One of the most urgent targets for improved efficiencies in inpatient hospital care is critical care services. Between 2000 and 2005, critical care medicine beds increased in the United States by 6.5% (from 88,252 to 93,955), and occupancy rates increased by 4.5%.1 In that period, critical care costs per day increased by 30.4% (from $2698 to $3518). In 2005, critical care medicine accounted for 13.4% of hospital costs in the United States and consumed 0.66% of gross domestic product. Patients requiring mechanical ventilation are among the largest consumers of critical care resources, and hospitals often experience financial losses in providing care for them. As many as 2.8% of hospitalized patients in the United States received mechanical ventilation in 2005, representing 2.7 episodes of mechanical ventilation per 1000 population.2 Estimated national costs were $27 billion. This chapter reviews the economic implications of mechanical ventilation. Basic principles of health economics are reviewed to provide a framework for interpreting health economic analyses related to mechanical ventilation. Actual costs of mechanical ventilation are addressed, followed by a discussion of whether mechanical ventilation is cost-effective. Finally, strategies for cost containment are reviewed.
The goal of health economics is to ascertain the highest level of efficiency in providing health care.3,4 A key assumption in this field is that health resources are a finite commodity. In such a system, a series of questions should be answered regarding any new or current medical intervention:
- Is the intervention effective relative to other available therapies?
- How much does it cost relative to other available therapies?
- From whose perspective are the costs being considered?
- How widely will the intervention be utilized?
Measured approaches to answering these questions allow health care systems to select medical therapies based upon evidence rather than assumptions, commercial marketing, or bias. Economic analysis has become a standard component of decision making for health systems in countries such as the United Kingdom or Australia, where health care policymaking is centralized on a national level. In countries such as the United States, delivery of health care is much less regulated, and many practitioners and most patients have unbounded access to any available therapies. Few physicians in the United States, however, are able to practice without significant awareness of the resource implications of their decision making. One goal of recent health care reform efforts in the United States is cost control, and it is highly likely that third-party payers will increase efforts to balance available services with more efficient delivery. The formation of Accountable Care Organizations, in which providers are incentivized to organize care delivery in a way that improves quality and outcomes and reduces costs, is mandated in the recent Affordable Care Act.5 Other delivery reform initiatives include pay-for-performance measures,6 expansion of medical homes, bundled payments, and value-based purchasing. Consequently, a basic understanding of how the efficiency of various health care practices is defined is becoming essential to the practicing ...