Quality, cost and outcome of intensive care in a public hospital in Bombay, India

Introduction: Intensive care is expensive and a strain on the health care budget even in economically developed countries like the United States and Canada. These countries spend on an average $1958 per capita on health care. In contrast, the per capita expenditure on health care in India is only US $21. In the face of scarce resources and shortage of trained medical and paramedical personnel, what is the status of critical care medicine in India? The present study attempts to answer some of these questions. Methods: Prospective collection of data in 17 bed Medical-neurology-neurosurgical intensive care unit (ICU) of a teaching hospital. Study of 993 consecutive ICU admissions over a 16 month period. Results: The 993 patients aged 36.5 ± 16 years had a Day-1 APACHE II score of 14.9 ± 9.6 with a predicted mortality of 21.7%; the observed mortality was 36.3% (standardized mortality ratio = 1.67). The Day-1 TISS points were 17.7 ± 6.2 and total TISS points per patient were 87.6 ± 110. Nurse to patient ratio in the ICU was 3 : 17 and the average workload per nurse was 64.2 TISS points. The average length of stay was 5.5 days (SD = 7.1 days). The overall cost of treating 993 patients was Rs 107,79,209 (US$ 307,997) and cost per patient per day Rs 1973 (US$ 57). The cost per survivor was Rs 17029 (US$ 487) and cost per TISS point was Rs 90.14 (US$ 2.57). The low cost per TISS point was because of reuse of disposable equipment and lower cost of drugs and salaries for medical and paramedical staff. Conclusions: Intensive care in India is cheaper than in the West; however, mortality is 1.67 times that for similar APACHE II scores in ICUs in the United States. This may be because of less intensity of care per patient (lower Day-1 TISS points), lower nurse to patient ratio due to shortage of trained personnel and budgetary constraints and higher workload per nurse (64.2 TISS points per nurse compared to 40 points per nurse in the West). Besides, the APACHE II scores may underestimate mortality for Indian patients because of differences in case-mix, higher lead-time between onset of admission and treatment before ICU admission and possible inappropriateness of age points derived from American patients for Indian subjects due to a higher burden of diseases at lower ages in Indians.