Tele-ICU: Is It Worth It?
Abstract & Commentary
By Saadia R. Akhtar, MD, MSc. St. Luke's Idaho Pulmonary Associates, Boise. Dr. Akhtar reports no financial relationships relevant to this field of study.
This article originally appeared in the October 2012 issue of Critical Care Alert. It was edited by David J. Pierson, MD, and peer reviewed by William Thompson, MD. Dr. Pierson is Professor Emeritus, Pulmonary and Critical Care Medicine, University of Washington, Seattle, and Dr. Thompson is Associate Professor of Medicine, University of Washington, Seattle. Drs. Pierson and Thompson report no financial relationships relevant to this field of study.
Synopsis: Based on their review of prior published studies of telemedicine ICUs and the initiation of a telemedicine ICU in a Veterans Health Administration hospital system, the authors find that costs of implementation are substantial and the sum impact on hospital expenses and profits remains unclear.
Source: Kumar G, et al. The costs of critical care telemedicine programs: A systematic review and analysis. Chest 2012; Jul 10. [Epub ahead of print.]
Kumar et al set out to describe the cost of ICU telemedicine programs (tele-ICU). They had two objectives: to systematically review the existing literature reporting costs of tele-ICU programs and to provide cost figures for tele-ICU implementation in a Veterans Health Administration (VHA) hospital network.
The literature review spanned about 11 years (Jan. 1, 1990 to July 1, 2011); 5 years (2006-2010) of research abstracts from relevant national organizations were included. The authors defined tele-ICU as "any form of technology that used telemedicine to facilitate communication between remotely located intensivists and distant providers or patients in an ICU." Included studies had to involve tele-ICU implementation and present relevant cost data. The studies were graded on quality using published criteria. At least two authors independently abstracted data using a predefined data extraction tool. The authors had access to detailed cost data for tele-ICU implementation in a seven-hospital VHA network (8 ICUs and 74 ICU beds); they applied validated depreciation methods to projected costs for the first year of operation (the system did not become active until August 2011). In order to compare the VHA data to the figures reported in the literature, costs were classified as tele-ICU program costs (technology, staffing, and real estate; presented as costs per ICU bed) or hospital variable costs (resources used in patient care).
Of 852 studies, eight (comprising 29 ICUs) met inclusion criteria; they were of lower methodological quality and varied considerably in type of technologies, setting, duration of monitoring per 24 hours, and costs entailed and reported. Overall estimated cost for a tele-ICU program for 1 year (implementation, site operation, and staffing) ranged from $50,000-$100,000 per ICU bed. Only six studies addressed hospital variable costs and sum impact on hospital expenses; those with authors having ties to the tele-ICU vendor reported cost savings (up to $3000 per patient) and profits (up to $4000 per patient). The remainder found no savings and possible increased costs. VHA network data revealed overall 1-year costs of $70,000-$87,000 per ICU bed; the authors note that due to prior existence of an electronic health record and other integrated structures at the VHA, costs of implementation may be lower than they would be in other hospital networks.
Commentary
Telemedicine (defined by the American Telemedicine Association as "use of medical information exchanged from one site to another via electronic communications to improve patients' health status") has been in existence in some form for several decades. These technologies are funded by health care systems themselves, rather than by third-party payors. Tele-ICU appears to be an attractive approach to improving access to (and potentially quality of) care in this era of shortage of specialists and rising population of older and sicker patients. There also seems to be potential for cost savings by increasing efficiency and quality of care, reducing adverse outcomes and length of stays, and even decreasing overall staffing costs. Robust data supporting these hypotheses, though, are lacking.
Kumar et al's work is a valuable first step in trying to better understand the cost-effectiveness of tele-ICU. Their report is limited by the quality and variability of previously published data (particularly the lack of detailed financial data for implementation or ultimate outcomes) and the fact that the VHA data presented are primarily projected, not actual, costs. However, the costs of implementation that these authors report are the most accurate and detailed numbers published to date and they provide a good framework for further study. In order to understand the true potential benefits of tele-ICU, we need additional detailed reports of costs of initiation and ongoing operation of tele-ICU in parallel with clinical outcomes data and their sum impact on health care expenses. It will also be important to try to elucidate the effect on patient, family, and staff experiences. Should every hospital set up a tele-ICU? Is tele-ICU cost effective only for health care systems of certain size or volume? Are benefits of tele-ICU significant for those facilities that already have on-site intensivists? Will ICU care be out-sourced and thus impact health care provider employment or reimbursement? Could tele-ICU depersonalize patient and family experiences?
Interest in tele-ICUs has grown rapidly and more and more U.S. health care systems (per Kumar et al, at least 40 thus far) are implementing them. As the authors note, the long-term viability of these systems remains unclear; this considerable initial enthusiasm is unlikely to last unless a positive clinical and financial impact is demonstrated. Is tele-ICU worth it? Stay tuned for the answer.
Based on their review of prior published studies of telemedicine ICUs and the initiation of a telemedicine ICU in a Veterans Health Administration hospital system, the authors find that costs of implementation are substantial and the sum impact on hospital expenses and profits remains unclear.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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