Cost analysis of Tele-ICU: The Memorial Hermann study Luisa Franzini, Eric Thomas, Kavita Sail, Laura Weste University of Texas Health Science Center Houston, TX Contact: Luisa.Franzini@uth.tmc.edu

Background ICU in the U.S.: account for 10% of hospital beds consume 20-34% of all acute care resources 7% of national health expenditure 1% of the U.S. gross domestic product. ICU are expected to grow by 50% from 2000 to 2020. ICU are expected to grow by 50% from 2000 to 2020 because of aging population

Quality of care in ICU High mortality rates in ICU. ICU are sites for medical errors and adverse events. Quality of care in ICU varies widely. There is a need to improve ICU outcomes.

Intensivists ICU staffed by intensivists report 30% lower mortality rates and 3 days shorter Length of Stay (LOS) (Leapfrog Group) Only 10% of hospitals have adequate intensivists staffing. Shortage of intensivists in the U.S. Tele-ICU offers a possible solution to the intensivist shortage. What are tele-ICU: network of audiovisual and computer systems that link intensivists (physicians and nurses) to ICU in remote hospitals. ‘Command center’ staff communicates with personnel in remote ICU. Command center staff monitors ICU patients.

Tele-ICU solution Tele-ICU leverage intensivist coverage over more beds. Tele-ICU could be particularly useful for: hospitals in remote or rural areas hospitals with few resources who can not afford on site intensivists hospitals with high mortality and LOS. The use of Tele-ICU is expanding. Useful in hospitals that need to improve outcomes and have no access to intensivists 40 command centers in US in 2007 3,850 adults ICU beds (4% of total) covered

Barriers to adopting Tele-ICU The costs of acquiring, installing, and operating a Tele-ICU are considerable. Resistance in physician acceptance of Tele-ICU. Tele-ICU costs not reimbursed by insurers. Intellectual property issues. The costs of acquiring, installing, and operating a Tele-ICU are considerable. The cost of setting up a Tele-ICU system is about $2 to $5 million (NEHI) and the average cost of hardware and software per ICU bed connected to the Tele-ICU system has been estimated at $48,000 (24 in NEHI). Operational costs are also high. In one study (26 in NEHI), the six-month operating cost were $248,000 for expenses to operate the system plus $624,000 for physician staffing. According to the NEHI, hospital managers have reported annual operating costs of upwards of $1.5 million. In addition to the costs of installing and operating the Tele-ICU, some hospitals have to shoulder the additional costs of implementing electronic records systems or of updating existing electronic records systems to be compatible with the Tele-ICU software. Different care models: eICU only alerts ICU staff, eICU can order /// Only 3 vendors: VISICU (started in 2000), Cerner and iMDSoft (in last 2 years). For profit.

Early adopters Only few evaluations of early Tele-ICU adopters. One published study by the founders of VISICU, the for-profit company who developed the eICU and is the leading vendor (Breslow et al, 2004) A report by the New England Healthcare Institute using published and unpublished data by early adopter hospitals (NEHI, March 2007). Because of the high costs, hospital managers must carefully weigh the evidence on the benefits of Tele-ICU before buying into a system. However, the evidence on the effectiveness of the Tele-ICU in delivering on its promises is scant. To date, only two studies have been published evaluating Tele-ICU programs (REF Breslow 2004, Zawada 2006). A report by the New England Healthcare Institute (NEHI) also evaluated Tele-ICU programs using published and unpublished data by early adopter hospitals (REF). Only Breslow et al and the NEHI report discussed the costs of Tele-ICU programs. The more comprehensive published evaluation (Breslow) was carried out by the founders of the VISICU company, the for-profit company who developed the eICU©. VISICU is one of the three Tele-ICU manufacturers marketing the program to hospitals and is the leading vendor in the US. The findings from that study are predominately displayed on the company’s website in its attempts to promote their product.

VISICU study Lower hospital mortality by 27% ICU LOS decreased from 4.35 to 3.63 days Lower average case-cost by 25% Higher hospital revenues. The authors conclude that the program was associated with improved clinical outcomes and was cost saving (higher hospital revenues generated by increased ICU cases more than covered the program costs). . The study compared clinical and economic outcomes in the periods before and after the implementation of the ICU telemedicine program in one 650-bed tertiary care teaching hospital affiliated with Sentara Healthcare. Clinical and economic outcomes were evaluated in a total of 2,140 patients in the medical ICU and surgical ICU in the pre- and the post-period. The authors focused on the following results: hospital mortality decreased by 27% from 12.9% to 9.4% lower, ICU length of stay decreased from 4.35 to 3.63 days, average case-cost was lower by 25%, and hospital revenues were higher. The authors conclude that the program was associated with improved clinical outcomes and was cost saving since higher hospital revenues generated by increased ICU cases more than covered the program costs. However, a more careful examination of the results indicated that not all results were favorable: overall ICU mortality and surgical ICU mortality were not statistically significantly lower and hospital LOS was unchanged overall and in the medical ICU. Finally, all economic outcomes were reported without confidence intervals, making it impossible to evaluate the statistical significance of the pre-post differences. The study suffers from further limitations (Leong 2005). As the authors acknowledge, despite efforts to control for patient mix and severity of illness in the pre and post periods, “the use of historical controls always raises concerns about possible changes in patient mix”. Despite checking for similarities in ICU admission criteria and APACHE III scores in the two periods, there may still remain unaccounted differences in patient mix between the two periods. Also, as admitted by the authors, the actual basis for the changes observed in the post-period compared to the pre-period is unknown. It could be attributed to the introduction of the eICU but there could be other unobserved factors changing between the periods. In particular, the attention paid by the hospital to the ICU in the period surrounding the implementation of the eICU may have changed practices in a subtle way that affected the outcomes. Finally, the evaluation study was carried out in only one tertiary care teaching hospital that previously has intensivists on site. The generalization of the findings from this study to community hospitals or rural hospitals without any intensivist coverage is problematic.

NEHI report Results from other early adopters of Tele-ICU programs have not been able to replicate improvements in clinical and economic outcomes of the same magnitude as the VISICU study. Leigh Valley Health System - ICU mortality decreased from 15% to 10% Sutter Health System – no changes in ICU or hospital mortality Cornell Medical Center - decrease in mortality of 15% Zawada et al. - mortality, ICU LOS, and hospital LOS less than predicted by APACHE III severity scores Results from other early adopters of Tele-ICU programs have not been able to replicate improvements in clinical and economic outcomes of the same magnitude as Breslow et al. Leigh Valley Health System in Pennsylvania reported that, after installing the eICU in six community hospitals and one university hospital, mortality among ICU patients decreased from 15% to 10%, but the improvement in mortality was apparent only among patients with moderately severe conditions and not among patients with low severity conditions (NEHI). Sutter Health System did not observe changes in ICU or hospital mortality after implementing a Tele-ICU program in 30 ICU with 200 beds (NEHI). They attributed these results to the good intensivist coverage even before the Tele-ICU. Cornell Medical Center in New York reported a decrease in mortality of 15% in the 18 months after the implementation of the program compared to the previous year (NEHI). Zawada et al. reports that mortality, ICU LOS, and hospital LOS were significantly less than predicted by APACHE III severity scores in the period after the initiation of the eICU in a rural health system, Avera McKennan in South Dakota . However, the authors didn’t provide baseline data so it is unknown if the clinical outcomes were more favorable than predicted by APACHE III also before the introduction of the eICU. Preliminary data at Memorial Hermann in Houston, Texas, provide mixed results. LOS decreased slightly in two ICU, increased slightly in two others, and was unchanged in one ICU (NEHI). Leigh Valley Health System, Sutter Health System, Cornell Medical Center and Avera McKennan did not report any information on costs. Only Memorial Hermann provided preliminary data on financial effects of the eICU. The average cost per case decreased in two ICU, increased in two ICU, and was unchanged in one ICU. Revenue per case increased in all but one ICU.

Memorial Hermann study Objective: Assess the cost-effectiveness of e-ICU in 6 ICU in the Houston metropolitan area.

Methods Assessed the cost-effectiveness of e-ICU by comparing the costs and clinical outcomes in the period after the full implementation of the eICU with the costs and clinical outcomes in the baseline period before the introduction of the eICU.

Outcomes Clinical outcomes Costs outcomes ICU and hospital LOS and ICU and hospital mortality, obtained from chart reviews. Costs outcomes hospital costs and the cost of operating the eICU. hospital costs based on hospitals’ cost-accounting system. hospital costs computed using average daily ICU costs and floor costs for patients in each ICU during the two study periods using individual patient data. Hospital costs are computed using average daily ICU costs and floor costs for patients in each ICU during the two study periods using individual patient data. Two methodologies for assessing costs are used. First, costs are obtained by multiplying charges by Medicare ratios of cost to charge. The second approach to assessing hospital costs is based on costs as computed by the hospitals’ cost-accounting system. Cost accounting costs are built up from information on resource-use and are a more accurate representation of economic costs.

Mortality ICU

LOS ICU, hospital

Costs ICU

Costs per case ICU

Costs floor

Costs floor per case

Results Clinical outcomes: Economic outcomes Small reductions in ICU mortality. ICU LOS increased in 5 out of 6 ICU. Floor LOS increased in all 6 ICU. Economic outcomes ICU and floor costs increased in all ICU. ICU and floor cost-per-case increased in all ICU. Conclusions clinical outcomes

Conclusions Memorial Hermann reported mixed clinical outcomes and increased costs after the introduction of the eICU. This study failed to replicate the positive findings of the VISCU study. Conclusions economic outcomes