Klinische und ökonomische Effekte aus der Anwendung von Qualitätsindikatoren in der Intensivmedizin am Beispiel der Überwachung von Schmerz, Sedierung und Delir

Background: Die Intensivmedizin hat durch die Behandlung von lebensbedrohlich erkrankten Patient*innen hohe medizinische Relevanz. Die apparativen, personellen und organisatorischen Standards bedingen eine zusätzliche ökonomische Relevanz. Eine Maßnahme zur Sicherstellung einer optimalen Behandlung von Patient*innen sind Qualitätsindikatoren. Diese verlangen die Überwachung von Schmerz, Sedierung und Delir in jeder Schicht. Es wurde die These aufgestellt, dass die durchgängige Überwachung von Schmerz, Sedierung und Delir das klinische Outcome verbessert und das ökonomische Outcome aufgrund der fehlenden finanziellen Vergütung verschlechtert. Die Bestätigung der These könnte somit ein Indikator für Fehlanreize im Vergütungssystem sein. Methoden: Es handelt sich um eine retrospektive Studie unter Nutzung von Routinedaten. Es wurden univariate und multiple lineare Analysen sowie Machine-Learning-Algorithmen und eine moderne Zusammenhangsanalyse zum Verhältnis der Überwachung von Schmerz, Sedierung und Delir sowie klinischem und ökonomischem Outcome durchgeführt. Ergebnisse: Es wurden 1.323 erwachsene Patient*innen einbezogen, welche mindestens einen Tag zwischen Aufnahme und Entlassung vom 1. Januar bis 31. Dezember 2016 auf einer Intensivstation behandelt wurden. Eine durchgängige Überwachung von Schmerz, Sedierung und Delir war mit einer geringeren Krankenhaus-Verweildauer (bpsw. Schmerz-Überwachung 13 vs. 10 Tage; p<0.001), ITS-Verweildauer sowie Beatmungsdauer verbunden. Neben diesen positiven klinischen Effekten wurden negative ökonomische Effekte anhand von geringerem Case Mix pro Tag sowie Gewinn pro Tag festgestellt. Eine multiple lineare Analyse konnte alle genannten Ergebnisse nicht bestätigen. Weiterhin wurde auf Basis eines Machine-Learning-Algorithmus festgestellt, dass die Überwachung von Schmerz, Sedierung und Delir relevanter für klinisches und ökonomisches Outcome ist als der Schweregrad. Schlussfolgerung: Die Einhaltung der Leitlinien zur Schmerz-, Sedierungs- und Delir-Überwachungen auf Intensivstationen sind relevant für das klinische und ökonomische Outcome. In der univariaten Analyse ist die durchgängige Überwachung verbunden mit besserem klinischen und schlechterem ökonomischen Outcome. Dies konnte jedoch mit der multiplen linearen Analyse nicht bestätigt werden. Es besteht die Notwendigkeit sich stärker mit (Fehl-)Anreizen im Vergütungssystem auseinander zu setzen.Background: Intensive care medicine has a high relevance due to the treatment of threateningly ill patients. It is therefore also resource intensive. Because of this medical and economic background, it is necessary to adhere to quality indicators. One quality indicator requires the monitoring of all cases of pain, sedation and delirium in every shift. It has been hypothesized that continuous monitoring of pain, sedation and delirium improves clinical outcome and reduces economic values due to the lack of financial compensation. Confirmation of the thesis could thus be an indicator of false incentives in the compensation system. Methods This is a retrospective study using routine data. Univariate and multiple linear analyses were used as well as a machine-learning algorithm and a modern correlation analysis to analyze the relationship between monitoring of pain, sedation and delirium and clinical and economic outcome. Results 1,323 adult patients were included. These patients were treated in an intensive care unit for at least one day between admission and discharge from January 1 to December 31, 2016. Continuous monitoring of pain, sedation and delirium was found with a lower hospital length of stay (e.g. pain monitoring 13 vs. 10 days; p<0.001), ICU length of stay and ventilation duration based on univariate analysis. In addition to the positive clinical effects, negative economic effects were determined based on a lower case mix per day and profit per day based on a univariate analysis. A multiple linear analysis could not confirm these results. Furthermore, based on a machine-learning algorithm, monitoring of pain, sedation and delirium is more relevant for clinical and economic outcome than severity. Conclusion Adherence with guidelines for pain, sedation and delirium monitoring in intensive care units is relevant for clinical and economic outcome. In univariate analysis, continuous monitoring is associated with better clinical and worse economic outcome. However, this could not be confirmed by the multiple linear analysis. A further analysis of the incentives in reimbursement strategies is necessary

Does adherence to a quality indicator regarding early weaning from invasive ventilation improve economic outcome? A single-centre retrospective study

ObjectivesTo measure and assess the economic impact of adherence to a single quality indicator (QI) regarding weaning from invasive ventilation.DesignRetrospective observational single-centre study, based on electronic medical and administrative records.SettingIntensive care unit (ICU) of a German university hospital, reference centre for acute respiratory distress syndrome.ParticipantsRecords of 3063 consecutive mechanically ventilated patients admitted to the ICU between 2012 and 2017 were extracted, of whom 583 were eligible adults for further analysis. Patients’ weaning protocols were evaluated for daily adherence to quality standards until ICU discharge. Patients with <65% compliance were assigned to the low adherence group (LAG), patients with ≥65% to the high adherence group (HAG).Primary and secondary outcome measuresEconomic healthcare costs, clinical outcomes and patients’ characteristics.ResultsThe LAG consisted of 378 patients with a median negative economic results of −€3969, HAG of 205 (−€1030), respectively (p<0.001). Median duration of ventilation was 476 (248; 769) hours in the LAG and 389 (247; 608) hours in the HAG (p<0.001). Length of stay (LOS) in the LAG on ICU was 21 (12; 35) days and 16 (11; 25) days in the HAG (p<0.001). LOS in the hospital was 36 (22; 61) days in the LAG, and within the HAG, respectively, 26 (18; 48) days (p=0.001).ConclusionsHigh adherence to this single QI is associated with better clinical outcome and improved economic returns. Therefore, the results support the adherence to QI. However, the examined QI does not influence economic outcome as the decisive factor

Effects of pain, sedation and delirium monitoring on clinical and economic outcome: A retrospective study

Background: Significant improvements in clinical outcome can be achieved by implementing effective strategies to optimise pain management, reduce sedative exposure, and prevent and treat delirium in ICU patients. One important strategy is the monitoring of pain, agitation and delirium (PAD bundle). We hypothesised that there is no sufficient financial benefit to implement a monitoring strategy in a Diagnosis Related Group (DRG)-based reimbursement system, therefore we expected better clinical and decreased economic outcome for monitored patients. Methods: This is a retrospective observational study using routinely collected data. We used univariate and multiple linear analysis, machine-learning analysis and a novel correlation statistic (maximal information coefficient) to explore the association between monitoring adherence and resulting clinical and economic outcome. For univariate analysis we split patients in an adherence achieved and an adherence non-achieved group. Results: In total 1,323 adult patients from two campuses of a German tertiary medical centre, who spent at least one day in the ICU between admission and discharge between 1. January 2016 and 31. December 2016. Adherence to PAD monitoring was associated with shorter hospital LoS (e.g. pain monitoring 13 vs. 10 days; p<0.001), ICU LoS, duration of mechanical ventilation shown by univariate analysis. Despite the improved clinical outcome, adherence to PAD elements was associated with a decreased case mix per day and profit per day shown by univariate analysis. Multiple linear analysis did not confirm these results. PAD monitoring is important for clinical as well as economic outcome and predicted case mix better than severity of illness shown by machine learning analysis. Conclusion: Adherence to PAD bundles is also important for clinical as well as economic outcome. It is associated with improved clinical and worse economic outcome in comparison to non-adherence in univariate analysis but not confirmed by multiple linear analysis. Trial registration: clinicaltrials.gov NCT02265263, Registered 15 October 2014