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An ICU director opts to add a registered nurse to the unit, but will hold off on buying a new, top-of-the-line ventilator.
An expensive, recently approved drug is used routinely by some hospital ICUs, but almost never by others.
These are hypothetical examples of “rationing” in ICUs – a practice that is becoming increasingly common in hospitals across the country, according to a recently formed task force of critical-care doctors and bioethicists, sponsored by Brown Medical School and Rhode Island Hospital.
The Values, Ethics and Rationing in Critical Care (VERICC) task force in June embarked on an 18-month, $1.8 million initiative to study the practice of rationing care in ICUs.
Upward pressure on medical costs has finally trickled into an area of medicine once thought untouchable by budget constraints, according to Dr. Mitchell Levy, the chairman of VERICC and director of Rhode Island Hospital’s medical ICU.
“You can’t work in intensive care and not be aware of the fact that rationing has become a frequent occurrence at the bedside,” said Levy, who also is an associate professor of medicine at Brown.
“We’re all afraid to talk about it because rationing has a negative connotation,” Levy said. “But rationing is a necessary aspect of medicine now. There are too many drugs and diagnostic procedures and interventions that cost a lot and have uncertain benefits.”
From that baseline – that rationing in critical-care medicine exists and that it isn’t always a bad thing – VERICC wants to start a national dialogue among ICU doctors and hospital administrators, and eventually develop a system to help clinicians make those tough choices.
The 20-member task force includes physicians and bioethicists from a number
of prestigious institutions, including Brown and Rhode Island Hospital, Harvard
Medical School, The Johns Hopkins School of Medicine, the National Institutes
of Health and Children’s Hospital in Boston.
No longer the sacred cow?
Critical-care medicine long has been the “sacred cow” when it comes to hospitals trimming costs, according to Dr. Nicholas Ward, a VERICC member, associate director of the medical ICU at Rhode Island Hospital and an assistant professor of medicine at Brown.
“The feeling has always been that if you’re sick enough to be in the ICU, you’re sick enough to let the doctors do what they need to do,” Ward said. “In critical-care medicine, we’ve pretty much had a Gold Card to do what we want.”
But spiraling medical costs – increasing at seven times the rate of inflation – coupled with swelling demand for critical-care services is shaping new realities in the ICU, task force members say.
More than half of 620 members of the Society of Critical Care Medicine surveyed last year said they withhold medications, tests or other services when they think the costs outweigh the potential benefit.
But that doesn’t mean critical-care doctors are compromising patient care, according to Dr. Marion Danis, a critical-care physician and member of VERICC, who now works as a bioethicist at the NIH.
“These are the kinds of questions businesses face everyday, ‘How can we allocate our resources to get the best outcome?’” Danis said in a phone interview. “People should not view these decisions negatively.”
Danis will work with the group to come up with a computer model for helping ICU personnel perform cost-benefit analyses. For example, the model would quantify the effect of, say, replacing an old ventilator with an expensive new one, or eliminating an RN position from the unit.
Danis emphasized that her comments on the rationing issue were as a member of VERICC, and do not reflect the views of the NIH.
‘Poster child’ for rationing debate
The discussion over rationing care in ICUs frequently goes back to what Levy calls the debate’s “poster child”: a drug made by Eli Lilly & Co. called Xigris, which hit the market two years ago.
Xigris is an intravenous treatment for septic shock, a potentially lethal drop in blood pressure caused by bacteria in the bloodstream. The condition kills an estimated 215,000 people in the United States each year.
But a 2001 report published in the New England Journal of Medicine said that Xigris reduced the death rate in sepsis patients by just 6 percent. It also comes with a big price tag: $6,800 for one treatment.
While some hospital ICUs have embraced the drug as a routine treatment for septic-shock patients, others have shied away from it altogether, VERICC members say.
“It’s the first instance I can think of where a new therapy has come on the scene with proven benefits that has not been automatically adopted,” Ward said. “The reason, although some people deny this, is cost.”
A nursing home patient, in her mid-80s and suffering from dementia, had been admitted to the ICU in septic shock. She was on a ventilator, on several medications and going on her second day in the ICU – at a cost of more than $3,000 per day.
Doctors decided to use Xigris on the patient, Ward said.
When recounting that anecdote to fellow critical-care physicians, Ward said his peers “invariably go bananas” at the decision. But he said a decision to not use the medication would have been arbitrary.
“At that point, I felt like we should be trying to get her out of the ICU
rather than trying to save money,” Ward said.
Finding a systematic approach
The point, Ward said, is that there needs to be a system in place for such decisions. The problem, he says, is that choices are made scattershot, resulting in a national patchwork of rationing practices.
VERICC plans to develop a national “resource-allocation model” that would be accessible to all ICUs in the country, giving clinicians and administrators practical, ethical guidelines for rationing limited resources.
The initiative would include:
• Creation of a document that would determine when rationing happens, how those decisions are made, whether the decisions are disclosed.
• Development of a computer model that will attempt to link the allocation of ICU resources to outcomes.
• A comprehensive survey of critical-care physicians, nurses, hospital administrators and patients – spanning large urban academic-medical centers to small rural hospitals – to gauge perceptions of rationing and its impact on patient care.
The effort is being funded through an educational grant from Eli Lilly – a potential conflict of interest that VERICC members are quick to acknowledge. Levy said the drug company will have “no involvement whatsoever in what we are doing.”
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