The cost of providing intensive care unit (ICU) care is substantial.
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Patients who receive ICU care following brain death to facilitate organ donation
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are not currently funded through activity-based funding for the component of their care post death.
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Support for organ donation is provided via a separate funding stream but, to our knowledge, this funding is not based on a specific detailed cost analysis.
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The objective of this study was to quantify the cost of caring for patients in an Australian ICU who have died and are awaiting transfer to the operating room.
Tan SS, Hakkaart-van Roijen L, Al MJ, et al. A microcosting study of intensive care unit stay in the Netherlands. J Intensive Care Med 2008; 23: 250-7
van Haren FMP, Carter A, Cavazzoni E, et al. Conflicts of interest in the context of end of life care for potential organ donors in Australia. J Crit Care 2020; 59: 166-71
Melville A, Kolt G, Anderson D, et al. Admission to intensive care for palliative care or potential organ donation: demographics, circumstances, outcomes, and resource use. Crit Care Med 2017; 45: e1050-9
Organ and Tissue Authority. Organ and Tissue Authority 2019–20 annual report. https://donatelife.gov.au/about-us/strategy-and-performance/annual-report-0 (viewed Dec 2020)
Organ and Tissue Authority. Organ and Tissue Authority annual report 2016–17. https://donatelife.gov.au/sites/default/files/OTA_AR2016-17.pdf (viewed Dec 2020)
Methods
Context
A microcosting analysis was conducted to calculate expenses incurred within a 32-bed adult medical–surgical–trauma ICU when caring for patients with brain death who became organ donors. The Royal Melbourne Hospital Research Ethics Committee approved this study (Study QA No. QA2019024).
All patients diagnosed with brain death who subsequently donated one or more organs between 1 January 2018 and 31 January 2019 were included.
All costs were provided in Australian dollars. The primary outcome was the cost incurred in the ICU from diagnosis of brain death to transfer to the operating theatre. A multivariable linear regression analysis explored potential factors associated with greater or lesser costs.
Costing methodology
The total expenditure attributable to ICU care after brain death was calculated using both direct and indirect costs.
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Direct costs are those attributable to the care of a specific donor,
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with indirect costs attributable to ICU-level costs, such as purchase and maintenance of equipment.
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Higgins AM, Harris AH. Health economic methods: cost-minimization, cost-effectiveness, cost-utility, and cost-benefit evaluations. Crit Care Clin 2012; 28: 11-24
Higgins AM, Brooker JE, Mackie M, et al. Health economic evaluations of sepsis interventions in critically ill adult patients: a systematic review. J Intensive Care 2020; 8: 5
Tan SS, Bakker J, Hoogendoorn ME, et al. Direct cost analysis of intensive care unit stay in four European countries: applying a standardized costing methodology. Value Health 2012; 15: 81-6
Tan SS. Microcosting in economic evaluations issues of accuracy, feasibility, consistency and generalisability; 1st ed. Rotterdam: Erasmus University Rotterdam, 2009
Karabatsou D, Tsironi M, Tsigou E, et al. Variable cost of ICU care, a micro-costing analysis. Intensive Crit Care Nurs 2016; 35: 66-73
Moerer O, Plock E, Mgbor U, et al. A German national prevalence study on the cost of intensive care: an evaluation from 51 intensive care units. Crit Care 2007; 11: R69
Jegers M, Edbrooke DL, Hibbert CL, et al. Definitions and methods of cost assessment: an intensivist’s guide. ESICM section on health research and outcome working group on cost effectiveness. Intensive Care Med 2002; 28: 680-5
Jegers M, Edbrooke DL, Hibbert CL, et al. Definitions and methods of cost assessment: an intensivist’s guide. ESICM section on health research and outcome working group on cost effectiveness. Intensive Care Med 2002; 28: 680-5
A microcosting methodology was used with a combination of bottom-up and top-down costing techniques.
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Microcosting analyses involve enumeration and valuation of all resources accessed in the course of care.
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Bottom-up costing is performed at the level of the individual patient by recording the cost of each component of care.
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Top-down techniques assign cost through consideration of total expenditure over a defined period.
Tan SS. Microcosting in economic evaluations issues of accuracy, feasibility, consistency and generalisability; 1st ed. Rotterdam: Erasmus University Rotterdam, 2009
Potter S, Davies C, Davies G, et al. The use of micro-costing in economic analyses of surgical interventions: a systematic review. Health Econ Rev 2020; 10: 3
Tan SS, Bouwmans CA, Rutten FF, et al. Update of the Dutch manual for costing in economic evaluations. Int J Technol Assess Health Care 2012; 28: 152-8
Gold M. Panel on cost-effectiveness in health and medicine. Med Care 1996; 34 (Suppl): DS197-9
Jegers M, Edbrooke DL, Hibbert CL, et al. Definitions and methods of cost assessment: an intensivist’s guide. ESICM section on health research and outcome working group on cost effectiveness. Intensive Care Med 2002; 28: 680-5
Direct costs comprised drugs, imaging, pathology and staff salaries. A bottom-up approach was taken for drugs, fluids and diagnostics,
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with a top-down methodology for salaries.
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All salaries were based on standard hourly rates using mid-level classification of staff. Adjustments were made to account for penalties, allowances and on-costs, including superannuation, education, and long service and sabbatical leave.
Guerre P, Hayes N, Bertaux AC, et al. [Hospital costs estimation by micro and gross-costing approaches] [French]. Rev Epidemiol Sante Publique 2018; 66 (Suppl): S65-72
Lefrant JY, Garrigues B, Pribil C, et al. The daily cost of ICU patients: a micro-costing study in 23 French intensive care units. Anaesth Crit Care Pain Med 2015; 34: 151-7
Tan SS. Microcosting in economic evaluations issues of accuracy, feasibility, consistency and generalisability; 1st ed. Rotterdam: Erasmus University Rotterdam, 2009
Tan SS, Bouwmans CA, Rutten FF, et al. Update of the Dutch manual for costing in economic evaluations. Int J Technol Assess Health Care 2012; 28: 152-8
Indirect patient costs were calculated per hour based on the financial ledger for the financial year ending June 2017 adjusted to the consumer price index.
Statistical analyses
Data were extracted from clinical and hospital records and analysed using Stata 16 (StataCorp, College Station, TX, USA). Variables were summarised using descriptive statistics and presented as mean and standard deviation (SD), median and interquartile range (IQR, [range]) or mean and 95% confidence interval (CI). Linear regression models incorporating robust error estimates were used to report selected costs, first without and then with adjustment for the influence of other covariates. Outcomes from these models are presented as increased or decreased mean cost (95% CIs).
Results
Forty-five individuals donated at least one organ after brain death (Table 1). The mean duration of care in the ICU after brain death was 37.9 hours (SD, 16.5).
The mean cost of providing ICU care after death was $7520 (SD, $3136) per donor (Figure 1). Staff salaries were the greatest contributor to the cost of care, comprising a median proportion of 0.72 of total expenditure (IQR, 0.68–0.75). The mean cost attributable to drugs and fluids was $478.4 (SD, $680.4). The mean cost of imaging was $288.6 (SD, $281.0) and of pathology was $687.2 (SD, $321.3). The mean cost of other patient expenses was $681.41 (SD, $297.50) and of indirect expenses $113.6 (SD, $49.6). Beyond the major component of staff salary, and thus duration of stay, there were no other identified independent predictors of increased cost on multivariable linear modelling.
Discussion
Organ donation is cost-effective at the community level.
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Our study estimated that the mean duration of care in ICU after donor death as 37.9 hours (SD, 16.5), accompanied by a mean cost of about $7500, the major component of which was staff salary. In the setting of limited previous Australian data, these updated estimates inform considerations of the adequacy of current hospital funding to provide ICU care to potential organ donor patients after death.
Howard K, Salkeld G, White S, et al. The cost-effectiveness of increasing kidney transplantation and home-based dialysis. Nephrology (Carlton) 2009; 14: 123-32
The most comprehensive recently published estimate of cost focused on donation after cardiac death in the United States.
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The mean cost of donation, including transportation and operating theatre expenses, was US$16 695 per donor. While not reporting ICU-based care as a separate variable, the mean cost was US$8794 per potential donor who did not proceed to theatre.
Lindemann J, Dageforde LA, Vachharajani N, et al. Cost evaluation of a donation after cardiac death program: how cost per organ compares to other donor types. J Am Coll Surg 2018; 226: 909-16
Microcosting analysis considers costs incurred during management of each patient.8,20 A major strength of our study lies in the microcosting methodology applied to salaries, radiology, pathology, drug, fluids, and blood products. When using the preferred bottom-up techniques was not possible, top-down microcosting techniques, which retain some accuracy, were applied.
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Tan SS. Microcosting in economic evaluations issues of accuracy, feasibility, consistency and generalisability; 1st ed. Rotterdam: Erasmus University Rotterdam, 2009
Tan SS, Bouwmans CA, Rutten FF, et al. Update of the Dutch manual for costing in economic evaluations. Int J Technol Assess Health Care 2012; 28: 152-8
Our study has some limitations. The staffing model was minimalist, with no inclusion of time solely dedicated to family donation conversations,
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additional clinicians (eg, senior registrars), and non-clinical roles. Given staff salaries constituted the greatest proportion of cost, such simplifications would underestimate the true cost.
Lewis VJ, White VM, Bell A, et al. Towards a national model for organ donation requests in Australia: evaluation of a pilot model. Crit Care Resusc 2015; 17: 233-8
Opdam H. The family donation conversation: time to move to evidence-based practice. Crit Care Resusc 2015; 17: 231-232
There are further limitations that bias toward conservative cost estimates. Specific costs were not captured that account for after-hours interventions, particularly those that may involve additional payments to specialised staff (eg, transthoracic [n = 29] and transoesophageal echocardiograms [n = 6] and coronary angiography [n = 4]). Moreover, the study did not include potential donors who did not proceed to organ donation, costs incurred before brain death, or costs attributable after ICU, such as theatre costs and surgical procurement team salaries.
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Nunnink L, Cook DA. Palliative ICU beds for potential organ donors: an effective use of resources based on quality-adjusted life-years gained. Crit Care Resusc 2016; 18: 37-42
Conclusions
Using a conservative microcosting analysis approach there appears to be substantial ICU expenditure in providing care after brain death and before organ donation. These estimates should inform decisions regarding future funding.
Acknowledgements: This work was performed at the Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia.