.E.
        Proactive palliative care in the medical intensive care unit: effects on length of stay for selected high-risk patients.
        Crit Care Med. 2007; 35: 1530-1535
        • Hua M.S.
        • Li G.
        • Blinderman C.D.
        • Wunsch H.
        Estimates of the need for palliative care consultation across United States intensive care units using a trigger-based model.
        Am J Respir Crit Care Med. 2014; 189: 428-436
        • Mularski R.A.
        • Heine C.E.
        • Osborne M.L.
        • Ganzini L.
        • Curtis J.R.
        Quality of dying in the ICU: ratings by family members.
        Chest. 2005; 128: 280-287
        • Nelson J.E.
        Identifying and overcoming the barriers to high-quality palliative care in the intensive care unit.
        Crit Care Med. 2006; 34: S324-S331
        • Wysham N.G.
        • Hua M.
        • Hough C.L.
        • et al.
        Improving ICU-based palliative care delivery: a multicenter, multidisciplinary survey of critical care clinician attitudes and beliefs.
        Crit Care Med. 2017; 45: e372-e378