TY - JOUR
T1 - Cost-utility in medical intensive care patients rationalizing ongoing care and timing of discharge from intensive care
AU - Thomas, Kurien
AU - Peter, John Victor
AU - Christina, Jony
AU - Jagadish, Anna Revathi
AU - Rajan, Amala
AU - Lionel, Prabha
AU - Jeyaseelan, Lakshmanan
AU - Yadav, Bijesh
AU - John, George
AU - Pichamuthu, Kishore
AU - Chacko, Binila
AU - Pari, Priscilla
AU - Murugesan, Thilagavathi
AU - Rajendran, Kavitha
AU - John, Anu
AU - Sathyendra, Sowmya
AU - Iyyadurai, Ramya
AU - Jasmine, Sudha
AU - Karthik, Rajiv
AU - Mathuram, Alice
AU - Hansdak, Samuel George
AU - Abhilash, Kundavaram Paul P.
AU - Kumar, Shuba
AU - John, K. R.
AU - Sudarsanam, Thambu David
N1 - Publisher Copyright:
Copyright © 2015 by the American Thoracic Society.
PY - 2015/7/1
Y1 - 2015/7/1
N2 - Rationale: Intensive care unit (ICU) treatment costs pose special challenges in developing countries. Objectives: To determine the prognostic value of the "utility" score and evaluate the relationship of willingness to pay assessment to utility score during ICU admission. Methods: We performed a prospective study spanning 12 months in a 24-bed medical ICU in India. Treatment cost was estimated by direct measurement. Global utility score was assessed daily by healthcare providers on a Likert scale (0-1 in increments of 0.1, with 0 indicating death/severe disability and 1 indicating cure/perfect health). The sensitivity, specificity, and likelihood ratios of utility in predicting ICU mortality was calculated. Receiver operating characteristic curves were generated to compare Day 2 utility withAPACHEII. The caregiver's willingness to pay for treatment was assessed on alternate days using the bidding method by presenting a cost bid. Based on the response ("yes" or "no"), bids were increased or decreased in a prespecified manner until a final bid value was reached. Simultaneously, treating doctors were asked how much institutional funds they would be willing to spend for treatment. Measurements and Main Results: Primary diagnosis in 499 patients included infection (26%) and poisoning (21%). The mean (SD) APACHE II score was 13.9 (5.8); 86% were ventilated. ICU stay was 7.8 (5.5) days. ICU mortality was 23.9% (95% confidence interval, 20.3-27.8). Survivalwithout disabilitywas 8.3%(2/24) forDay 2 utility score ≤0.3 and 95.8% (53/56) for Day 5 score >0.8 (P<0.001). The likelihood ratio to predict mortality increased as utility values decreased and was highest (5.85) for utility 0.2. Area under the receiver operating characteristic curves for utility and APACHE II were similar. Willingness to pay by the caregiverwas 53%of treatment cost and was not influenced by utility. Willingness to pay by ICU doctors showed an inverted U-shaped relationship with utility. Conclusions: Utility scores help prognosticate, with Day 2 score ≤0.3 associated with poor outcome and ≥0.8 Day 5 score with survival. The caregiver's willingness to pay was inadequate to meet treatment cost. ICU doctors were willing to spend more for moderate utility scores than for very high or low utility values. Further prospective studies are needed to optimize the utilization of scarce ICU resources by identifying patients for appropriate step-down care using utility and willingness to pay.
AB - Rationale: Intensive care unit (ICU) treatment costs pose special challenges in developing countries. Objectives: To determine the prognostic value of the "utility" score and evaluate the relationship of willingness to pay assessment to utility score during ICU admission. Methods: We performed a prospective study spanning 12 months in a 24-bed medical ICU in India. Treatment cost was estimated by direct measurement. Global utility score was assessed daily by healthcare providers on a Likert scale (0-1 in increments of 0.1, with 0 indicating death/severe disability and 1 indicating cure/perfect health). The sensitivity, specificity, and likelihood ratios of utility in predicting ICU mortality was calculated. Receiver operating characteristic curves were generated to compare Day 2 utility withAPACHEII. The caregiver's willingness to pay for treatment was assessed on alternate days using the bidding method by presenting a cost bid. Based on the response ("yes" or "no"), bids were increased or decreased in a prespecified manner until a final bid value was reached. Simultaneously, treating doctors were asked how much institutional funds they would be willing to spend for treatment. Measurements and Main Results: Primary diagnosis in 499 patients included infection (26%) and poisoning (21%). The mean (SD) APACHE II score was 13.9 (5.8); 86% were ventilated. ICU stay was 7.8 (5.5) days. ICU mortality was 23.9% (95% confidence interval, 20.3-27.8). Survivalwithout disabilitywas 8.3%(2/24) forDay 2 utility score ≤0.3 and 95.8% (53/56) for Day 5 score >0.8 (P<0.001). The likelihood ratio to predict mortality increased as utility values decreased and was highest (5.85) for utility 0.2. Area under the receiver operating characteristic curves for utility and APACHE II were similar. Willingness to pay by the caregiverwas 53%of treatment cost and was not influenced by utility. Willingness to pay by ICU doctors showed an inverted U-shaped relationship with utility. Conclusions: Utility scores help prognosticate, with Day 2 score ≤0.3 associated with poor outcome and ≥0.8 Day 5 score with survival. The caregiver's willingness to pay was inadequate to meet treatment cost. ICU doctors were willing to spend more for moderate utility scores than for very high or low utility values. Further prospective studies are needed to optimize the utilization of scarce ICU resources by identifying patients for appropriate step-down care using utility and willingness to pay.
KW - Cost-utility
KW - Health economics
KW - Intensive care
KW - Willingness-to-pay
UR - http://www.scopus.com/inward/record.url?scp=84942236904&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=84942236904&partnerID=8YFLogxK
U2 - 10.1513/AnnalsATS.201411-527OC
DO - 10.1513/AnnalsATS.201411-527OC
M3 - Article
C2 - 26011090
AN - SCOPUS:84942236904
SN - 2325-6621
VL - 12
SP - 1058
EP - 1065
JO - Annals of the American Thoracic Society
JF - Annals of the American Thoracic Society
IS - 7
ER -