MONDAY, Nov. 1, 2004 (HealthDayNews) -- The very few patients who repeatedly require intensive care for their illnesses are responsible for a sizable chunk of the money used for this purpose, a new study finds.

And as people age, they are less likely to avail themselves of critical care, even when they are seriously ill, the researchers add.

Data on 1.1 million Medicare patients revealed that almost 55 percent of the patients used critical care at some time after their diagnosis. Patients who were 90 had one-third the odds of using critical care, compared with patients aged 68 to 70 years old.

Moreover, just 31,348 patients -- 3 percent -- were repeated users of the intensive care unit. They accounted for 23 percent of the hospitalizations, $3.6 billion in hospital charges, and $1.4 billion in Medicare reimbursement, according to the report in the November issue of the American Journal of Respiratory and Critical Care Medicine.

"Critical care use is very common among elderly Americans," said study author Dr. Theodore J. Iwashyna, from the Department of Medicine at the Hospital of the University of Pennsylvania.

According to Iwashyna, his study included almost all Americans over the age of 68 who were diagnosed with one of 13 common conditions in one particular year. Those 13 conditions included cancers, stroke, congestive heart failure, hip fracture and heart attack.

"More than half of those patients used critical care at some point before they died," he said. "It is my impression that people think of critical care as unusual, but our data suggests that most people may face critical care at some point."

While critical care is common, a tiny minority of users account for much of the costs. These are patients who repeatedly use critical care. "Since critical care is so expensive, we spend almost one full percentage point of the gross domestic product on it. If we can find ways to redirect these patients to safe, less intensive care, there may be a lot of money to be saved," Iwashyna said.

"People need to think hard about the kind of care they want if they get sick," he said. For some, critical care is an example of the best of American medicine. But for others, it may be more invasive and risky than they want, Iwashyna added.

Iwashyna believes researchers need to explore whether there are significant cost savings if less intensive -- but equally safe -- treatments are found for patients who repeatedly end up in intensive care.

As the U.S. population ages, there will be more demand for critical care. "If people are not open and honest with their loved ones about the choices that they want in how aggressive their care should be, not everybody may get as intensive care as they want," Iwashyna said.

"People need to talk with their doctors and family realistically about how they would approach some of the hard choices involved in using, or not using, intensive care," he added.

The findings in this study are things that experts strongly suspected, said Dr. Gordon D. Rubenfeld, a specialist in pulmonary and critical care medicine at Harborview Medical Center in Seattle and an associate professor of medicine at the University of Washington.

"Older folks tend to get less aggressive care," Rubenfeld said. But many people continue to get intensive care even when they have severe diseases with poor prognosis, he added.

The reason many older patients don't get admitted to intensive care is probably due to what patients want, Rubenfeld said. For the elderly, it is probably a combination of physicians providing less care and patients asking for less care.

Rubenfeld added that high costs of medical care are usually associated with a minority of patients. The amount spent on a small percentage of patients repeatedly admitted to intensive care is a drop in the bucket when one looks at the total Medicare budget, he explained.

"Most survivors of intensive care are satisfied with the quality of life," Rubenfeld said. "Most of them would undergo intensive care again for their current quality of life, and so would their family members."

However, with the number of patients on Medicare increasing and the need for intensive care growing, there appears to be only two solutions to the problem of access to this care, Rubenfeld said. "We are either going to have to curb the amount of intensive care we provide, or we are going to have to figure out how to grow our intensive care resources," he said.

More information

The National Library of Medicine has more about critical care at the end of life.

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