CERC'S Model for Critical Care

Fellowship Year 2014-2015

Background

Critical illness is a significant driver of health care utilization in the US, with more than five million patients admitted annually to intensive care units (ICUs) and associated costs approaching 1% of the US gross domestic product. Demand is only increasing, as evidenced by the growth in US critical care spending during 2000-2010 from $56 billion to $108 billion. This growth reflects increased ICU utilization, an aging population, and the rising costs of advanced therapies.

For decades, the one-size-fits-all function of the ICU has been a successful and efficient means of caring for critically ill patients. While the progression of scientific knowledge and technology has allowed for dramatic improvements in monitoring and therapeutics, the organization of critical care delivery in the hospital has failed to keep pace. Those who are well-suited to receive care in the ICU have acute, reversible critical illness and require the expertise available in that location. However, up to 40% of current ICU patients may be “too well” to benefit from the full brunt of ICU care. These patients have a low mortality risk on admission and are at low risk for needing active ICU therapies but have high labor or frequent monitoring needs that cannot be met elsewhere.

At the other end of the illness severity spectrum are millions of patients cared for in ICUs who are “too sick” to benefit from critical care, having serious illnesses and values inconsistent with ICU care. These days spent in the ICU are 2.5 – 4 times more expensive than days on the hospital floor and may be avoided. We set out to understand and design a model of ICU care delivery that would more appropriately address the needs of these patients and reduce the exorbitant costs associated with one-size-fits-all ICU care.

Safely reducing per capita critical care spending

We have identified three major design targets that, if achieved, will significantly improve the value of care delivered to patients who are critically ill or at risk of becoming critically ill: (1) Prevent just-in-case ICU admissions; (2) Accelerate ICU admission for subtly deteriorating patients, and (3) Prevent ICU admissions unwanted by patients near the end of life (EOL).

Estimated savings

A conservative estimate of national savings from full implementation of the CERC model is $21 billion in direct health care spending per year, or 20% of annual spending for critical care.

Authors

Meghan Ramsey, MD, Kelly Vranas MD, Jeffrey Jopling, MD, MSHS, Terry Platchek, MD, Arnold Milstein, MD, MPH, 2015