Chronic Critical Illness: Best Practices, Call for Research

In the latest issue of the American Journal of Respiratory and Critical Care Medicine, Judith Nelson and colleagues provide a very nice overview of chronic critical illness.  From the abstract: “Although advances in intensive care have enabled more patients to survive an acute critical illness, they also have created a large and growing population of chronically critically ill patients with prolonged dependence on mechanical ventilation and other intensive care therapies. Chronic critical illness is a devastating condition: mortality exceeds that for most malignancies, and functional dependence persists for most survivors. Costs of treating the chronically critically ill in the United States already exceed $20 billion and are increasing.”

Nelson et al. proceed to describe chronic critical illness as far more than just “prolonged ventilator dependence” but as a “syndrome” including features from brain dysfunction to skin breakdown.  Nearly 90% of chronically critically ill patients do not survive one year and most of those lack sufficient cognitive function.  Should we attempt to save these patients or let them die?  Nelson et al. conclude that the state of the evidence “does not yet support a definite response.”

Nelson et al. observe that "DRGs covering these patients are among the most heavily weighted, supporting relatively high reimbursement to acute care hospitals."  Nevertheless, the authors note, "high costs for long-stay outliers are a burden for these hospitals creating an incentive for transferring chronically critically ill patients . . . ."  This is a point that is often overlooked by those commenting on hospital incentives for providing or refusing ICU care.  It is rarely useful to ask whether the patient was insured or not insured.  At least as far as Medicare goes, the answer is not "yes" or "no," but "how much."