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Quality–efficiency square: a new way to look at cost and quality in critical care

Critical care units are under increasing pressure to account for the large cost of managing complex patients. Ideally, cost-utilisation analysis (€/QALY) [1] should be used to assess treatment; however, this is very difficult in the uncontrolled environment of a working critical care unit with a heterogeneous patient population. Cost/ survivor is often used as a cost measure that considers outcome and is easier to measure; however, this is case-mix dependent so comparisons between units are flawed. We aimed to develop a measure of cost efficiency and quality that was independent of factors outside the control of each unit. We postulated that this could be achieved using a cost factor based on patient days weighted for average risk of death (RoD) and annual admission number [2], which along with the SMR would allow construction of a matrix that could assess both cost efficiency and outcome quality (the QES).

Forty-seven units from the UK National Cost Block Programme (2003–2004) were included. Regression analysis was used to create a formula for cost/patient-day based on the admission number and RoD. Residuals representing the deviation from the predicted cost were plotted against the SMR. Units that had both low SMR and low cost (<95% CI) were considered to have high quality and high economy or high quality–efficiency (QE). Those with high SMR and high cost were considered to have low QE. We identified seven units that had high QE and six units that had low QE.

We categorised units by cost/survivor and then assessed the QE categories in these terms. There was only limited correlation between the two methods.

We believe that the QES is a relatively easy measure of both economic efficiency and quality, and may be a useful, powerful and convenient tool to assess critical care units.


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  1. 1.

    Curr Opin Crit. 2002, 8: 337. 10.1097/00075198-200208000-00011

  2. 2.

    Intensive Care Med. 2004, 30: 660. 10.1007/s00134-003-2123-2

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Blunt, M., Burchett, K. & Young, P. Quality–efficiency square: a new way to look at cost and quality in critical care. Crit Care 10, P396 (2006).

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  • Cost Efficiency
  • Average Risk
  • Critical Care Unit
  • Convenient Tool
  • Complex Patient