Although critical or intensive care units save lives, the high costs of ICU treatment in most private hospitals in India are largely unaffordable for those who are not insured. The novel free treatment policy of the West Bengal government and the project of decentralising basic critical care services to district hospitals have achieved success. Despite the absence of formally qualified critical care specialists, training arranged by the government’s Critical Care Medicine Cell has helped reduce critical care referrals to tertiary hospital CCUs. Although primary investments were high, the decentralisation project proved to be cost-effective. It helped in fighting the Covid-19 pandemic too. The costs for such projects are borne by the exchequer. Hence everybody involved directly or indirectly in providing and availing critical care services should have a rational understanding of quality and cost-effectiveness in critical care.
The essential components of quality assurance in critical care concern the formulation of rational quality standards and continuous monitoring for strict adherence to these. The problems with guidelines framed by the Indian Society of Critical Care Medicine are that they are non-regulatory and non-binding by law. There is thus a need to develop legally-binding quality standards in collaboration with the government, professional bodies, hospital administrators and domain experts.
Given India’s heterogeneity in resources and infrastructure, ICUs can be officially allocated by government authorities responsible for the supervision of clinical establishments into different tiers as recommended by the ISCCM. The system will definitely improve if vital quality-control measures of critical care — ICU designing, staffing, equipment, conformance to protocols and key performance indicators — are brought under the Quality Assurance Standards of the National Health Mission.
The system should try to address impediments like high attrition rates among private hospital staff and the lack of qualified critical care specialists (intensivists) in most hospitals. Evidence shows that ‘Closed ICUs’, where patients are admitted under the responsibility of a trained intensivist, give much better results in terms of quality, outcome and cost-effectiveness as opposed to ‘Open ICUs’, where intensivists may or may not be available for consultation. Applying telemedicine in critical care can improve quality and cost-effectiveness if qualified intensivists supervise treatment and protocol adherence via trained care ‘effectors’ at the bedside. Developing a centralised referral system and improving the efficacy of inter-hospital transport of critically ill patients by trained paramedics are essential.
There are two main components of expenses for any ICU. ‘Fixed’ expenses include costs for establishment, maintenance, equipment and salaries, while ‘variable’ expenses include the cost of drugs, consumables and investigations. Disease does not follow mathematical formulae and national-level regulatory protocols are scarce. Guidelines from foreign literature are not always available given resource limitations in public health. Hence, occasional slips in adherence to protocols should be rationally judged.
Although it is impossible to bind critical care into packages due to the unpredictable nature of illnesses, some basic service packages can be displayed beforehand. However, packages imposed unilaterally by policy-makers or regulatory authorities are detrimental. Overbilling for profiteering should be restrained by the system. Standardisation and uniformity in prices of essential necessities should be considered. Doctors, professional bodies and hospital management should refrain from taking advantage from medical companies to prevent obligations. Over-expectation in cases involving terminal patients, an ‘insurance means ICU’ attitude in private hospitals and pushing non-salvageable patients to free ICUs in government hospitals waste vital resources.
Individual efforts are important, but it’s the system that can ensure quality and cost-effectiveness in critical care.
Sugata Dasgupta is the In-charge-professor of Critical Care Medicine at R.G. Kar Medical College & Hospital, Calcutta
