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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 8  |  Issue : 3  |  Page : 268-276

Cost of medical management of patients in intensive care unit in a tertiary care teaching hospital, Pune, India


1 Department of Clinical Pharmacy, Poona College of Pharmacy, Bharati Vidyapeeth Deemed University, Pune, Maharashtra, India
2 Department of Critical Care Medicine, Bharati Hospital and Research Centre, Pune, Maharashtra, India
3 Department of Pharmaceutics, Poona College of Pharmacy, Bharati Vidyapeeth Deemed University, Pune, Maharashtra, India

Date of Submission26-May-2021
Date of Acceptance12-Jul-2021
Date of Web Publication03-Sep-2021

Correspondence Address:
Dr. Prasanna R Deshpande
Department of Clinical Pharmacy, Poona College of Pharmacy, Bharati Vidyapeeth Deemed University, Pune 411030, Maharashtra.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mgmj.mgmj_31_21

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  Abstract 

Aims and Objectives: The aim of this study was to assess the cost of illness of the patients admitted to the intensive care unit (ICU). Materials and Methods: A prospective observational study was conducted on patients admitted and discharged from ICU above 18 years of any medical illness for 6 months in ICU in a tertiary care teaching hospital, Pune. Data such as demographic details, diagnosis, disease class, cost of drug therapy, and medical care cost were obtained. The cost was analyzed using the bottom-up method and statistical analysis of data was done using Pearson’s correlation coefficient and Mann–Whitney U test. Results: Of 400 patients, the average age was 54.27 years with a length of stay of 3.69 days and mortality rate of 12.25%. The average total cost per patient accounted for Rs. 52,840 and the per day cost was Rs. 14,319. Amongst various diagnoses, the cost incurred in alcoholic liver disease (ALD) accounted for Rs. 75,060 of the total cost, whereas the average per day cost observed in myocardial infarction (MI) was Rs. 15,495. The cost of drug therapy per patient was Rs. 5204.33 and total drug therapy accounted for 12.08%. The average number of drugs prescribed per patient was 8.44. Antimicrobial costs were observed as 28% of the total cost. The cost of antimicrobials was Rs. 1473 per patient. Medical care costs, including consultant and investigation charges per patient, were found to be Rs. 632 and Rs. 6861, respectively. Conclusion: The study reveals that ICU bed charges, miscellaneous charges, and drug therapy costs have more contribution to the direct medical cost of hospitalization.

Keywords: Cost of illness, drug use evaluation, economics, health economics, intensive care unit, India


How to cite this article:
Mathew AA, Karsiya JN, Patel NK, Limbachiya DA, Shah JN, Pawar AP, Deshpande PR. Cost of medical management of patients in intensive care unit in a tertiary care teaching hospital, Pune, India. MGM J Med Sci 2021;8:268-76

How to cite this URL:
Mathew AA, Karsiya JN, Patel NK, Limbachiya DA, Shah JN, Pawar AP, Deshpande PR. Cost of medical management of patients in intensive care unit in a tertiary care teaching hospital, Pune, India. MGM J Med Sci [serial online] 2021 [cited 2021 Sep 21];8:268-76. Available from: http://www.mgmjms.com/text.asp?2021/8/3/268/325539




  Introduction Top


Pharmacoeconomics is the study of analyzing hospitalization costs and the consequences of such on therapeutic benefit.[1] The cost of illness (COI) to the patient is the personal cost and of acute and chronic disease. The cost to the patient may be an economic, social, psychological, or personal loss to self, family, and intermediate relative. The COI in the intensive care unit (ICU) encompasses direct medical care cost, indirect cost, and intangible cost. The outcome of COI is expressed in monetary terms.

ICU is a specialized unit in a healthcare establishment that caters medical care services to patients who are acutely ill and are significantly injured and for whom recovery is possible. The specialized practices which make them different from other units such as uninterrupted artificial ventilators, neurologic support, shock management, and renal dialysis using specialized equipment such as ventilators, multi-parameter monitors, among many others. Critical care medicine is relatively a new field in India and it is estimated that India has 95,000 ICU beds.[2],[3] Therefore, due to the extreme dearth of ICUs, the available ICUs are in great demand.[4] The average per day cost in a study conducted by Shweta et al.[5] accounted for Rs. 10,364 and hence even one-time admission into the ICU carries a huge economic burden to the patient and their family.[6],[7] In the third world country, the concept of insurance has not yet reached the masses, and the people have to struggle for monetary arrangements. This is also because of a lack of social security policies among the majority of both rural and urban populations; 80% of the patients have to pay out of their pocket.[2],[5],[6] As a consequence, families are forced to sell their assets and borrow money.[2],[6] Despite the high cost incurred in ICU, there is a paucity of studies with good scientific consistency, about the expenses in an ICU.[8] Hence, assessment of such costs and subsequent identification of drivers of ICU-related costs is in desperate need of the day.


  Objectives Top


Primary objectives

  • To assess the cost of management of the patients admitted to the ICU.


  • To assess the financial burden of patients admitted in ICU.


  • Secondary objectives

  • To assess the drug use pattern in ICU patients.


  • To assess the difference in cost of treatment across multiple diseases.


  • To identify the per patient cost for treatment across multiple clinical services for ICU patients.


  • To assess the cost associated with patients on ventilator vs. patients not on a ventilator.


  • To compare the cost associated with patients undergoing surgery with patients not undergoing surgery.


  • To conduct statistical analysis (association/differences) between demographic parameters and study outcomes.



  •   Materials and methods Top


    Study design

    This was a prospective observational study

    Setting

    An ICU in a tertiary care setting hospital in Pune city, India from October 2018 to April 2019.

    Participants

    Patients admitted and discharged from ICU above 18 years of any medical illness and discharge against medical advice criteria were included and reviewed daily. Medico-legal cases of any kind were excluded from the study.

    Ethical clearance

    The study protocol was reviewed and approved by the Institutional Ethics Committee (approval number BVDUMC/IEC/4, dated October 9, 2018). With it, informed consent was obtained from the patients.

    Sample size: 400

    Sampling: Convenience sampling

    Study procedure

    Data from both patient files and hospital records sources were used. ICU resource use and costs of each component were tracked over 6 month’s period for 400 patients using the billing records till the date of discharge (DOD) from the ICU. Data were recorded according to the parameters in the preformed record form. It contains demographic data such as patient registration numbers (PRN), inpatient department (IPD), date of admission (DOA), DOD, name, age, gender, diagnosis, and disease class.

    Cost of medication: Brand names, generic names, route of administration, dose, unit cost, frequency, and total cost of individual drugs.

    Medical care cost: It includes bed, nursing, equipment, laboratory, radiology, and pathology charges. The cost analysis was performed on all the patients using the bottom-up method and the margin of error was calculated by RaosoftCalculator.[9] Direct medical costs (variable costs) were estimated. The costs were computed by demographic parameters such as age profile (average age of the patient), length of stay (LOS) (included the cost of all 400 patients, surgical and nonsurgical patients, patients with or without mechanical ventilation, and according to disease class), mortality rate. Cost assessment of total therapy included medical care costs (such as pathology, radiology, equipment, nursing, bed, inventory, miscellaneous) and drug therapy costs (from hospital bills and online drug cost resources). Miscellaneous costs included diet cost, registration charges, consultation cost, physiotherapy cost, biomedical waste disposal costs, and other random charges. Per patient per day, costs were also analyzed. All costs were calculated in Indian National Rupees (INR).

    Statistics

    P-Value was estimated using Pearson’s correlation coefficient[10] and thus the parameters considered were age vs. total cost, medical care, and drug therapy followed by LOS. Mann–Whitney U test[11] was used to compare costs (total costs, medical care cost, and drug therapy) between males and females. A value of P < 0.05 was considered statistically significant.


      Results Top


    In this study, a total of 400 patients were evaluated. The margin of error was found to be 4.85% according to the Raosoft Sample Size calculator,[9] considering parameters like confidence level as 95% and response distribution as 50%.

    Age profile

    It was found that the maximum number of patients admitted to the ICU ward was of the age group 59–68 years, which accounted for 21.75% of the total number of patients followed by the age group 49–58 (17%). The average age of the patient in our study was found to be 54.27±18.14 years.

    Of 400 patients, 237 were male patients which showed predominant (59.25%) followed by 163 female patients (40.75%). The average LOS of various parameters was found out to be as follows:

    • For 400 patients, LOS was 3.69 days.


    • For nonsurgical patients, it was 3.53 days.


    • For surgical patients, it was 5.29 days.


    • For patients with ventilator, it was 7.44 days.


    • For patients without ventilator, it was 3.04 days.


    Average LOS according to disease class is shown in [Table 1]. Of the total 400 patients, 49 patients were dead. Hence, the mortality rate was 12.25%.
    Table 1: Length of stay (LOS) with disease class

    Click here to view


    Drug use analysis

    Pantoprazole (94%) was prescribed in the maximum number of patients, followed by ondansetron (82.75%). [Table 2] represents the cost consumption of various drugs.
    Table 2: Most commonly prescribed drugs

    Click here to view


    Diagnosis classification of patients

    A total sample size of 400 patients showed 14 commonly occurring diseases. These diseases were classified according to their diagnosis into alcoholic liver disease (ALD) (2.76%), asthma (1.58%), congestive cardiac failure (CCF) (1.18%), chronic kidney disease(11.06%), chronic obstructive pulmonary disease (5.92%), cerebrovascular accident (CVAs) (14.22%), dengue (2.76%), diabetes mellitus/diabetic ketoacidosis (13.83%), generalized tonic-clonic seizures (12.25%), hypertension (7.90%), intracranial bleed (7.11%), myocardial infarction (MI) (11.46%), pneumonia (6.71%), and septic shock (1.97%). Patients suffering from CVAs were highest among the population. [Figure 1] shows the number of patients with each type of diagnosis.
    Figure 1: Diagnosis vs. number of patients. Showing the diagnosis classification for patients admitted in ICU. MI = myocardial infraction; IC = intracranial bleeding; HTN = hypertension; GTCS = generalized tonic-clonic seizures; DM/DKA = diabetes mellitus/ diabetic ketoacidosis; CVA = cerebrovascular accidents; COPD = chronic obstructive pulmonary disease; CKD = chronic kidney disease; CCF = congestive cardiac failure; ALD = acute liver disease

    Click here to view


    Disease class classification

    Patients suffering from central nervous system complications were seen highest (31%).

    Patients were also classified according to their disease class, as shown in [Figure 2].
    Figure 2: Number of patients vs. patient disease class

    Click here to view


    Route of administration analysis

    The most common route of administration was found to be the parenteral route (52.63%) followed by the oral route (42.89%), nebulization (3.95%), and topical (0.54%).

    Total cost assessment

    The study concluded that the total cost of therapy for 400 patients was found to be Rs. 1,72, 19, 662.41± 45,822.49, of which drug therapy consumed 12.08% of the total cost, whereas medical care cost (pathology, radiology, equipment, nursing, inventory, surgical, bed, and miscellaneous) was found to be 87.91%.

    The cost parameters assessed in the study were pathology cost, radiology cost, equipment cost, nursing cost, inventory cost, surgical cost, bed cost, drug therapy cost, and miscellaneous cost. Investigational cost per patient was found to be Rs. 6, 861.05. The total cost of individual parameters is shown in [Figure 3].
    Figure 3: Total cost assessment

    Click here to view


    Per patient cost analysis

    The cost per day of each patient of all parameters was calculated, and an average of the value was taken to derive per patient cost. Per day cost of bed charges was found to be the highest that accounted for 34% of the total per day cost of therapy of patients. Based on the above values, the total cost of therapy per day per patient was found to be Rs. 3 875.49. Per patient cost analysis of individual parameters is shown in [Table 3].
    Table 3: Cost assessment

    Click here to view


    Patients on surgical vs. nonsurgical patients and ventilator vs. nonventilator

    The cost of resources used by surgical and nonsurgical patients was assessed where the total cost of therapy per day per patient in nonsurgical was Rs. 3475.11 with LOS of 3 days and surgical patients were 5299.84 with LOS of 5 days. Mechanical ventilation was used in 5.23% of nonsurgical patients, whereas 13.51% in surgical patients. The total number of patients with ventilators was 59 (14.75%) with an average LOS of 8 days and without ventilators were 341 (85.25%) and an average LOS of 3 days. Per day per patient cost in patients without a ventilator and in patients with a ventilator was found to be 4140.12 and 1679.88, respectively. Cost comparison according to special classification is shown in [Table 4].
    Table 4: Cost associated with a specific class of patients

    Click here to view


    Cost associated with diagnosis

    Analysis of diagnosis of patients in this study showed that patients with ALD, chronic obstructive pulmonary disease, and septic shock were found to show the highest cost of therapy, whereas patients with CCF showed the lowest cost of therapy. Average cost consumption based on diagnosis is shown in [Table 5].
    Table 5: Analysis of diagnosis cost

    Click here to view


    Cost associated with drugs

    According to the study, antibiotics are majorly consumed to be 28% of total drug therapy cost. Of 28% of total antibiotic consumption, ceftriaxone consumed 17% of the total cost of antibiotics, followed by piperacillin + tazobactum (46%) and amoxicillin (18%), respectively. The cost distribution among different antibiotics is shown graphically in [Figure 4]. Pantoprazole was incidentally found to be the most commonly used drug in ICU patients and was prescribed for 94% (n = 376) of patients. However, pantoprazole consumed only 3.03% (Rs. 63,153.81) of the total drug therapy cost (Rs. 6,89,210).
    Figure 4: Cost distribution in drug class

    Click here to view


    Route of administration analysis

    The most common route of administration was found to be the parenteral route (52.63%) followed by the oral route (42.89%), nebulization (3.95%), and topical (0.54%).

    Statistical analysis

    P-values for association or differences between demographic parameters and different costs are illustrated in [Table 6]. For example, P-value for correlation of age and the total cost was 0.8685 by using the Pearson correlation coefficient and vice versa. The difference in total cost was not significantly associated with patient age. The COI significantly varied according to the LOS for patients. No significant difference was observed in the COI in men and women.
    Table 6: P-Values of parameter

    Click here to view



      Discussion Top


    To the best of our knowledge, there are very few observational analyses on expenses specific to ICU irrespective of the medical condition of the patient. In our study, the demographic details of the patients admitted to ICU revealed an average age of 54.27 years, which is attributed to life-threatening diseases such as cardiovascular disease, respiratory infections, and stroke, which is more common in above 45 years of age. Studies are done previously in John et al.[12] and Amit et al.[13] along with Agrawal et al.,[7] which showed results of 60 years and above. Male predominance has also been reported in a few international studies.[14],[15]

    The average LOS in ICU in this study was found to be 3.69 days, which was less as compared to antecedent studies done in ICUs in North India, South India, Nepal, and the USA where the average LOS in ICU 5.75, 6.22,4.0, and 5.22 days, respectively.[12],[13],[16] Patients on a ventilator had an LOS of 7.44 days, which was significantly higher compared to the nonventilator patients in this study. The mortality rate of 12.25% in our study was less as compared to 18.98% in Shweta et al.[5] In contrast, a study conducted by Parikh and Karnad[17] in Mumbai revealed a higher mortality rate of 36.2%.

    The average total cost per patient assessed by us was Rs. 52,840 and per day cost was Rs. 14,319, which was more as compared to per day cost of Rs. 10,364 reported by Shweta et al.[5] in respiratory ICU (RICU) and Rs. 1973 reported by Parikh and Karnad.[17] Studies from European countries revealed mean daily cost in ICU ranging between €1125 and 1590 (Rs. 87726.30–123986.50) per day.[18],[19],[20],[21],[22],[23] In a German study done by Moerer et al.,[24] total cost per patient and day cost were from €791 to 2815 (Rs. 61681.33–219510.69) during inflation in 2008. In the United States, the total cost in ICU per day was €3221(Rs. 251,170.14). A study conducted by Dasta et al.[25] reported a mean cost of $31,574 (Rs. 2205,507.05). Hence, it reveals that there is a gap in the ICU cost in western countries and developing countries like India.

    Average cost was highest for ALD followed by septic shock, which accounted for Rs. 75,060.00 and Rs. 65,983.00, respectively, followed by an average LOS of 8 days in both conditions. In contrast, in a study conducted by Agrawal et al.[7] the cost was found highest for organophosphorus poisoning followed by CCF, which accounted for Rs. 49,198 and Rs. 39,860.00, respectively, with an average LOS of 6.75 and 6.4 days, respectively. In a study conducted by Putignano et al.,[26] the highest cost accounted for left heart failure (€141.809). Average per day cost was highest for MI (Rs. 15,495.00) in the existing study followed by chronic obstructive pulmonary disease (Rs. 11,954.00).

    This study investigated the consultation cost per patient to be Rs. 632.55, which is less than Rs. 1050.00, Rs. 3700.00 as reported by Kumpatla et al.[27] and Shelat and Kumbar,[6] respectively. Investigation charges per patient were Rs. 6861, which was more than Rs. 2500.00 as reported by Shelat and Kumbar[6] and less than Rs. 25,030.00 as reported by Pattanaik et al.[28] and similar to Rs. 5981.00 reported by Agrawal et al.[7]

    Looking at the drug use evaluation, the average number of drugs prescribed per patient was around 8.44 in our investigation, which is less than 9.9 and more than 8.0 as reported by Thomas et al.[29] and Al-Zakwani et al.[30] The most common route of administration in our analysis was found to be the parenteral route, which accounted for 52.63% followed by oral route 42.89%, nebulization 3.95%, and topical 0.54% which was quite similar to the study conducted by Thomas et al.[29] In contrast, a study conducted by Paudel et al.[31] stated oral administration (48%) as the most commonly used dosage form in ICU was followed by injections and intravenous fluids, which accounted for 33% and 7.8%. Patients admitted to ICU require immediate drug action, which might be the reason for the parental route. In our study, pantoprazole was the most commonly prescribed drug (n = 376). The findings of our study are appropriate as Mohebbi and Hesch[32] observed that 75%–100% of the patients had stress-related mucosal bleeding within 24h of admission.

    The cost of drug therapy per patient was found to be Rs. 5204.33 in the present investigation, which was similar to Rs. 4336.00, Rs. 3225.00 as described by Agrawal et al.,[7] Patel et al.,[33] and lower as compared to Rs. 19,725.00 examined by Biswal et al.[16] Western literature revealed drug cost per patient to be around $208–$312 (Rs. 14529.22–Rs. 21793.82) which was quite more than our study.[34] The cost of drug therapy for surgical patients in this study was Rs. 6733.94, whereas for nonsurgical patients it was Rs. 5048.22 which is significantly less as compared to Rs. 16208.00 (surgical) and Rs. 13326.00 (nonsurgical) as reported by Shelat and Kumbar.[6] Total drug therapy cost accounted for 12.08% which was less as compared to 25%, 75% reported by Shweta et al.[5] and Chatterjee et al.[35]

    Speaking about costs associated with antimicrobials per patient, it was found to be Rs. 1473 which was similar to a study conducted in Nepal which reported $16(Rs. 1117.63.[36] The study conducted by Shelat and Kumbar[6] stated cost of antimicrobials per patient was Rs. 5356 in surgical the patient, which was significantly higher compared to medical patients. The daily antimicrobial cost was around €114 (Rs. 8889.60) and $89 (Rs. 6216.83) in Belgium and Turkey, respectively.[37],[38] Antimicrobial costs accounted for more in total drug therapy costs due to long stays in an unconscious state of ICU patients. They are more prone to hospital-acquired infection which affects about 30% of ICU patients as reported by Vincent et al.[39] Antimicrobial cost in the present evaluation accounted for 28%, antecedent studies accounted for 33%, 25%, and 73% of the total drug therapy costs.[6],[30],[40] The most commonly prescribed antimicrobials were ceftriaxone (n = 161) followed by piperacillin + tazobactum (n = 57) and amoxicillin + clavulanic acid (n = 24), but the most commonly prescribed class was piperacillin and tazobactum in Al-Zakwani et al.’s[30] study. In our study, piperacillin + tazobactum cost accounted for 46% of the total antimicrobial cost.

    Limitations

    The major limitation of the study was that it was conducted for a short duration and the sample size included was limited. We did not include patients less than 18 years of age, pregnant women, or medical-legal cases in critical care. Our study excluded indirect costs such as transport costs, staff salary costs, and intangible costs. Calculation of unit cost of drugs (insulin and injection heparin) and syrups was not taken instead the entire price was considered. Our study focuses on a single private hospital. Cost related findings may be different in the hospitals of diverse set-ups like government, semi-government, charitable or corporate. Amount claimed from insurance was not deducted from the original billing amount, if any. Various health schemes such as Rajiv Gandhi, Jeevandayee Arogya Yojana, Mahatma Jyotiba Phule, and Jan Arogya Yojana concessions were not taken into consideration; in fact such patients were not included in the study. We did not measure socioeconomic and severity of disease in critical care using the Kuppuswamy scale and APACHE scale, respectively. Further, only maximum retail prices were considered for economic evaluation, no discounts.


      Conclusion Top


    In conclusion, our study reveals that ICU bed charge, miscellaneous cost, and drug therapy costs have more contribution to the direct medical costs of hospitalization. The cost of drug therapy accounted for 12.08% of the total drug therapy cost. The cost of antimicrobials accounted for 28% of the total drug therapy cost. This study may be helpful for hospital administrators to monitor their hospital charges to be affordable for patients and educate the prescriber for inexpensive prescriptions of antimicrobial and better management of patients.

    The maximum number of patients admitted in ICU was associated with CNS complications, which accounted for 31%. The costliest disease to treat in ICU was ALD with an average expenditure per patient of Rs. 75,060.00 followed by septic shock where it was Rs. 65,983.00. The average per day cost was the highest for MI which accounted for Rs. 15,495.00. More studies need to be done in this respect, especially in developing countries where data are inadequate. Similar studies form the basis for cost reduction studies. To the best of our knowledge, there is very little observational analysis on the expenses specific to ICU irrespective of the medical condition of the patient.

    Ethical consideration

    The study protocol was reviewed and approved by the Institutional Ethics Committee (approval number BVDUMC/IEC/4, dated October 9, 2018).

    Financial support and sponsorship

    Nil.

    Conflicts of interest

    There are no conflicts of interest.

    Declaration of patient consent

    The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.



     
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