Perceptions of cost constraints, resource limitations, and rationing in United States intensive care units: Results of a national survey

Objective: To examine cost constraints, resource limitations, and rationing within U.S. intensive care units (ICUs) as perceived by ICU clinicians and the roles of ICU physician and nurse directors in resource allocation decisions. Design: A national survey of hospitals with ICUs. Setting: The study included 447 U.S. hospitals with ICUs. Subjects: ICU nurse and physician directors. Interventions: None. Measurements and Main Results: We randomly selected 447 U.S. hospitals stratified for location and ICU size and contacted them for this survey. The institutional response rate was 63%. When asked to characterize their involvement in budgetary decisions, 55% of nurse directors vs. 3% (p < .001) of physician directors answered "heavy" involvement. Additionally, 91% of nurse vs. 38% of physician directors were given feedback on expenditures (p <.001). Responses to questions about specific situations or practices that may be associated with rationing showed that a substantial minority respondents perceived these practices "sometimes" (occurring 25% to 74% of the time) but the majority perceived it "rarely" (occurring < 25% of the time) or not at all. Few perceived rationing as occurring "frequently" (occurring > 75% of the time) because of costs or availability. When asked if any rationing occurs in their ICUs (using a prestated definition), only 11% of physician and 6% of nurse directors responded yes. Only 6% of nurses and 5% of physicians said that cost constraints have a significant effect on care. In contrast, when asked how often patients receive "too much" care, 46% of respondents said "sometimes or frequently." Conclusions: Nurse managers have a larger role in managing ICU costs than physicians. Furthermore, both groups perceive that rationing and other cost-related practices sometimes occur in their ICU, but they more commonly perceived excessive care in ICUs. These data may be helpful for policy makers and administrators and may serve as a benchmark for future studies in critical care or other realms of health care.