A Challenge to Congress: A Critical Care Blueprint
March 17th, 2011
 by
Jeffrey Grossman
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While Congress’ recent efforts to repeal the healthcare reform legislation signed by President Obama last year may have been ‘dead on arrival,’ efforts to dismantle the bill continue, and likely will for months to come. Rather than simply repeat the same battles again and again, legislators on both sides of the aisle might also take the opportunity to consider what was missed when the law was enacted.
The Affordable Care Act did much to focus on the need for national policy on improvements in primary, preventive and chronic care, but far too little to address the challenges that persist for the roughly five million Americans each year who, due to critical illness or injury, require intensive and expensive care, typically in one of the country’s most sophisticated inpatient facilities. Care for the critically ill consumes some $80 billion a year, or about one percent of U.S. GDP. Real health care reform cannot occur without reforming the critical care system.
The current challenges to our critical care delivery system include improving our national systems for disaster preparedness; providing end-of-life care that is more responsive to patient needs and desires; augmenting our critical care workforce and training it better; and supporting and coordinating U.S. research in critical care medicine. These challenges should be addressed systematically in partnership with the providers and administrators who best understand what is needed to make critical care medicine more efficient, effective and accessible to those who need it. Absent such steps, federal policymakers will have failed to address one of the single most costly elements of our health care system.
A focused examination of, and response to, these challenges will allow policymakers to improve the state and impact of our critical care system, not to mention make it more cost-effective — goals that transcend the politics of the post-election season. One such effort —which rose above the current partisan rancor— was put forth recently by U.S. Representatives Tammy Baldwin (D-WI) and Erik Paulsen (R-MN). While it does not tackle the issue of end-of-life, the “Critical Care Assessment and Improvement Act” would prompt a serious federal assessment of the current state of the critical care delivery system — capacity, capabilities and gaps. In 2010, a similar measure introduced in the U.S. House received acclaim throughout the critical care medical community.
We need only consider four important reasons why this bill —and other measures to address the gaps in critical care delivery— ought to be a top priority for policymakers as they seek to refine health care reform.
Inadequate Disaster Preparedness Strains Critical Care
Profound illustrations remind us of the need for a review of the readiness of our critical care system. Natural disasters like Hurricane Katrina and pandemic infections like H1N1 place exponential demands on the critical care system, exposing its structural and functional deficits in pockets of the nation, or across the nation itself. To be truly prepared for such eventualities, we must be poised to rapidly deploy critical care professionals and the infrastructure they require where and when it is needed. And yet we know all too well that this does not always happen.
Consider the story of Dr. Jason Woo, currently a physician with the National Institute of Child Health & Human Development. Dr. Woo, who was a delegate to the 2009 Roundtable on Critical Care Policy in Washington, DC, described how he had attempted to provide volunteer medical care to victims of Hurricane Katrina. Upon arriving in New Orleans, Dr. Woo was sent to a ‘holding facility’ —a local warehouse— with more than 80 healthcare professionals. Only a handful of them received assignments – most of them random – each day they were there; the remainder were decamped in the warehouse and not put to work. After 11 days, and just two days before his entire team was called back from the field, Dr. Woo finally received an assignment to a temporary clinic. The system had failed to recognize where his services were needed and to deploy him, in spite of grave needs.
This kind of story, repeated often during the Katrina disaster and others, is but one stark illustration of what can happen when neither the federal government nor the critical care community have reliable and consistent means for matching critical care needs with available resources — from personnel to facilities, equipment and supplies — on a real-time basis. The federal databases that exist to address medical “surge” capacity, such as the Emergency Systems Advance Registration of Voluntary Health Professionals and National Ventilator Inventory, have proven unreliable, under-communicated and underutilized during states of emergency.
Our resource awareness has improved in the five years since Hurricane Katrina has passed, but it is still insufficient to meet the challenge of another large scale disaster. As the Department of Health and Human Services and the Centers for Disease Control examined the threats of mass respiratory illness during the H1N1 pandemic, the total and regional availability of ventilators emerged as a considerable concern, unresolved to this day. Had infection rates been higher, this country would have experienced life-threatening mismatches of ventilator resources and need, leading to the very real possibility that care would need to be rationed.
End of Life Care is Out of Sync with Patient Needs
Inadequate disaster preparedness is only one of the facets of critical care that deserves a place on the national agenda. We continue to face serious challenges in ensuring that, at the end of a patient’s life, they receive appropriate care and support. While an estimated 70 percent of Americans say they prefer to die at home, only 25 percent will, largely because of the biases built in to our healthcare system and their failure to align quality, cost and patient autonomy. Nearly one fourth of Medicare spending occurs in the last year of a patient’s life, and more than half of those costs occur in an in-patient hospital setting.
Terminally ill hospitalized patients will likely be subjected to tests and interventions they don’t want, that won’t have any material benefit to their condition, and that will detract from, rather than enhance, the quality of their end-of-life experience. The Urban Institute recently found that taxpayers could save more than $90 billion over 10 years by avoiding such mismanagement of care. By better aligning care with the wishes of patients and family members, we can achieve the Institute for Healthcare Improvement’s “Triple Aim” goals of improved population health and improved care of individual patients at a lower cost.
How do we do this? As unlikely as it may seem in the current environment, a rational national conversation must occur. If our national psyche can move past the side-show rhetoric of “death panels,” perhaps we can create an environment that supports the education of clinicians needed to excel at this most important work and a policy framework that reflects the immediate and long-run value of providing these services. We can and should set aside politics to make appropriate and compassionate end-of-life care —from clinician dialogue to sustainable hospice care to palliative interventions — part of our national health policy.
Shortage of Trained Specialists Also Undermines Critical Care
Efficient disaster response and enhanced end-of-life care each depend on the existence of a highly competent critical care workforce. Yet the supply of critical care clinicians is grossly inadequate to meet our population needs. The need for critical care today, and projected into the future, is outpacing the numbers of qualified clinicians in this field.
The current workforce shortage, expected to grow as the Baby Boom generation ages and chronic disease leads to critical illness, has the potential to adversely affect patient outcomes and undermine every aspect of critical care delivery. While critical care may seem a world away from primary care generalism, there is a close parallel between these essential generalists and the critical care practitioners who care for those with imminently life-threatening illnesses. Both sets of physicians act as diagnosticians, therapists, organizers of care, system navigators and patient advocates.
Although we know that patient outcomes improve when ICU services are provided by clinicians with training in critical care medicine, the current dearth of U.S. critical care clinicians means that they are only available to treat a third of critically ill patients today, and that does not account for what will be required in the future as Baby Boomers age and the increasing numbers of the chronically ill place greater tolls on ICUs nationwide. Without measures to expand the critical care workforce, we can expect that, by decade’s end, only a quarter or even a fifth of critically patients will have access to a critical care clinician.
We must find ways to encourage more clinicians to enter the field of the critical care, and simultaneously explore ways to improve the capabilities and efficiency of the existing workforce. We must explore policies that support new staffing models along with expanded use of telemedicine to improve patient outcomes. We can and should also do more in the area of “comparative effectiveness” research to generate data on the best investments of resources for patients in the ICU.
The United States Lags in New Research
Finally, there is the matter of creating new knowledge about the pathophysiology and effective treatment of critical illness. The United States is making strides in establishing and supporting critical care trials networks via the United States Critical Illness and Injury Trials Group, yet we lag considerably behind other countries —Canada and Australia— in facilitating pathways for the discovery of safe and effective new therapies for the critically ill. Disease-specific trial networks that exist in the U.S., such as Acute Respiratory Distress Syndrome Clinical Network, have produced remarkable results that have improved outcomes and lowered costs, and it is reasonable to expect that similar trial networks could also have productive results for critical care medicine.
A Way Forward
America needs a blueprint for critical care so that we can align our resources with our policy goals, and so that we can serve our patients and our communities better. In the absence of a plan that can accomplish this —beginning with the Critical Care Assessment and Improvement Act— critical care will continue to be delivered well in some places, ineffectively in others and not at all in places where it may be most urgently needed.
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