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Bigger Is Not Always Better: An Examination of Cost Efficiency in Managing Acute Respiratory Failure FREE TO VIEW

Frank Genese, DO; Katherine Fuhrmann, DO; Marie Mortel, MD; Raymond Jean, MD; Charlisa Gibson, MBBS; Nisha Kotecha, MBBS; Pius Ochieng, MBBS; Raymonde Jean, MD
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Mount Sinal St. Luke's and Roosevelt Hospitals, New York, NY

Chest. 2015;148(4_MeetingAbstracts):299A. doi:10.1378/chest.2261797
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SESSION TITLE: Hot Topics in Critical Care

SESSION TYPE: Original Investigation Slide

PRESENTED ON: Sunday, October 25, 2015 at 04:30 PM - 05:30 PM

PURPOSE: Cost effectiveness in the intensive care unit (ICU) is a growing concern in healthcare. Despite accounting for less than 10% of beds in US hospitals, ICU costs account for 1/3 total inpatient expenditure with mechanical ventilation representing up to 12% of all hospital costs. Although cost reduction is increasingly targeted, there’s paucity of studies examining cost efficiency between small and large volume hospitals.

METHODS: The Nationwide Inpatient Sample (NIS) dataset between 2009-2011 was investigated for discharges that included diagnosis of Acute Respiratory Failure (ARF) requiring Invasive Mechanical Ventilation (IMV) in patients aged 18-90 years. Hospitals were separated into equal terciles by volume, with high volume hospitals (HVH) averaging >400 discharges/year, medium volume hospitals (MVH) averaging 200-399 discharges/year, and low volume hospitals (LVH) averaging <200 discharges/year. Discharges were then weighted to make all estimates nationally representative. Patient characteristics were described by volume status using multi-stage, stratified tabulation and multivariate linear regression procedures. We compared outcomes of hospitals by volume in terms of total charges and in-hospital mortality.

RESULTS: Total of 323,389 discharges were selected, which was representative of 1,599,255 weighted discharges nationally. The average length of stay (LOS) was 13.6 days and average total charge was $144,509 USD. A total of 151, 329, and 1339 hospitals were grouped as the HVH, MVH and LVH, and representative of 737, 1601, and 6538 hospitals nationally, respectively. LVH had significantly shorter LOS (12.0 days; 95% CI [11.7-12.3]) compared to MVH (13.6; 95% CI [13.2-14]) and HVH (15; 95% CI [14.3-15.6]), significantly lower in-hospital mortality (LVH 29.4% vs MVH 38.1% and HVH 32.4 %, p<0.01) and lower median total charges (LVH $72037 vs. HVH $96863 and MVH $103179, p<0.01). After adjustment for age, sex, race, comorbidity, LOS, septicemia and shock, LVH were associated with decreased total charges (estimate increased charge: MVH $25140 and HVH $28998, both p<0.01) and in-hospital mortality (OR: MVH 1.09 and HVH 1.10, both p<0.01).

CONCLUSIONS: After adjustment for variables, management of ARF requiring IMV at high volume centers was associated with higher total charges and increased in-hospital mortality.

CLINICAL IMPLICATIONS: The cause of this is likely multi-factorial, and further research to explore this is warranted.

DISCLOSURE: The following authors have nothing to disclose: Frank Genese, Katherine Fuhrmann, Marie Mortel, Raymond Jean, Charlisa Gibson, Nisha Kotecha, Pius Ochieng, Raymonde Jean

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