Lessons learned: Durability and progress of a program for ancillary cost reduction in surgical critical care - Discussion

Objective: Modern surgical care must meet high standards of quality but must also be cost-effective. Critical care uses huge amounts of resources, and strategies for effective use of scarce, expensive intensive care unit beds must be implemented. Previously, we demonstrated that ancillary expenditures can be decreased without compromising care. The present study was performed to determine whether our cost-containment strategies were durable and could be extended to areas, such as chest roentgenography, where savings previously proved elusive. Methods: Costs for laboratory tests, radiographs, and drugs were determined prospectively for all surgical intensive care unit care for a 34-month period (January 1, 1994-October 31, 1996) at an urban university center. A systematic, multidisciplinary cost- reduction program began on May 1, 1994, with emphasis on laboratory and radiographic testing and procedures and drug therapies. Calendar-year cohorts were compared by age and Acute Physiology and Chronic Health Evaluation II and III admission scores. Outcome variables were hospital mortality, days in the intensive care unit and hospital, and expenditures. Cost data were taken weekly from the hospital's clinical information system. Results: All admission noncost variables were identical. There were significant reductions in intensive care unit and hospital length of stay, and there was a trend (p = 0.07) toward decreased hospital mortality. Normalized by the number of patient-days per week, arterial blood gas determinations were reduced 46% between 1994 and 1996, and nonarterial blood gas laboratory tests were reduced by 29% (both p < 0.0001). Within the latter group, electrolyte determinations decreased by 38% and serum creatinine determinations decreased by 32%. Chest roentgenograms decreased by 34%, but pharmaceutical costs decreased by a remarkable 73%. Conclusion: Durable reductions in physician- ordered ancillary expenditures are possible without compromising the standard of care of critically ill patients, but active management and daily reinforcement are necessary to the process. Shorter length of stay and lower costs benefit the patient, the surgeon, the intensivist, and the institution.