Total health care costs in the United States (U.S.) reached $989 billion in 1995 and now exceed $1 trillion, 14% of the Gross Domestic Product (GDP) (1). Of this total, a disproportionate share is attributable to the care of elderly patients shortly before their deaths. According to Lubitz and Prihoda (2) and Lubitz and Riley (3), 6% of Medicare recipients 65 yr of age and older who died in 1978 and 1988 accounted for 28% of all costs of the Medicare program. In the same two years, 77% of the Medicare decedents' expenditures occurred in the last year of life, 52% of them in the last 2 mo, and 40% in the last month. Inpatient expenses accounted for over 70% of the decedents' total costs. ....
The major reason that cost reduction should be possible in the ICU is that critical care is extremely expensive. Of the $989 billion spent on health care in the U.S. in 1995, expenditures for hospital care amounted to approximately $350 billion and constituted the largest portion (1). Assuming that ICU costs were 20% of all hospital costs, which they were estimated to be in 1986 (7), these costs were around $70 billion in 1995 or 1% of the GDP. The costs of ICU care probably are higher today, not only because total hospital costs are higher but also because ICU costs may represent a larger fraction of hospital costs, inasmuch as a greater percentage of hospitalized patients are cared for in the ICU.
The high cost of intensive care is reflected in daily ICU costs, which range from $2,000 to $3,000 in many U.S. hospitals (8). As Chaix and colleagues (9) have demonstrated, the ICU costs of individual patients may be equated with the amount of time the patients are cared for in the ICU, their length of stay (LOS). As a result, clinicians and administrators alike may assume that health care, hospital, and ICU costs can be reduced by thousands of dollars simply by decreasing ICU LOS. Such a decrease might involve not only the few patients with a long LOS, who are most expensive on a per-patient basis, but also the larger number of patients who stay in the ICU only a few days