This chapter deals with the poorly understood topic of introducing something new into clinical practice in the ICU, some "new component of care". This could be a new transfusion guideline you just drafted, or some sort of new equipment, or a highly fascist hand-washing protocol, new janitorial staff, or any damn thing. In summary, the process involves evaluating the need for the component, discrete goals for its implementation, evidence in support of it, analysis of the costs and benefits, assessment of alternatives, and post-implementation audit to determine whether the goals are being met.

Question 4 from the second paper of 2002 asked about "the factors you would consider in making a cost-benefit analysis of introducing a new component of care", which was a vague and poorly answered stem (33% were successful in blathering something worth over five marks in response to this question). Such a question has thus far not ben repeated, but history has demonstrated the willingness of the college to recycle decade-old questions, particularly ones which do not age (like this one, which is not susceptible to becoming irrelevant with the publication of new evidence).">

Adoption of a new component of care

Evidence in support of the new component

  • Is there robust evidence to support the use of this component
  • Is this evidence generaliseable to the relevant population
  • What is the expected benefit (eg. expressed as OR or RRR)
  • What is the magnitude of its impact (eg. expressed in NNT)

Cost-benefit analysis of new component

  • What is the cost of the new component
  • How does this cost compare to the cost of existing practice
  • Does the cost-benefit ratio favour this new component over the existing practice (eg. if the new component is more expensive but also more effective, how much extra QALY does each extra dollar buy?)
  • How does this specific new component compare to an alternative in terms of cost-benefit ratio? A comparison of several alternatives would be required.

Logistics of implementation

  • Where will the funding come from
  • Is the incremental cost of the component covered by the funding
  • What savings or costs will be generated by the abandonment of the existing practice
  • What costs are involved in the training and education of staff
  • What costs are involved in the processes of quality assurance audit and follow-up for this new component
  • What degree of acceptance is there for this new component among the staff
  • How will the satisfaction of staff with this new component be assessed?

Puchasing new ICU equiment

How does one go shopping for ECMO oxygenators? There is no such EBay category. They are not reviewed on AnandTech. Fortunately, LITFL has an excellent article to inform your consumer-whoring. Peer-reviewed literature is scarce, but this article also has electronic supplementary material which contains a checklist for selection of ICU whitegoods. One can download this document from Intensive Care Medicine if one has CIAP access.

Additionally, a 1992 article from the CMAJ discusses exactly how attractive a new technology has to be in order to warrant adoption, and presents an itemised checklist for economic valuation of costs and effect.

Cost-benefit analysis

What makes a good cost-benefit analysis?

  • All relevant clinical outcomes and costs are included in the analysis and valued sensibly
  • The difference in cost and clinical outcome is compared between one technology and another
  • Costs and clinical outcomes are discounted
  • Robustness of the conclusion is assessed by sensitivity analysis
  • The perspective of the decisionmaker is clearly identified
  • Incremental cost-utility ratio of one program is compared with another program.

Do you really need this gadget?

  • Is there a real need?
  • Whats wrong with the existing equipment?
  • Who actually requiested this, and why do they want it?
  • How many do you need?

Which model to buy? Consider the following:

  • Availability of upgrades
  • Compliance with standards
  • Compatibility with existing equipment
  • Is it user-friendly?
  • Does the company offer essential services, such as:
    • Training for your staff
    • Spare parts
    • 24-hour service commitment
    • Warranty
  • Can your department afford it?

Acquisition of funding

  • Part of existing budget
  • Formal application for additional budget
    • This may require a cost-benefit analysis
  • Application for special funding from an institution

Implementation

  • Installation by manufacturer
  • Education of staff by manufacturer
  • Regular upgrades
  • Regular servicing

Audit

  • Frequency of use
  • Complaints about usability
  • Frequency of malfunction
  • Staff satisfaction
  • Retrospective cost-benefit analysis

Inappropriate attachment to technology

The ICU is all about the machines that go beep. LITFL have an article entitled "Gizmo idolatry" which draws heavily from a 2008 JAMA paper by the same name. Concerns about the mechanisation of healthcare was also voiced by some Canadian urologists, who were concerned that they were being seduced by a robot.

Salient points:

  • This tendency is a part of the human need to view more complicated solutions as somehow "cleverer" and more effective.
  • The following inappropriate beliefs have formed:
    • Technology-rich care is a higher standard of care
    • Technology-heavy investigations yield better objective information
    • A technology-fancying practitioner is somehow more competent
    • Simple non-technological interventions are less exciting, and thus less effective.
  • Early adoption = exposure of patients to unproven technology
  • Purchase of interesting equipment is an incentive to perform more high-tech interventions where low-tech solutions would have sufficed
  • Decreased affordability of healthcare, both for the patient and for the taxpayer.

References

Valentin, Andreas, and Patrick Ferdinande. "Recommendations on basic requirements for intensive care units: structural and organizational aspects."Intensive care medicine 37.10 (2011): 1575-1587.

Laupacis, A., et al. "How attractive does a new technology have to be to warrant adoption and utilization? tentative guidelines for using clinical and economic evaluations." CMAJ: Canadian Medical Association Journal 146.4 (1992): 473.

Leff, Bruce, and Thomas E. Finucane. "Gizmo idolatry." JAMA 299.15 (2008): 1830-1832.

Nickel, J. Curtis. "Are we being seduced by a robot?." Canadian Urological Association Journal 3.5 (2009): 359.

Rosenfeld, Richard M. "Gizmos." Otolaryngology--Head and Neck Surgery 150.4 (2014): 505-508.