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Cost Comparison of Care for Chronic Ventilator Patients
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Cost Comparison of Carefor Chronic Ventilator Patients 1b the FAilor: The comparable costs of chronic ventilator care in five locations in the metropolitan St. PauVMinneapolis area are evaluated. These comparison locations include an intensive care setting, the Pr0longed Respiratory Care Unit (PRCU) of Bethesda Lutheran Medical Center, a group borne for ventilator patients, and three bome care options. These bome care options are based on three variations of nursing personnel requirements. Two case studies, with the patients serving as their own controls, are utilized as the basis for this comparison. The first case is a 75year-old woman wbo required mechanical ventilation; sbe developed significant cardiac arrhythmias and required transfer to a tertiary care setting intensive care unit for monitoring only. although telemetry was available in both localities. The second case is a 22year-old man with muscular dystrophy who was ventilator dependent. After multiple weaning attempts in the PRCU failed, the patient was eventually transferred-after comparison proposals were evaluated-to a group home for young, ventilator-dependent patients. With regard to the first case, the cost for 30 days of care in the intensive care unit vs the PRCU was $82,643.70 and $32,021.10, respectively. These costs, in the same hospital system, were inclusive of room, board, telemetry, ventilator, nursing and respiratory therapy personnel and services, oxygen, drugs, and supplies. The specialized respiratory care unit's lower cost can be attributed to the unique sharing of duties by nursing and respiratory therapy personnel. Also, the lack of high-eost services in the institution where the PRCU is located (emergency room, operating suites, and intensive care units) lowers the indirect cost attributed to the unit.
Table I-CM Comparilonl' Monthly Cost PRCU Group Home Home Care A" Home Care 8' Home Care C'
$26,964.30 $9,378.00
$8,265.00 $25,870.50 $34,665.00
'Case 2 'Equivalent durable medical equipment (DME): 12-14 h attendant; family primary care giver; ventilator 'Equivalent DME: 12-14 h attendant + 8 h RN-LPN; ventilator 'Equivalent DME; 24 h RN-LPN; ventilator
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'Iable 1 outlines the cost for 1 month's care for the second case. The three home care options vary basically in the amount of RN/ LPN/attendant care provided. Durable medical equipment, provision of oxygen, and other basic care needs were equivalent in all settings. It should be mentioned that the difference in medication cost, as well as the fact that telemetry was not used, accounts for the difference in cost of the PRCU for both cases. Three conclusions can be drawn from these data: 1) Costs for the care of the chronic ventilator-dependent patient are lower in specialized units, due to various factors outlined above, than in intensive care units. Two corollaries to this conclusion, therefore, are: a) patients should be transferred to specialized units as soon as possible when it becomes apparent that ventilation will last more than a few days; and b) additional specialized units for ventilatordependent patients need to be formed in centers across the United States. 2) The cost of home care, when comparing equivalent personnel (a major determinant of cost), is not always particularly cost-effective when compared to other forms of institutional care. 3) For certain types of patients, group homes may provide a costeffective and humanizing source of care, although these patients must be carefully selected.
Frankl lndihar; M.D., F.C.C.P., Bethesda Lutheran Medical CenterlHealthEast, St. Ebul, Minnesota Reprint requests: Dr. lndihar; 710 Gallery Building, 17 ~st Exchange Street, St. Ebul 55102
Economic Costs of Spontaneous Pneumothorax 7b the Editor:
Increasing knowledge bas been acquired about the nature of spontaneous pneumothorax (SP). We know that the underlying mechanisms include both internal factors (such as pulmonary stress,'·' impaired regional ventilation, and diminished perfusion in the apices of the lungs"); bronchial anomalies;' and external factors (such as smoking,'·· inactivity,' and decreasing extracorporeal pressure.··· In a retrospective, comparative, age-matched study" of the smoking habits of a series of SP patients and a recent Swedish material, it was found (with high statistical si~ificance) that smoking increases the incidence of SP ninefold among women and 22-fold among men. Thus, cessation of smoking reduces the occurrence of primary SP by approximately 70 percent among women and 90 percent among men.·'· In order to elucidate the total economic costs to society ofSp, we have calculated the direct and indirect costs with reference to the present situation in Sweden, with 2,000 cases per year" (based on treatment data from Huddinge University Hospital Stockholm.) As regards direct costs, 90 percent of all patients receive inpatient care, with an average hospital stay of 12 days for men and 14 days for women. In addition, all patients consult a physician twice on an outpatient basis during the year. After discharge the patients are sick-listed for 14 days; this period also includes nonbospitalized SP patients. Indirect costs consist of productivity losses caused by sicklisting patients age 16 to 64 years. CommunIcatIons to the EdIeDr
Cost Comparison of Carefor Chronic Ventilator Patients 1b the FAilor: The comparable costs of chronic ventilator care in five locations in the metropolitan St. PauVMinneapolis area are evaluated. These comparison locations include an intensive care setting, the Pr0longed Respiratory Care Unit (PRCU) of Bethesda Lutheran Medical Center, a group borne for ventilator patients, and three bome care options. These bome care options are based on three variations of nursing personnel requirements. Two case studies, with the patients serving as their own controls, are utilized as the basis for this comparison. The first case is a 75year-old woman wbo required mechanical ventilation; sbe developed significant cardiac arrhythmias and required transfer to a tertiary care setting intensive care unit for monitoring only. although telemetry was available in both localities. The second case is a 22year-old man with muscular dystrophy who was ventilator dependent. After multiple weaning attempts in the PRCU failed, the patient was eventually transferred-after comparison proposals were evaluated-to a group home for young, ventilator-dependent patients. With regard to the first case, the cost for 30 days of care in the intensive care unit vs the PRCU was $82,643.70 and $32,021.10, respectively. These costs, in the same hospital system, were inclusive of room, board, telemetry, ventilator, nursing and respiratory therapy personnel and services, oxygen, drugs, and supplies. The specialized respiratory care unit's lower cost can be attributed to the unique sharing of duties by nursing and respiratory therapy personnel. Also, the lack of high-eost services in the institution where the PRCU is located (emergency room, operating suites, and intensive care units) lowers the indirect cost attributed to the unit.
Table I-CM Comparilonl' Monthly Cost PRCU Group Home Home Care A" Home Care 8' Home Care C'
$26,964.30 $9,378.00
$8,265.00 $25,870.50 $34,665.00
'Case 2 'Equivalent durable medical equipment (DME): 12-14 h attendant; family primary care giver; ventilator 'Equivalent DME: 12-14 h attendant + 8 h RN-LPN; ventilator 'Equivalent DME; 24 h RN-LPN; ventilator
210
'Iable 1 outlines the cost for 1 month's care for the second case. The three home care options vary basically in the amount of RN/ LPN/attendant care provided. Durable medical equipment, provision of oxygen, and other basic care needs were equivalent in all settings. It should be mentioned that the difference in medication cost, as well as the fact that telemetry was not used, accounts for the difference in cost of the PRCU for both cases. Three conclusions can be drawn from these data: 1) Costs for the care of the chronic ventilator-dependent patient are lower in specialized units, due to various factors outlined above, than in intensive care units. Two corollaries to this conclusion, therefore, are: a) patients should be transferred to specialized units as soon as possible when it becomes apparent that ventilation will last more than a few days; and b) additional specialized units for ventilatordependent patients need to be formed in centers across the United States. 2) The cost of home care, when comparing equivalent personnel (a major determinant of cost), is not always particularly cost-effective when compared to other forms of institutional care. 3) For certain types of patients, group homes may provide a costeffective and humanizing source of care, although these patients must be carefully selected.
Frankl lndihar; M.D., F.C.C.P., Bethesda Lutheran Medical CenterlHealthEast, St. Ebul, Minnesota Reprint requests: Dr. lndihar; 710 Gallery Building, 17 ~st Exchange Street, St. Ebul 55102
Economic Costs of Spontaneous Pneumothorax 7b the Editor:
Increasing knowledge bas been acquired about the nature of spontaneous pneumothorax (SP). We know that the underlying mechanisms include both internal factors (such as pulmonary stress,'·' impaired regional ventilation, and diminished perfusion in the apices of the lungs"); bronchial anomalies;' and external factors (such as smoking,'·· inactivity,' and decreasing extracorporeal pressure.··· In a retrospective, comparative, age-matched study" of the smoking habits of a series of SP patients and a recent Swedish material, it was found (with high statistical si~ificance) that smoking increases the incidence of SP ninefold among women and 22-fold among men. Thus, cessation of smoking reduces the occurrence of primary SP by approximately 70 percent among women and 90 percent among men.·'· In order to elucidate the total economic costs to society ofSp, we have calculated the direct and indirect costs with reference to the present situation in Sweden, with 2,000 cases per year" (based on treatment data from Huddinge University Hospital Stockholm.) As regards direct costs, 90 percent of all patients receive inpatient care, with an average hospital stay of 12 days for men and 14 days for women. In addition, all patients consult a physician twice on an outpatient basis during the year. After discharge the patients are sick-listed for 14 days; this period also includes nonbospitalized SP patients. Indirect costs consist of productivity losses caused by sicklisting patients age 16 to 64 years. CommunIcatIons to the EdIeDr