a large part of healthcare costs is spent on intensive care units in the developed countries .
intensive care units offer care that is resource - intensive both in terms of equipment and manpower .
icu costs have been reported to be between three to six times the costs of treatment in a general hospital ward , and in the usa , intensive care medicine uses up 30% of total hospital resource allocation .
the high cost of intensive care therapy is attributed to the need for specially trained and experienced staff , the cost of equipment , and the increased use of diagnostic tests , drugs , and therapeutic interventions .
calculating costs of intensive care is helpful in assessing intensity of interventions and analyzing patient characteristics while identification of cost drivers leads to optimum utilization of resources .
critical care for cancer patients is of special interest in this regard , as the high costs of intensive care are coupled with poorer outcomes .
the cost per year of life gained for patients with hematological cancers ( $ 189,339 ) was found to be much higher than those with solid tumors ( $ 82,845 ) . however , over the years , intensive care outcomes of cancer patients have improved due to better patient selection , better understanding of pathophysiology of complications of cancer treatment , and improved intensive care management strategies .
india is a developing country , and the gross national income ( gni ) per capita for india was 820 us $ .
this is extremely low when compared to figures for the us ( 44970 us $ ) and the uk ( 40180 us $ ) for the same year .
using the purchasing power parity ( ppp ) method , the gni per capita for india rises to 3800 international dollars ( i d ) , compared to 44,260 i d for the usa and 35,580 i d for the uk .
in addition to the low incomes , indian government funding of the public health system is low .
there is no nationalized health scheme in india , and government contribution to health care is negligible .
according to the who data in 2004 , only 5% of the gross domestic product of the government of india was spent on health care as compared to 8% and 15% , respectively , for the uk and the usa . the per capita government spending on health was 15.8 i$ , a meager amount , as compared to us expenditure of 2724.7 i$. health care facilities in india are either privately - run institutions or public - funded .
only a small section of the population , predominantly those in urban centers , has opted for private health insurance coverage .
of the total expenditure on health care in india , 83% was private expenditure and only 17% of expenditure was borne by the government .
more than 92% of private healthcare financing was through unplanned for , non - contributory spending .
however , costs of icu care in india appear to be much lower than those in the developed nations . in a study from a public hospital , karnad and
$ 487 ) . in this unique setting of patients with a low income per capita , but lower costs of intensive care , based on the limited data available , it is essential to undertake a detailed cost - effectiveness analysis of intensive care in india .
we conducted a prospective study to calculate the costs of intensive care in cancer patients .
we aimed at finding out the cost differences for intensive care for post - surgical patients and those admitted from wards .
we also calculated the effective cost per survivor and money loss per patient in our patients .
this study was conducted at the intensive care unit ( icu ) of a partially government - funded , 550 bed , tertiary referral cancer center . the need for informed consent
professional fees are not charged to public patients , and other hospital charges are considerably subsidized .
the costs of care of public patients are cross - subsidized partly by the revenue generated from the private patient and in part from government funding .
the icu has nine intensive care beds , which are equipped for advanced hemodynamic monitoring , ventilatory support , and continuous renal replacement therapy ( crrt ) ; and an adjoining 14-bedded recovery room .
the icu receives patients from the operating rooms ( or ) as well as from the emergency room and medical wards .
the case mix thus consists of high - risk post - surgical patients , hematological malignancy patients , and an occasional patient from the radiotherapy unit .
it is a semi - closed unit staffed by two intensivists during daytime and two qualified residents ( anesthesiology ) and two postgraduate students round the clock .
we have 46 nurses with varying experience ( 6 - 12 yrs ) who work in three shifts with nurse to patient ratios ranging from 1:2 to 1:4 .
we used a combination of bottom - up approach and cost block method . for patient - related costs , a specially designed form , which was kept in the patient 's case record file till death or discharge ,
data was collected for 101 consecutive patients admitted to the icu after 8 november 2005 .
demographic data and source of icu admission , icu admission diagnosis , and icu outcomes were recorded .
the ampoules , vials of drugs , and consumables used for a patient were collected in a cardboard box kept at the foot end of the bed in the cubicle . at the end of every 24 hrs till the time of discharge , the items and their quantity used was noted .
blood and blood products transfused , investigations ordered , outside consultations obtained , and procedures performed were also noted every day .
non - patient - related costs for intensive care were collected from various departments involved .
of the 11 consultants in anesthesiology department , we assumed that one consultant is working full time in the icu per week and thus calculated salary for four consultants working for four weeks .
similarly of the 24 residents and 12 postgraduate students in our department , of whom eight residents are on duty in the icu every month in two shifts of four each the salary was calculated . for salary calculation
the electricity costs for running various pieces of equipment were obtained from the specifications given in the service manuals of that piece of equipment .
no patient needed crrt during the period of the data collection , thus the variable costs do not include those costs .
crrt is not very commonly performed , and this should not present problems in the calculation of variable costs . the electricity costs for the air conditioning were obtained from the ac section of the engineering department .
costs of linen , laundry , and sterilization of instrument packs were obtained from daily supply .
costs of sterilization of instruments , which are quite old , were obtained from cssd .
icu overheads for various departments such as administration , engineering , stores , purchase , maintenance and verification cell , accounts , security , etc . , were calculated as a proportion of the general management costs as per the floor area of the icu .
data was collected for 101 consecutive patients admitted to the icu from the or after elective or emergency surgeries ( 55 patients ) and from the ward ( hemato - oncology ) or emergency room ( 46 patients ) from 8 november  29 december 2005 .
there were 59 males , and the mean age ( sd ) was 42.94 ( 17.54 ) yrs .
fifty - three of 55 patients admitted from or and 26 of 46 patients admitted from ward survived to discharge .
the patients admitted from ward stayed longer than patients admitted from the or ; however , this difference was not statistically significant table 1 .
maximum costs were incurred for drugs , investigations , fluids and blood , and blood products table 3 .
the patient - related costs were significantly higher in the patients admitted from the ward or casualty .
the largest component of non - patient - related costs was medical and support staff salaries table 4 .
83,558.30 ( us$ 2088.95 ) for a patient admitted from the ward , significantly higher than the costs for patients admitted from the or rs .
15,049.14 ( us$ 376.29 ) . similarly , the money loss per patient ( expenditure for patients who died / total number of patients ) was higher [ rs .
patients , source of admission , and icu los overall patient - related costs components of patient - related costs non - patient - related costs effective cost per survivor *
in an indian cancer hospital icu , we found that the patient - related cost of intensive care was much higher in patients admitted from the ward than those admitted from the operating rooms .
this may be because the patients admitted from operating rooms were relatively stable and stayed in the icu for a shorter duration of time .
also , we did not include the costs of endotracheal tubes , central lines or arterial lines , and pressure transducers while calculating the costs as the patient would have been charged for these items during anesthesia .
in contrast , the patients admitted from the wards were sicker , more unstable as reflected by a longer icu stay and poorer icu outcomes .
most patients admitted from wards to our icu are hemato - oncology patients , the most common admission diagnoses being febrile neutropenia , sepsis , and septic shock , needing high intensity of critical care .
these patients need - advanced hemodynamic monitoring , broad - spectrum antibiotics , and multiple transfusions with blood and blood products .
thus , patients admitted from ward spent significantly higher amounts on drugs , fluids and blood , and on hemodynamic monitoring consumables as compared to their postoperative counterparts .
courtney and colleagues evaluated costs of managing patients with febrile neutropenia in emergency department ( ed ) . for a median stay of 3.3 hours ( iqr 2.3 - 4 hrs ) , the costs of care in the ed was $ 1,455 ( iqr , $ 1,300-$1,579 ) . during this short
stay in ed , maximum resources were spent on routine and critical care nursing , laboratory and imaging , and blood and blood product transfusion .
a retrospective cohort study used therapeutic intervention scoring system points to compare resource utilization in hemato - oncological patients and those without malignancy .
the resource use of hemato - oncological patients was higher ( median ( iqr ) , 214 ( 102 to 642 ) versus 95 ( 54 to 224 ) , p < 0.0001 ) ; but the outcomes were similar for the same severity of illness .
edbrooke and colleagues reported that the costs of treating sepsis and early sepsis to be higher than treating non - sepsis patients .
a large retrospective cohort study compared hospital length of stay and costs of hospitalization in severe sepsis patients with and without cancer .
the length of hospital stay and costs were three times higher in cancer patients with severe sepsis .
they found the costs for trauma patients to be 4076 euros , much higher than for elective coronary surgery patients , at 380 euros .
the maximum expenditure was for infusions , laboratory tests and imaging , and drugs in patients with polytrauma , whereas in coronary artery bypass patients , laboratory tests consumed the most resources .
the costs of intensive care vary according to admission diagnosis , intensity of interventions required , and whether admission was elective or emergency .
the costs of intensive care thus vary with various diagnostic categories and nature of admission viz .
costs of staffing , variously termed nursing shifts and ward rounds ( 44% of total costs ) , staff ( 53.6% to 54.9% ) , staff costs ( 56% ) have consistently been shown to be the main component of non - patient - related costs . in our study also , staffing costs were the highest component ( nearly 67% ) of non - patient - related costs .
intensive care units are often under administrative control of some larger department , for instance , our icu is part of department of anesthesia , with no separate budget .
this precludes accurate calculation of overheads of other departments as well as staff salary due to common staffing . in india ,
several brands of the same medication are available at varying prices and the prescribing practices vary , making for difficulties in computing the costs of the medications . in public institutes , in particular ; and sometimes also in private institutes , all medications and consumables may not be available in the dispensaries and patients are expected to buy these from outside chemists . as patients are paying out of pocket , these costs may be overlooked while working out patient - related costs .
they are often downgraded when icu stay is prolonged to lower charge category to limit their expenses . to keep the costs uniform
the data collection period was short and , therefore , may not represent the full case - mix or interventions done in our icu .
for instance , during the data collection , no patient required crrt , so our costs do not include patient - related costs of crrt .
this may be offset however , by the fact that our use of crrt is often hampered by lack of affordability as most patients are paying out of pocket .
we have assumed 100% occupancy while calculating the costs , which may not be the case always . often , when icu is full , we are forced to ventilate critically ill patients in the recovery room .
we have , however , followed standard practice and calculated 10% linear depreciated cost of the icu equipment .
a limitation of our study is that in spite of icu admission criteria being in place for admission to our icu , patients with advanced malignancies in unstable condition may be admitted during late hours .
subsequently , decisions regarding the limitation of care or withdrawal of care are made during working hours next day . in the ideal world
, intensivists will prefer that such patients not be admitted to the icu by adhering to icu admission protocol , however , that is unlikely to happen due to extraneous factors such as insistence by primary physician , insistence by family , and lack of clarity in final diagnosis of malignancy .
since this was an observational study , in an effort to being pragmatic , we did not exclude such patients and included all consecutively admitted patients in the study .
another limitation is that we do not have severity of illness scores for these patients and we have assumed that icu length of stay , interventions and mortality reflect the severity of illness of these patients
the cost per year of life gained for patients with hematological cancers was $ 189,339 , much higher than those with solid tumors ( $ 82,845 ) in a study published in early 1990 .
effective cost per survivor ( ecps ) and money loss per patient are useful measures of cost performance .
the ecps rises considerably at higher probability of death when more resources are spent for non - survivors . in cancer patients
, we found that it is more cost - effective to treat post - surgical patients than patients admitted from the ward .
the cost efficacy can be improved in this group of patients by triage of patients before icu admission and setting limits of care in patients likely to have poor outcomes .
should we offer intensive care to patients with hematological malignancies who have suffered a complication of chemotherapy ?
this decision needs to be taken in the light of cost of treatment of primary malignancy .
the cost of 1 cycle of rituximab , vincristine , adriamycin , cyclophosphamide , and prednisolone chemotherapy for non - hodgkin 's lymphoma is rs .
1,50,000.00 ( us$3750 ) for the medications alone , and 6 such cycles are usually given .
9,00,000.00 ( us$22,500 ) . assuming a 70% 5-year survival , the cost per survivor is rs .
this does not include cost of hospitalization , professional charges , and supportive care ( growth factors , blood and blood products , antibiotics ) .
thus , although intensive care is expensive in cancer patients , it is far less expensive than treatment of non - hodgkin 's lymphoma .
may be based on presence of external constraints , a reference to clinical guidelines and lastly based on clinical judgment alone .
81 per day and the costs per day must be looked at bearing this gross disparity in income and the costs of icu .
in other words the daily cost of icu care is approximately 100 times the per capita income of an indian . in developing countries ,
where the patient is paying out of pocket , icu cost is one of the major external constraints , in the decision of whether to offer intensive care to the patient or not .
the data such as ours can be used to inform the referring physicians and patients families about anticipated costs of intensive care .
the costs of intensive care were much higher and outcomes poorer for hemato - oncology patients as compared to patients with solid tumors undergoing resection , resulting in higher ecps .
though the costs of intensive care seem to be lower as compared to the western icus , a greater burden is placed on indian patients due to much lower per capita incomes .
a better selection process is needed for hemato - oncology patients for icu admission for better utilization of scarce resources .
data such as ours can be used to inform families and referring physicians about anticipated costs .
 background : the costs of healthcare are increasing . 
 intensive care poses largest burden on the hospital budget , even in developed countries . 
 we attempted to find out the costs of intensive care in an indian cancer hospital.materials and methods : cost data was prospectively collected for patient - related and non - patient - related activities in a mixed surgical , medical cancer icu . 
 demographic data , source , reason , and length of icu stay were recorded . 
 total per day costs , costs for patients admitted from wards and operating rooms , and effective cost per survivor ( ecps ) were calculated.results:data was collected for 101 consecutive icu patients . 
 fifty - five patients were admitted after surgery ( total patient hours 3485 i.e. , 145.21 patient days ) . 
 the mean ( sd ) intensive care unit length of stay ( icu los ) was 64.84 ( 58.47 ) hrs . 
 ( 8.25 to 552 ) . 
 fifty - three patients survived to discharge . 
 forty - six patients were admitted from wards ( hematooncology ) or casualty and stayed 3980.25 patient hrs ( 165.84 patient days ) . 
 the mean ( sd , range ) icu los was 106.84 ( 64.05 , 1 - 336 ) hrs . 
 of these , 26 patients survived to discharge . 
 the effective cost per survivor ( ecps ) was significantly higher for patients admitted from wards . 
 [ rs . 
 83,558 = 00 ( usd 1856.84 ) vs. rs . 
 15,049 = 00 ( usd 334.42)].conclusion : the costs of icu place much higher burden on the patients as the indian gdp and per capita income is much lower . 
 better selection process is needed for hemato - oncology patients for icu admission for better utilization of scarce resources . 
 such data as ours can be used to inform families and physicians about anticipated costs . 
Introduction
Materials and Methods
Results
Discussion
Conclusions