• Nita Khandelwal, David Benkeser, Norma B Coe, Ruth A Engelberg, Joan M Teno, and Curtis J Randall JR 4 Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington , Seattle, Washington. .
• 1 Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington , Seattle, Washington.
• J Palliat Med. 2016 Nov 1; 19 (11): 1171-1178.

BackgroundTerminal intensive care unit (ICU) stays represent an important target to increase value of care.ObjectiveTo characterize patterns of daily costs of ICU care at the end of life and, based on these patterns, examine the role for palliative care interventions in enhancing value.DesignSecondary analysis of an intervention study to improve quality of care for critically ill patients.Setting/Patients572 patients who died in the ICU between 2003 and 2005 at a Level-1 trauma center.MethodsData were linked with hospital financial records. Costs were categorized into direct fixed, direct variable, and indirect costs. Patterns of daily costs were explored using generalized estimating equations stratified by length of stay, cause of death, ICU type, and insurance status. Estimates from the literature of effects of palliative care interventions on ICU utilization were used to simulate potential cost savings under different time horizons and reimbursement models.Main ResultsMean cost for a terminal ICU stay was 39.3K ± 45.1K. Direct fixed costs represented 45% of total hospital costs, direct variable costs 20%, and indirect costs 34%. Day of admission was most expensive (mean 9.6K ± 7.6K); average cost for subsequent days was 4.8K ± 3.4K and stable over time and patient characteristics.ConclusionsTerminal ICU stays display consistent cost patterns across patient characteristics. Savings can be realized with interventions that align care with patient preferences, helping to prevent unwanted ICU utilization at end of life. Cost modeling suggests that implications vary depending on time horizon and reimbursement models.

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