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Impact of Telemedicine on Mortality, Length of Stay, and Cost Among Baptist Health South Florida Scholarly Commons @ Baptist Health South Florida All Publications 2018 Impact of Telemedicine on Mortality, Length of Stay, and Cost Among Patients in Progressive Care Units: Experience From a Large Healthcare System Donna Lee Armaignac Baptist Health South Florida, [email protected] Anshul Saxena Baptist Health Medical Group, [email protected] Muni Rubens Miami Cancer Institute, [email protected] Carlos Valle Baptist Health South Florida, [email protected] Lisa-Mae Williams Baptist Health South Florida, [email protected] See next page for additional authors Follow this and additional works at: https://scholarlycommons.baptisthealth.net/se-all-publications Citation Critical Care Medicine (2018) 46(5):728-735 This Article -- Open Access is brought to you for free and open access by Scholarly Commons @ Baptist Health South Florida. It has been accepted for inclusion in All Publications by an authorized administrator of Scholarly Commons @ Baptist Health South Florida. For more information, please contact [email protected]. Authors Donna Lee Armaignac, Anshul Saxena, Muni Rubens, Carlos Valle, Lisa-Mae Williams, Emir Veledar, and Louis Gidel This article -- open access is available at Scholarly Commons @ Baptist Health South Florida: https://scholarlycommons.baptisthealth.net/se-all-publications/2598 Impact of Telemedicine on Mortality, Length of Stay, and Cost Among Patients in Progressive Care Units: Experience From a Large Healthcare System* Donna Lee Armaignac, PhD, APRN CNS-BC, CCNS, CCRN; Anshul Saxena, PhD; Muni Rubens, PhD; Carlos A. Valle, MSIT; Lisa-Mae S. Williams, MSN; Emir Veledar, PhD; Louis T. Gidel MD, PhD Objectives: To determine whether Telemedicine intervention can patients, compared with NTPCU (7.3 vs 6.8 d; p < 0.0001). The affect hospital mortality, length of stay, and direct costs for pro- overall mean direct cost was higher for TPCU ($13,180), com- gressive care unit patients. pared with NTPCU ($12,301; p < 0.0001). Design: Retrospective observational. Conclusions: Although there are many studies about the effects of Setting: Large healthcare system in Florida. telemedicine in ICU, currently there are no studies on the effects of Patients: Adult patients admitted to progressive care unit (PCU) telemedicine in progressive care unit settings. Our study showed as their primary admission between December 2011 and August that TPCU intervention significantly decreased mortality in pro- 2016 (n = 16,091). gressive care unit and hospital and progressive care unit length of Interventions: Progressive care unit patients with telemedicine inter- stay despite the fact patients in TPCU were older and had higher vention (telemedicine PCU [TPCU]; n = 8091) and without tele- disease severity, and risk of mortality. Increased postprogres- medicine control (nontelemedicine PCU [NTPCU]; n = 8000) were sive care unit hospital length of stay and total mean direct costs compared concurrently during study period. inclusive of telemedicine costs coincided with improved survival Measurements and Main Results: Primary outcome was progres- rates. Telemedicine intervention decreased overall mortality and sive care unit and hospital mortality. Secondary outcomes were length of stay within progressive care units without substantial hospital length of stay, progressive care unit length of stay, and cost incurrences. (Crit Care Med 2018; 46:728–735) mean direct costs. The mean age NTPCU and TPCU patients Key Words: direct costs; hospital mortality; length of stay; were 63.4 years (95% CI, 62.9–63.8 yr) and 71.1 years (95% CI, progressive care unit; telemedicine 70.7–71.4 yr), respectively. All Patient Refined-Diagnosis Related Group Disease Severity (p < 0.0001) and All Patient Refined- Diagnosis Related Group patient Risk of Mortality (p < 0.0001) scores were significantly higher among TPCU versus NTPCU. atients admitted to hospitals have different disease severity After adjusting for age, sex, race, disease severity, risk of mortal- and require different levels of care (1). A large proportion ity, hospital entity, and organ systems, TPCU survival benefit was Pof low risk patients are admitted to ICUs just for monitor- 20%. Mean progressive care unit length of stay was lower among ing purposes, thus increasing patient load and affecting function- TPCU compared with NTPCU (2.6 vs 3.2 d; p < 0.0001). Post- ality of ICUs (2). Similarly, a significant proportion of patients progressive care unit hospital length of stay was longer for TPCU who require more intensive care are treated in the wards (3, 4). There is an increasing need for step-down units such as progres- *See also p. 816. sive care units (PCUs) due to diverse population characteristics, All authors: Telehealth Center of Excellence, Baptist Health South Florida, increased proportion of aging patient population, increasing cost Coral Gables, FL. of care, and shortage of intensivists (5). PCUs manage patients The authors have disclosed that they do not have any potential conflicts who need “intermediate” level of care—patients who require of interest. more extensive care than in general wards, but less than in For information regarding this article, E-mail: [email protected] ICUs (6). PCUs were created to provide cost-effective and high- Copyright © 2018 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine and Wolters Kluwer standard care without negatively impacting patient outcomes for Health, Inc. This is an open-access article distributed under the terms less severely ill patients who are admitted to ICUs for monitoring of the Creative Commons Attribution-Non Commercial-No Derivatives or more serious patients who are treated in the wards (2, 7). License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed To overcome increasing patient demands and shortage of in any way or used commercially without permission from the journal. intensivists, telemedicine, a relatively new method of care deliv- DOI: 10.1097/CCM.0000000000002994 ery, has been applied to critical care (8, 9). Approximately, 11% 728 www.ccmjournal.org May 2018 • Volume 46 • Number 5 Clinical Investigations of critical care units in the United States have integrated tele- medicine and many have reported positive health outcomes (10). Telemedicine includes managing patients through monitoring devices controlled by physicians and nurses in remote locations. Telemedicine has improved patient outcomes through advanced monitoring, cognitive affordances, clinical decision-support functions, execution of life saving, and evidence-based critical care protocols. In a retrospective study that looked for the effect of telemedicine on mortality and length of stay (LOS) in com- munity hospital ICUs, it was observed that telemedicine signifi- cantly decreased odds of ICU mortality (odds ratio, 0.46; 95% CI, 0.32–0.66) when compared with pretelemedicine imple- mentation stages (11). In addition, telemedicine also decreased LOS. Similarly, another study by Lilly et al (10) reported that hospital mortality rate significantly decreased from 13.6% before Figure 1. Inclusion of patients into telemedicine progressive care unit (PCU) (TPCU) and nontelemedicine PCU (NTPCU) groups. telemedicine implementation to 11.8% after intervention. ICU mortality also significantly reduced from 10.7% to 8.6% after the Care Medicine guidelines (3). Inclusion criteria were all adult implementation. In a review article on acceptance of telemedi- patients admitted in PCUs as their primary admission with- cine coverage among ICU staff, it was observed that telemedi- out a prior ICU admission. All patients required a minimum cine in ICU (Tele-ICU) installations were rapidly accepted by of 24 hours of PCU LOS to be included. If the encounter did ICU staff despite initial difficulties in autonomy, training, scru- not reach these thresholds, patients were excluded. When tiny, and malfunctions, primarily due to perceived benefits for patients were downgraded to telemetry or med/surgical unit, patients among the ICU staff (12). Telemedicine coverage was they were consequently discharged from TPCU, regardless of associated with decreased ICU mortality and LOS as reported bed availability. Patients were also excluded if demographics in a meta-analysis (13). Although many studies report improved information was missing (Fig. 1). patient quality and outcomes due to telemedicine (10, 11, 13– 15), some studies have noted mixed and inconsistent benefits Measures and stark variations in the application of telemedicine (16–21). Demographic variables included age, gender, and race/ethnic- Intricacy and variability in the application of telemedicine, along ity. Measures included admission diagnosis, PCU and hospital with differences in study designs, creates a challenge to determine LOS, PCU and hospital mortality, and the “total direct cost” of the impact on quality and return on investment (22–25). hospitalization. Total direct cost is comprised of “direct fixed” Although previous studies have reported challenges, advan- and “direct variable.” Direct fixed costs are for unit level opera- tages, and disadvantages of telemedicine implementation tions, and the cost of telemedicine is reflected in direct fixed (9, 15, 22, 26–31), there are no studies exploring effect of these costs per licensed bed per patient stay; “direct variable” includes innovations
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