Table 2.

Summary of Challenges to Consider and Recommendations When Evaluating the Economic Impact of Palliative and End-of-Life Care Interventions on ICU Costs and Utilization

Challenge to consider	Rationale	Recommendations
ICU LOS as an outcome measure	This outcome measure is often reported stratified by death in the ICU, which is determined after randomization. Stratifying on a postrandomization variable may introduce bias.	Consider alternate approaches such as (a) creating a new outcome variable that takes the value of the observed LOS for those who leave the ICU alive and a prespecified value for those who die in the ICU, (b) modeling the time alive and not in the ICU for some prespecified time after randomization
Variation in cost by day of stay and marginal difference between ICU days and acute care floor days	ICU costs are not the same on all days of a stay. Using the average cost of an ICU day and multiplying it by LOS does not accurately reflect costs for a particular number of days in the ICU.	1. Obtain primary cost/day if possible, rather than calculating costs based on LOS. 2. If unable to obtain primary cost data, use published estimates of variation in costs by day of stay from the literature (37, 38, 40)
Breaking down costs from hospital perspective	Reporting total cost savings does not accurately reflect potential savings from the hospital perspective	1. When able to obtain primary cost data, break down reporting of costs into indirect, direct fixed and direct variable components. 2. If unable to obtain components of costs, consider using percentage estimates from the literature as a discussion point (37, 40).
Selecting a time horizon	Degree of potential savings depends on the time horizon that is being considered.	1. When selecting a short time horizon, savings should reflect direct variable costs. 2. When selecting a long time horizon, savings can reflect both direct variable costs and discussion of potential direct fixed costs than can be saved.

LOS, Length of stay.