ICU Telemedicine and Critical Care Mortality

Abstract

Background Intensive care unit (ICU) telemedicine is an increasingly common strategy for improving the outcome of critical care, but its overall impact is uncertain. Objectives To determine the effectiveness of ICU telemedicine in a national sample of hospitals and quantify variation in effectiveness across hospitals. Research design We performed a multi-center retrospective case-control study using 2001–2010 Medicare claims data linked to a national survey identifying United States hospitals adopting ICU telemedicine. We matched each adopting hospital (cases) to up to 3 non-adopting hospitals (controls) based on size, case-mix and geographic proximity during the year of adoption. Using ICU admissions from 2 years before and after the adoption date, we compared outcomes between case and control hospitals using a difference-in-differences approach. Results 132 adopting case hospitals were matched to 389 similar non-adopting control hospitals. The pre- and post-adoption unadjusted 90-day mortality was similar in both case hospitals (24.0% vs. 24.3%, p=0.07) and control hospitals (23.5% vs. 23.7%, p<0.01). In the difference-in-differences analysis, ICU telemedicine adoption was associated with a small relative reduction in 90-day mortality (ratio of odds ratios: 0.96, 95% CI = 0.95–0.98, p<0.001). However, there was wide variation in the ICU telemedicine effect across individual hospitals (median ratio of odds ratios: 1.01; interquartile range 0.85–1.12; range 0.45–2.54). Only 16 case hospitals (12.2%) experienced statistically significant mortality reductions post-adoption. Hospitals with a significant mortality reduction were more likely to have large annual admission volumes (p<0.001) and be located in urban areas (p=0.04) compared to other hospitals. Conclusions Although ICU telemedicine adoption resulted in a small relative overall mortality reduction, there was heterogeneity in effect across adopting hospitals, with large-volume urban hospitals experiencing the greatest mortality reductions.

Telemedicine Coverage of Intensive Care Units: A Narrative Review

“…Indeed, if patients are not actually critically ill, then having an intensivist involved in their care may not be cost-effective or even beneficial (61). Second, although it was originally conceived as a way to expand intensivists' reach and availability to rural areas, ICU telemedicine may be particularly effective in large urban hospitals (21,52). ICU capacity strain -when demand on an ICU's resources exceeds availability -may be the mechanism for this finding (62).…”

“…By identifying individual domains associated with improved outcomes post-ICU telemedicine implementation, authors offered plausible mechanisms for the potential effectiveness of this intervention(29). Finally, a recent large national study evaluating the effectiveness of ICU telemedicine programs with concurrent controls showed a small relative mortality reduction with wide variation in ICU telemedicine effect across adopting hospitals, although this study used an administrative database that lacked detailed clinical risk adjustment(52).However, multiple other observational studies with similar limitations did not find any association of ICU telemedicine with improved patient outcomes(42,53,54). Specifically, one study in multiple ICUs across a large US healthcare system evaluated the association of ICU telemedicine with patient outcomes.…”

Does Size Matter in ICU Telemedicine?

“…While one would expect ICU telemedicine, known also as tele-ICU, to improve outcomes in small rural hospitals with no intensivist, urban large-volume hospitals seem to benefit the most. 2 Small ICUs need to be grouped with others to create a financially sustainable tele-ICU program, whereas large ICUs may already have the optimal number of ICU beds covered by one telemedicine center. This may be critical for the operation of a telemedicine program for the following reasons:…”

Study protocol for the Anesthesiology Control Tower—Feedback Alerts to Supplement Treatments (ACTFAST-3) trial: a pilot randomized controlled trial in intraoperative telemedicine

“…While this type of clinical decision support has seen robust adoption in the critical care setting, its utilization in the intraoperative care of surgical patients is limited 50 . In light of the benefits that have been demonstrated from using telemedicine in the ICU setting, we believe that the implementation of such a system in the operating room has the potential to elevate the general safety and quality of perioperative care.…”