Overall, the introduction of the tele-ICU in the six ICUs at this large non-profit health care system in the Gulf Coast region was associated with higher costs. After the implementation of the tele-ICU, the hospital daily cost increased from $4,302 to $5,340 (24%), the hospital cost per case from $21,967 to $31,318 (43%), and the cost per patient from $20,231 to $25,846 (28%). Most of these increases in costs are due to increases in ICU costs (77% for average daily costs, 67% for costs per case and 50% for patient costs). These increases in costs after the introduction of the tele-ICU are in contrast with Breslow et al. (2004) which found that tele-ICU was cost saving,10
but support the findings of increasing costs by Morrison et al. (2009).11
The higher costs in the post-period could not be explained by medical inflation. From 2003 to 2006, when cost data were collected, the medical inflation rate was less than 4% which is well below the increase in costs reported in this study. We did not adjust for medical inflation because cost data were collected within one year for three ICUs and within 15 months for two ICUs. Only for one ICU, ICU5, the pre-period extended for 14 months and overall data collection for over 2 years. It is unclear if other potential cost drivers were operating at the healthcare system during the study period. During that period, there was a significant increase in the number of ICU beds in the healthcare system which would increase overall costs, but not necessarily per patient costs.
The tele-ICU implementation did not reduce length of stay, complications, or mortality in the overall sample. The main positive clinical outcome was a reduction in ICU and hospital mortality in the sickest patients, those with SAPS II > 50 which represent 17% of patients.12
In this subgroup of sickest patients, the tele-ICU intervention was cost effective as it decreased hospital mortality without increasing costs significantly. In the patients who were less sick, those with SAPS II ≤ 50 or 83% of the patients, the tele-ICU intervention was not cost effective as it increased per patient costs without improving hospital mortality. While this study does not support the use of tele-ICU in less sick patients, hospital administrators may well conclude that a tele-ICU program aimed at the sickest patients is worth implementing.
A limitation of this study is the use of the health care system perspective in the cost-effectiveness analysis. Health economists usually recommend adopting a societal perspective when conducting cost-effectiveness studies. However, there are several challenges in using a societal perspective in cost-effectiveness studies with ICU patients. While the societal perspective tends to use quality adjusted survival as an outcome, the outcome measures used in ICUs tend to be short term and hospital based, such as complications, length of stay, or hospital mortality, which occur in the hospital and do not lend themselves to a societal perspective. Therefore, it has been recommended that cost-effectiveness studies in ICUs present a ‘data rich’ case which is generated from data on actual patient outcomes and costs measured at the hospital level.15
Unlike some other studies that report on volume or revenue measures, we were not able to address the impact of the tele-ICU on hospital volume and revenue because of lack of data. Other limitations, including the lack of randomization, are discussed in our previous publication.12
Notably, about 2/3 of the physicians in the monitored ICUs gave the tele-ICU only minimal delegation (the tele-ICU could only intervene for life threatening situations as judged by the tele-ICU staff), but did not give full delegation (the tele-ICU could give routine orders, change treatment plans, and intervene for life threatening situations). Furthermore, the tele-ICU software was not fully integrated with the hospital system’s electronic medical record. Therefore, ICUs with better physician acceptance and integration of information systems may have more favorable clinical and outcomes. One further limitation is that all the costs of operating the tele-ICU program were obtained from the tele-ICU administration.
the strengths of the study are numerous. It is the largest study of tele-ICU programs to date, includes a diverse mix of ICUs, and results are based on high quality data.