Cost-effectiveness of an Emergency Department-Based Intensive Care Unit.

Importance: Value in health care is quality per unit cost (V = Q/C), and an emergency department-based intensive care unit (ED-ICU) model has been associated with improved quality. To assess the value of this care delivery model, it is essential to determine the incremental direct cost of care. Objective: To determine the association of an ED-ICU with inflation-adjusted change in mean direct cost of care, net revenue, and direct margin per ED patient encounter. Design, Setting, and Participants: This retrospective economic analysis evaluated the cost of care delivery to patients in the ED before and after deployment of the Joyce and Don Massey Family Foundation Emergency Critical Care Center, an ED-ICU, on February 16, 2015, at a large academic medical center in the US with approximately 75 000 adult ED visits per year. The pre-ED-ICU cohort was defined as all documented ED visits by patients 18 years or older with a complete financial record from September 8, 2012, through June 30, 2014 (660 days); the post-ED-ICU cohort, all visits from July 1, 2015, through April 21, 2017 (660 days). Fiscal year 2015 was excluded from analysis to phase in the new care model. Statistical analysis was performed March 1 through December 30, 2021. Exposures: Implementation of an ED-ICU. Main Outcomes and Measures: Inflation-adjusted direct cost of care, net revenue, and direct margin per patient encounter in the ED. Results: A total of 234 884 ED visits during the study period were analyzed, with 115 052 patients (54.7% women) in the pre-ED-ICU cohort and 119 832 patients (54.5% women) in the post-ED-ICU cohort. The post-ED-ICU cohort was older (mean [SD] age, 49.1 [19.9] vs 47.8 [19.6] years; P < .001), required more intensive respiratory support (2.2% vs 1.1%; P < .001) and more vasopressor use (0.5% vs 0.2%; P < .001), and had a higher overall case mix index (mean [SD], 1.7 [2.0] vs 1.5 [1.7]; P < .001). Implementation of the ED-ICU was associated with similar inflation-adjusted total direct cost per ED encounter (pre-ED-ICU, mean [SD], $4875 [$15 175]; post-ED-ICU, $4877 [$17 400]; P = .98). Inflation-adjusted net revenue per encounter increased by 7.0% (95% CI, 3.4%-10.6%; P < .001), and inflation-adjusted direct margin per encounter increased by 46.6% (95% CI, 32.1%-61.2%; P < .001). Conclusions and Relevance: Implementation of an ED-ICU was associated with no significant change in inflation-adjusted total direct cost per ED encounter. Holding delivery costs constant while improving quality demonstrates improved value via the ED-ICU model of care.

Cost Implications of Oral Contrast Administration in the Emergency Department: A Time-Driven Activity-Based Costing Analysis.

PURPOSE: To quantify the monetary and time costs associated with oral contrast administration in the emergency department (ED) for patients with nontraumatic abdominal pain and to evaluate the cost savings associated with an institutional policy change in the criteria for oral contrast administration. METHODS: A HIPAA-complaint, institutional review board-approved time-driven activity-based costing analysis was performed using both prospective time studies and retrospective data obtained from a quaternary care center. Retrospective data spanned a 1-year period (January 1, 2016, to December 31, 2016). A process map was generated. Examination volume-related data, labor costs, and material costs were determined and applied to a base-case model. Univariate and multivariate sensitivity analyses were conducted. Multivariate analysis was used to estimate the cost savings associated with a policy change eliminating oral contrast for patients with body mass index ≥ 25 kg/m2, no prior abdominal surgery within 30 days preceding CT, and no inflammatory bowel disease. RESULTS: The baseline oral contrast utilization rate was 86% (4,541 of 5,263). The annual base-case cost estimate for oral contrast administration was $82,552. In multivariate analyses, this ranged from $13,685 to $315,393. The model was most sensitive to the volume of CTs requiring oral contrast. Applying parameters from the new policy change reduced the annual cost by 52% (cost saving: $35,836.57). Impact of oral contrast on time to discharge was highly variable and dependent on the contrast agent utilized. CONCLUSION: Costs associated with oral contrast in the ED are modest and should be balanced with its potential diagnostic benefits. Our criteria reduced oral contrast utilization by 52%.