Icu Bed Capacity How Does Supply Affect Utilization
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Transcript of Icu Bed Capacity How Does Supply Affect Utilization
7/23/2019 Icu Bed Capacity How Does Supply Affect Utilization
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C R I S M A
C R I S M A
The Wi ll iam J. Sibbald Symposium
Critical Care Capacity
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C R I S M A
C R I S M A
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C R I S M A
C R I S M A
ICU bed capacity: doessupply affect utilization?
Jeremy M. Kahn, MD MSAssociate Professor of Critical Care Medicine
Director, Program on Critical Care Health Policy
University of Pittsburgh
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C R I S M A
C R I S M A
Disclosures
• Grant funding from US Government
• Consulting fees from the USDepartment of Veterans Affairs
• Speaking honoraria and travel fromacademic medical centers
•
No industry relationships
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C R I S M A
C R I S M A
Outline
• ICUs are overburdened, affectingquality
• One response to has been to buildmore ICU beds
• Increasing bed supply will solve someproblems but may cause others
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C R I S M A
C R I S M A
Demand for critical care isincreasing
Angus JAMA 2002
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Chalfin CCM 2007 Cardoso CCM 2011 Roberts AJRCCM 2012
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Response: build more ICU beds
Variable 2000 2005 % Change
Acute care hospitals 4718 3747 -20.6%
Hospital beds 665,758 628,409 -4.2%
ICU beds 88,252 93,955 +6.5%
ICU bed days 21 M 23 M +10.6%
ICU occupancy 65% 68% +4.5%
Halpern CCM 2010
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Could this strategy do moreharm than good?
• Increasing supply will decrease waittimes, but…
–
Costs: Increasing capacity by itselfcreates inefficiencies
– Utilization: Increasing capacity can drivepotentially harmful utilization
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The problem of costs
Cost Center Total Variable % Fixed
All ICU $54.5 K $ 10.5 K 81%
By cost-center
Blood bank $2.7 K $ 1.6 K 40%
Laboratory $1.9 K $ 0.3 K 83%
Pharmacy $4.0 K $ 1.9 K 52%
Radiology $2.1 K $ 0.2 K 90%
Respiratory $3.0 K $ 0.01 K 97%
Kahn, Med Care 2008
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The problem of utilization
• Excess capacity can drive utilization
• “Supply induced demand”
•
Depends on – Asymmetric information
– No marginal societal gain
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A model of demand elasticityin the ICU
SICK
NOT SICK
DIESLIVES
✓
✗
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Increasing the supply of ICUbeds will…
SICK
NOT SICK
DIESLIVES
✓
✗
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Decreasing the supply of ICUbeds will…
SICK
NOT SICK
DIESLIVES
✓
✗
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Is there evidence of demandelasticity in the ICU?
• Not really
• Indirect evidence from
– International comparisons – Variation within health systems
– Natural experiments
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More beds means less sickpatients in the ICU
Wunsch CCM 2008
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Lower mortality for low risk patients buthigher mortality for high risk patients
Wunsch AJRCCM 2011
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More ICU beds means morecare at the end of life
Carr JAMA 2010, Dartmouth Atlas
• More ICU beds
– More ICU use atthe end of life
–Higherspending at theend of life
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Also true at the hospital level:
• Increasing beds size associated with
increasing composite end-of-lifeutilization score (p=0.002)
Lin Medical Care 2009
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On low bed availability daysMET activation leads to:
Decreased
odds of going
to ICU
Increased odds
of comfort care
on ward
No change in
odds of death
Stelfox Archives 2012
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A caveat
• Demand elasticity is not inherently bad
• Bed supply is a drug with benefits andside effects
• The “dose” will determine on:
– How good are the benefits?
– How bad are the side-effects?
– How do we value these?
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The intended effects The side effects
Decreased waitingtimes
Higher costs
Decreased boarding Greater demand
Decreased ED
crowding
Less patient-centered
decision making
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Future directions
• Let no bed supply go unevaluated• Empirically determine what works best for
the various stakeholders
•
Make informed decisions