August 20, 2009
12:01 a.m. Eastern Time
Despite Wide Adoption, Little Evidence of eICU Impact on Intensive Care Cost/Quality
Comparative Effectiveness Studies Should Examine Delivery-System and Work-Process Innovations--Not Just Drugs, Devices, and Services
Bethesda, MD -- While nearly 10 percent of U.S. hospital intensive care unit (ICU) beds use advanced telemonitoring--known as eICUs-- there has never been a systematic evaluation of how the innovative approach to caring for critically ill patients affects quality and costs, according to a study by the Center for Studying Health System Change (HSC) published today as a Health Affairs Web Exclusive.
The study explores why hospitals have chosen to embrace or eschew ICU telemedicine--trademarked as eICU by the dominant vendor VISICU Inc.--finding that "hospital clinical leaders hold strong views but have little objective information on which to judge the worthiness of this innovation," according to the study funded by the Robert Wood Johnson Foundation.
"The rapid diffusion of eICUs in hospitals across the country, which remains largely unstudied, illustrates the need for comparative effectiveness initiatives to include innovations in how we care for patients--not just specific drugs, devices, and services," said HSC Senior Consulting Researcher Robert A. Berenson, M.D., also an institute fellow at the Urban Institute and co-author of the study with HSC Senior Researcher Joy M. Grossman, Ph.D., and Elizabeth November, J.D., an HSC health research analyst.
"Proponents and detractors of eICUs feel strongly that their assessments are correct," Berenson added. "But without a rigorous assessment, who knows which side is right?"
The Health Affairs article, titled "Does Telemonitoring of Patients--The eICU--Improve Intensive Care?" was a follow-up study from HSC's 2007 site visits to 12 nationally representative communities--Boston; Cleveland; Greenville, S.C.; Indianapolis; Lansing, Mich.; Little Rock, Ark.; Miami; northern New Jersey; Orange County, Calif.; Phoenix; Seattle; and Syracuse, N.Y. HSC has been tracking change in these markets since 1995.
During the 2007 site visits, HSC researchers learned that hospital systems in five--Indianapolis, Little Rock, Miami, Phoenix and Seattle--of the 12 communities had adopted eICU systems. In the follow-up study, researchers interviewed clinicians in the five hospital systems with an eICU, clinicians in 19 non-eICU hospitals in the 12 markets, and national experts on ICU staffing, quality, and ICU telemedicine.
The eICU system combines the use of telemedicine with software applications to manage ICU patients from a central monitoring station, usually located off-site from the actual ICU and staffed with physicians with advanced training in critical care known as intensivists, critical care nurses, and administrative personnel.
Other key study findings include:
• Hospitals adopting eICUs generally were motivated by the potential to improve clinical quality and patient safety rather than expectations of cost savings from reduced complications and lengths-of-stay.
• Among hospitals not adopting eICUs, there was general agreement that the limited potential benefits did not justify significant upfront and ongoing operating costs--estimated at $3 million to $5 million in startup costs for 100 ICU beds, along with ongoing annual operating and staff costs of $1.3 million to $2.3 million per 100 beds. Virtually all of the hospitals without eICUs believed their current on-site ICU staffing was adequate and preferable to off-site staff. The lack of third-party reimbursement also was seen as a disincentive to adopt eICUs.
• Despite the lack of specific payment or other incentives, most hospitals in the study--both with and without eICUs--were working to improve ICU performance, primarily by adding more intensivists and adopting ICU–specific quality improvement tools, including prevention of ventilator-associated pneumonia and central-line infections.
• In all but one of the five eICU hospitals, poor interoperability between the eICU software and the hospitals' enterprise-wide information technology systems created barriers to using the full extent of eICU's advanced monitoring and outcome analysis features.
After the embargo lifts, you can read the article by Berenson, Grossman, and November at http://content.healthaffairs.org/cgi/content/abstract/hlthaff.28.5.w937
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