Learning to Not Know

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Abstract
Objective Compelling internal and external influences are stimulating global re-evaluations of care standards for efficacy and cost. Critical care uses huge amounts of resources despite widespread shortages of beds and nurses. This study tested the hypothesis that ancillary expenditures can be decreased without compromising care. Methods Costs for laboratory tests, radiographs, blood products, nutritional supplements, and drugs were compared prospectively for all surgical intensive care unit care for two 4-month periods (January 1 to April 30, 1994 and January 1 to April 30, 1995) at a urban university center. A systematic, multidisciplinary cost-reduction program began May 1, 1994, with emphasis on laboratory and radiographic testing and procedures, and blood product, nutritional, and drug therapies. Cohorts were compared by age, Acute Physiology and Chronic Health Evaluation (APACHE) II and III admission scores, and case mix. Outcome variables were hospital mortality, days in the intensive care unit and hospital, the development of multiple organ dysfunction syndrome, and expenditures. Cost data were taken weekly from the hospital's clinical information system. No new equipment was introduced during the study period except for pumps for patient-controlled analgesia, and there were no new critical pathways or other patient care guidelines. Results Case mix and all noncost variables were identical. Overall costs were reduced by 29% when normalized by the number of patient-days in each period. Laboratory testing was reduced in frequency by 24 to 32%, and cost by 26 to 28%. Comparable reductions in the cost of blood products (32%) were exceeded by the reductions in expenditures for nutritional supplements (49%) and pharmaceuticals (45%) (all, p < 0.01 or less). Modestly increased (2%) x-ray charges in 1995 were owing entirely to insertion of prophylactic inferior vena cava filters (each, $2,800, n = 5) and computed tomography scans for sinusitis (each, $350, n = 5), although the 7% reduction in portable chest radiographs that was achieved did not meet expectations. Conclusions Substantial reductions in physician-ordered ancillary expenditures are possible without compromising the standard of care of critically ill patients, or the support of an elaborate framework of defined care plans. With additional experience, incremental savings may accrue from refinement of successful strategies and new approaches to intractable problems.