This article, “Direct Cost Analysis of Intensive Care Unit Stay in Four European Countries: Applying a Standardized Costing Methodology,” published in Value in Health in 2012, presents a comprehensive analysis of the direct costs associated with Intensive Care Unit (ICU) stays across seven departments in Germany, Italy, the Netherlands, and the United Kingdom. The study was conducted by Siok Swan Tan and a team of researchers and medical professionals from various institutions, including the Institute for Medical Technology Assessment at Erasmus Universiteit Rotterdam and several intensive care departments across Europe.
Background and Rationale: The study highlights the substantial financial burden of ICU departments on hospital budgets, noting that while ICU beds constitute less than 10% of hospital beds, they consume approximately 22% of total hospital costs in the United States and about 20% in the Netherlands. Previous research has shown wide variations in ICU cost estimations, ranging from €855 per ICU day in a German study to €3221 in the United States (inflated to 2008). These discrepancies have often been attributed not only to actual differences in patient case-mix, study settings, medical practices, or healthcare resources, but also significantly to inconsistencies in the methodologies used for cost estimation. Recognizing that different costing methodologies make comparative analyses challenging, the authors emphasize the need for a standardized approach to enable meaningful comparisons of actual cost differences between healthcare services.
Objectives and Methodology: The primary objective of this retrospective cost analysis was to measure and compare the direct costs of ICU days at the participating departments using a standardized costing methodology. From a hospital’s perspective, the researchers focused on four key cost components: “diagnostics” (medical imaging and laboratory services), “consumables” (drugs, fluids, and disposables), “hotel and nutrition,” and “labor” (ICU specialists, nurses, and consulted specialists). Overheads were intentionally excluded due to their wide variability across jurisdictions.
A crucial aspect of their methodology was adapting the costing approach to the availability of data at each ICU department. While the bottom-up approach, which values each cost component for individual patients, is generally preferred for its accuracy and enabling statistical analyses, it is often hindered by the need for patient-level data, which can be time-consuming and expensive to collect, especially with diverse coding systems. Conversely, the top-down approach, requiring data at the department level, is more feasible but provides average costs for patients, limiting detailed statistical analysis of individual differences. To overcome these practical limitations and ensure robustness, the study employed a hybrid approach: a bottom-up approach for “hotel and nutrition” (where patient-level data was consistently available) and a top-down approach for “diagnostics,” “consumables,” and “labor” (where patient-level data was not universally available or posed significant collection challenges due to varying coding systems or staff training). All costs were standardized to Euro 2008 values using Eurostat harmonized indices.
Key Findings and Conclusions: The study revealed significant variations in direct costs per ICU day, ranging from €1168 to €2025 across the seven departments, with an overall average of €1383 ± 398. The most important finding was that “labor” emerged as the predominant cost driver at all departments. Notably, department G (in the UK) had significantly higher labor costs (€1629) compared to the average of €711 at other departments, primarily due to higher unit costs for ICU specialists and nurses, as well as substantially higher costs for consulted specialists, particularly physiotherapists. “Diagnostics” accounted for approximately 14% of direct costs, and “consumables” for about 22%, while “hotel and nutrition” represented only 4%.
The authors concluded that their standardized costing methodology proved to be a valuable instrument for comparing actual cost differences, rather than differences arising from methodological variations. While patient case-mix, study setting, and medical practice influenced the observed cost differences, the country of treatment was identified as the most important factor in explaining these variations. Despite limitations such as recruitment restrictions and the number of departments per country, the study provides valuable preliminary insights into the relative costs of ICU stays across different European countries, setting a foundation for future, larger-scale studies. The consistency and generalizability of the established methodology are also highlighted, suggesting its potential applicability to other settings.
Reference: Tan, S. S., Bakker, J., Hoogendoorn, M. E., Kapila, A., Martin, J., Pezzi, A., Pittoni, G., Spronk, P. E., Welte, R., & Hakkaart-van Roijen, L. (2012). Direct Cost Analysis of Intensive Care Unit Stay in Four European Countries: Applying a Standardized Costing Methodology. Value in Health, 15(2012), 81–86.