A Systematic Review of the Cost-

Effectiveness of Noncardiac Transitional

Care Units*
Sean P. Keenan, MD; David Massel, MD; Kevin J. Inman, MSc; and
William J. Sibbald, MD, FCCP

Objective: To critically appraise and summarize the studies examining the cost-effectiveness of
noncardiac transitional care units (TCUs).
Data sources: We conducted a computerized literature search using MEDLINE, and Current
Contents from January 1, 1986 to December 31, 1995 and HealthSTAR from January 1, 1989 to
December 31, 1995 with the key words intermediate care unit, respiratory care unit, and
step-down unit. Bibliographies of all selected articles and review articles were examined. Personal
files were also reviewed.
Study selection: (1) Population: patients in a noncardiac TCU of an acute-care institution; (2)
intervention: addition of a noncardiac TCU to the institution; and (3) outcomes: patient
outcome.survival and associated costs.
Data extraction: The necessary data were abstracted and study validity was evaluated by two
independent reviewers using a modification of previously published criteria.
Data synthesis: The studies were summarized qualitatively; upon inspection, they were too
heterogeneous to allow quantitative analysis. While the studies all claimed that their TCUs were
cost-effective, the economic evaluation designs were flawed to such an extent that the validity of
the conclusions is suspect.
Conclusions: To date, the evidence in the literature is insufficient to determine under which
circumstances, if any, TCUs are a cost-effective alternative technology to the traditional
institution with only ICU and general ward beds. (CHEST 1998; 113:172-77)
Key words: cost-effective; intensive care; intermediate care unit; step-down unit; critical care
Abbreviation: TCU=transitional care unit

HP he cost associated with caring for patients in the
¦*¦critical care units of the United States has been
estimated to be 1 to 1.5% of the gross national
product.1"3 Canada has seen a similar, rapid growth
in the cost of critical care.4 Resources dedicated to
health care will not increase appreciably in the
*From the Richard Ivey Critical Care Trauma Center (Drs.
Keenan and Sibbald and Mr. Inman) and the Department of
Cardiology (Dr. Massel), London Health Sciences Centre, Vic¬
toria Campus, University of Western Ontario, London, Ontario,
Canada.
This study was supported by the Departments of Critical Care,
Cardiology, General Surgery, and Nursing, London Health Sci¬
ences Centre, Victoria Campus, University of Western Ontario,
London, Ontario, Canada. Dr. Keenan is supported by a Cana¬
dian Lung Association/Medical Research Council of Canada
Fellowship. received November
Manuscript 26, 1996; revision accepted June
10, 1997.
Reprint requests: Sean P. Keenan, MD, Department of Critical
Care Medicine, London Health Sciences Centre, Victoria Cam¬
pus, 375 South St, London, ON, Canada, N6A 4G5
172
future, necessitating an emphasis on efficient triag-
ing of patients to areas of care appropriate to patient
need.
In the past, a significant proportion of patients
were cared for in ICUs for monitoring purposes
alone15"7 or for single-system failure (prolonged
ventilation in hemodynamically stable patients). The
proportion of these patients admitted to ICUs varied
among hospitals and countries depending on the
resources available and the philosophies of the
health-care workers involved.89 As a result of these
observations, units were developed to provide vary¬
ing levels of noninvasive monitoring with or without
the capability to ventilate patients. For this review,
we have chosen to call these units transitional care
units (TCUs) (Table 1). TCUs are a technology in
themselves and, like all technologies, should be
critically evaluated prior to widespread adoption.
Patients in TCUs require a lower nurse: patient ratio
and may require fewer investigations when com¬
pared to patients in ICUs. While a number of
Clinical Investigations in Critical Care
 Table 1.Potential Levels of Care Available
Level of Care Nurse: Patient Ratio Mechanical Ventilation Noninvasive Monitoring Invasive Monitoring
General ward Low(<l:10) Not available Intermittent oximetry Not available
TCU Intermediate (1:3 to 1:6) Available Not available*
ICU High (1:1, 1:2) Available Available Available
*Some TCUs may provide limited invasive monitoring.

authors claim that TCUs are, de facto, cost-effec¬ ties) is imperative. Finally, the conclusions drawn in the discus¬
sion must reflect the results presented. Conclusions based on
tive,10-15 it may be presumptuous to accept these invalid study design cannot themselves be respected as valid. A
claims without a rigorous review of the evidence. number of important articles have been written that allow greater
The objective of this systematic review was to explanation of these concepts than are possible here.1621 The
determine whether noncardiac TCUs are cost-effec¬ maximum score possible was 18. In addition, an overall rating of
tive. the study quality was independently made by the two reviewers
using a five-point Likert scale (very poor, fair, good, very
poor,
good) after completing the validity criteria.
Materials and Methods Analysis
Interobserver variability in assessment of study validity and
Search Strategy and Study Selection Criteria overall quality was described qualitatively, and differences in
We performed a computerized literature search using MED¬ opinion were decided by consensus. No attempt was made to
LINE and Current Contents from January 1, 1986 to December pool the results of the studies quantitatively due to the hetero¬
31,1995 and HealthSTAR from January 1, 1989 to December 31, geneity of study design and TCU populations.
1995 with the following key words: intermediate care unit,
respiratory care unit, and step-down unit. Our search was Results
restricted from 1986 onwards as noncardiac TCUs were only
introduced in the early to middle 1980s and the literature lagged
about 5 years behind this. We also reviewed the citations from all Summary of Selected Studies
articles retrieved to identify other articles of interest. Our Only three articles fulfilled the selection crite¬
selection criteria included the following: (1) population: patients ria.1315 Other studies on implementation of a TCU
in a noncardiac TCU of an acute-care institution; (2) intervention:
addition of noncardiac TCU to the institution; and (3)
a
patient outcome.survival and associated costs.
out¬ Table 2.Modified Checklist for Assessing Economic
comes:
Evaluations*
Assessment of Study Validity Checklist
The validity of studies that fulfilled our selection criteria was 1. Was a well-defined question posed in an answerable form?
independently appraised (S.P.K., K.J.I.) using modified criteria (No 0; yes 2)
for economic evaluation (Drummond and colleagues16.see Ta¬ 2. Was a comprehensive description of competing alternatives
ble 2). A properly posed question should identify the different given?
alternatives being compared and the relevant viewpoint of the (Neither alternative 0; one alternative 1; both alternatives 2)
economic evaluation. 3. Was there evidence that the program's effectiveness had been
The viewpoint selected can be that of the hospital, insurance established?
company, society, or others. A complete description of both
(No 0; yes 2)
alternatives should be given (a hospital with or without a TCU). 4. Were all the important and relevant costs and consequences for
The effectiveness of the two alternatives must be established each alternative identified?
either from previously conducted, valid studies or within the (Neither costs nor consequences 0; one of two or most of both
economic evaluation itself. All relevant costs and consequences 1; both 2)
must be included (usually dictated by the viewpoint of the 5. Were costs and consequences measured accurately in
economic evaluation). These costs and consequences must be appropriate physical units?
ascribed in physical units initially to allow generalizability to other (No 0; partially 1; all 2)
institutions and then valued in a credible and clear fashion. In 6. Were costs and consequences valued credibly?
most cases, adjustment for differential timing is required (costs (Neither 0; one of two 1; both 2)
7. Was an incremental analysis of costs and consequences of
may be incurred at different times for alternative therapies); alternatives performed?
however, in economic evaluations assessing short-term outcomes, (No 0; yes 2)
this is not necessary (we therefore did not include these criteria
8. Wasa sensitivity analysis performed?
in our review). Analysis should be conducted in an incremental
fashion, describing the increase in effectiveness relative to the (None 0; some but insufficient 1; sufficient number 2)
increase in cost (for example, the increased cost required to save 9. Did the presentation and discussion of study results include all
one further life). As a number of assumptions or estimates are
issues of concern to users?
often required, the use of sensitivity analysis (reanalyzing the data (None 0; partial 1; most 2)
after varying the assumptions to the extremes of their possibili¬ * Modified from Drummond et al.16

CHEST / 113 / 1 / JANUARY, 1998 173

were found but were excluded because they de¬
scribed TCUs in specialized nonacute-care hospi¬
tals2225 or they did not perform an economic
evaluation.10"12'22"2426"31 All three studies involved
respiratory TCUs. Two were conducted by the same
group of authors and all three originated in the
United States (Table 3).
Validity Assessment of TCU Economic Evaluations
Two of three studies1314 scored poorly using the
modified criteria for validity assessment of economic
evaluation (Table 4). Neither study began with a
well-defined question or established the relative
effectiveness of the two alternative technologies
(rather they referred to historical controls).32-34 The
relevant viewpoint was never specified but appeared
to be somewhere between that of the third-party
payer and the hospital. While their respective TCUs
were well described, alternative setting (an insti¬
the
tution without a TCU) was not. Consequences were
properly identified but only for the TCU alternative.
Costs were derived from cost-to-eharge ratios in the
study by Elpern and colleagues,13 a method that is
difficult to interpret.35-36 In the first study by Krieger
and associates,14 there appeared to be a better
approach to identifying and measuring some of the
costs; however, the cost analysis was restricted to
ventilated Medicare patients, a minority of the total
patients admitted to the hospital.14 Neither study
performed analoneincremental analysis (presented as cost
with associated outcome) or sen¬
comparison
sitivity analysis. As a result of the above flaws, the
conclusions that TCUs are cost-effective are of ques¬
tionable validity.
The second study by Krieger and coworkers15
scored slightly higher on the validity criteria. While
greater taken to substantiate the equiva¬
care was
lence of effectiveness of the alternative technolo¬
gies,343740 the patient population focused on were
those with respiratory failure who were undergoing
weaning in the TCU, representing only 33 of their
109 patients. They also reported more extensive cost
data than previously; however, they did not break
down how they arrived at the cost for beds in the
ICU, TCU, and ward in a way that would allow
others to generalize their results. While sensitivity
analysis was used, no reason was given for why they
used 2 SDs as their interval. The baseline assump¬
tions were listed but the acceptable ranges chosen
for sensitivity analyses should be based on known
variability of each assumption. As a result of these
variations from the proposed validity criteria, the
conclusions reached by the authors (that their TCU
was cost-effective) must be questioned.
The two reviewers agreed completely on six of the
nine criteria. In criteria 4, 5, and 6, the reviewers
disagreed on one of the three studies. The cause of
the disagreement was the use of cost-to-charge ratios
in the study in question. One reviewer believed that
this should negate any points in these three criteria,
while the other reviewer was more liberal in his
assessment. Together they agreed to give one point
for each criterion. The two reviewers were in total
agreement on overall quality, rating all studies as
poor.
Discussion
This systematic review of the literature suggests
that there is currently insufficient evidence to sup-

Table 3.Summary of Studies of Noninvasive TCUs*

Type of
Intermediate Nurse: Patient Estimated
Article, yr Study Design Setting Care Unit Beds, No. Ratio Patients, No. Time Frame Savings
(1) Elpern Observational Tertiary care Respiratory 11 (8 ventilators) 1:3 to 1:5 136 Fiscal yr, 1988 $20,000
et al,13 1991 cohort study hospital per patient
(2) Krieger Observational Tertiary care Respiratory 4 (all ventilators) 1:4 to 1:6 54 Oct 1986 to $l,975±$l,061f
et al,14 1988 cohort studv hospital 12 vent March 1987 per patient
15 airway
27 monitor
11 patients
analyzed
(3) Krieger Observational Tertiary care Respiratory 4 (all ventilators) 1:4 to 1:6 109 May 1987 to $1,551
et al,15 1990 cohort study hospital 33 vent May 1988 per patient
11 trach
65 monitor
94 analyzed
*vent=ventilated patients; airway=patients requiring airway protection alone; monitor=patients who required monitoring only;
trach=tracheostomy patients.
f±SD.

174 Clinical Investigations in Critical Care

 Table 4.Validity Assessment of Economic Evaluations
Validity Criteria* Elpern et al,13 1991 Krieger et al,14 1988 Krieger et al,15 1990
1. Well-defined question 0 0 0
2. Description of competing alternatives 1 1 1
3. Program effectiveness established 0 0 0
4. All costs/consequences identified 1 1 1
5. Costs/consequences measured in appropriate physical units 1 1 1
6. Costs/consequences valued credibly 1 1 2
7. Incremental analysis performed 0 0 0
8. Sensitivity analysis performed 0 0 1
9. Complete discussion 1 1 1
Total 5/18 5/18 7/18
Overall quality assessment Poor Poor Poor
* Possible score of
0, 1, or 2.

port the viewpoint that the addition of a TCU to an accepted asdetermine

institution with ICU and general ward beds is cost-
effective. We do not claim
that the addition of a TCU
is not a cost-effective measure. Rather, we have
highlighted the design flaws of the economic evalu¬
ations available that compromise the validity of these
studies and any conclusions drawn. We believe that
while a TCU may be cost-effective, the design and
implementation of a TCU must be carefully con¬
ducted and continuously evaluated to ensure that
resources are utilized as planned.
The strengths of a systematic review include a
comprehensive search strategy, objective study se¬
lection criteria, and validity assessment of the pri¬
mary studies. We summarized these studies qualita¬
tively as their study designs did not lend themselves
to quantitative pooling. In this systematic review, we
conducted an extensive search using computerized
databases, bibliographies of selected and review
articles, and personal files. We limited our search to
the time period of relevance as TCUs were not
evaluated prior to this era. We restricted ourselves to
evaluation of the English-language literature as we
were most interested in the economic impact of
TCUs in North America. Unpublished studies were
not included in our systematic review. While we
agree that it is important to consider unpublished
literature in any systematic review,4142 after witness¬
ing the poor rating on study validity of the published
studies, we do not believe that unpublished studies
would have changed our conclusions.
Economic evaluations are becoming increasingly
common in the medical literature as physicians and
health administrators struggle to balance patient
benefit with limited resources. It is imperative that
we appropriately evaluate each new technology, not
only for its effectiveness, but also its associated cost
prior to accepting its adoption. Economic evalua¬
tions are as open to bias as clinical trials and must
adhere to specific criteria for their results to be
valid. The studies reviewed herein at¬
tempted toTCUs the cost-effectiveness of their
short of doing so because of
respective but fell
a number of design flaws.
The criteria used in this review to critically ap¬
praise cost-effective analyses were derived from
those described by Drummond and colleagues.16
Similar criteria were used by Udvarhelyi and cowork-
ers17 in a review of published cost-effectiveness and
cost-benefit analyses. The Task Force on Principles
for Economic Analysis of Health Care Technology
released a report recently that presented similar
criteria for critically appraising economic evaluations
but provide additional comment on how to conduct
economic evaluations, including recommendations
on how sponsors and researchers should interact.18
In 1996, the Panel on Cost-Effectiveness in Health
and Medicine published a series of three articles19-21
designed to guide the conduct of economic evalua¬
tions. The authors emphasize the importance of the
results of economic evaluations being able to inform
resource allocation decisions. They suggest the use
of a standard "reference case" format, using the
perspective of society and valuing outcomes in terms
of health-related quality of life, for all economic
evaluations. They suggest that additional specific
baseline cases, using other perspectives and means
of expressing outcome, may be added to the eco¬
nomic evaluation to answer specific study questions,
at the investigator's discretion.
It is intuitively appealing to assume that the
introduction of a TCU into a hospital would enhance
overall efficiency of patient care by providing a more
cost-effective approach for patients requiring only
intensive monitoring with or without mechanical
ventilation. The studies presented in this review
appear to begin with the assumption that TCUs are,
by definition, cost-effective. This may explain why
many investigators did not attempt any form of
economic evaluation. 10-12,22-24,26-31 Tne few studies

CHEST / 113 / 1 / JANUARY, 1998 175

that did report an economic evaluation were of poor
quality. Despite this objection, how could TCUs not
be cost-effective and hence enhance efficiency?
We will address the issue of effectiveness first.
There are no studies in the literature to date (to our
knowledge) that have demonstrated a clear differ¬
ence in effectiveness between a hospital setting with
an ICU and ward beds alone compared to a similar
hospital setting that also has a TCU. While in a study
by Franklin and coworkers26 an improved survival
was noted with introduction of a medical TCU, the
before-after design and lack of control for severity of
illness makes it impossible to draw direct inferences.
Indeed, the studies reviewed herein tried to empha¬
size that survival was not negatively influenced by
the introduction of a TCU. We must conclude,
therefore, that currently there is no evidence that
allows one to determine whether the introduction of
a TCU will improve, worsen, or not affect patient
outcomes.
If we make the assumption that TCUs do not
affect outcome, then to prove that a TCU is cost-
effective we must demonstrate a reduction in cost. In
order for TCUs to be cost-effective, they must be
well planned prior to implementation. The approach
used by Hilton and coworkers,31 performing an
initial pilot study to determine the size of TCU
required, should be adopted by all those planning to
open a TCU. Strict guidelines for admissions to and
discharge from a TCU also need to be developed and
adhered to. If units are not properly planned prior to
opening, they may be too small to provide the service
that is required, or too large, creating the opportu¬
nity for admission of inappropriately low-risk pa¬
tients. In the latter case, the costs per patient care for
these low-risk patients would potentially be in¬
creased by treating them in a TCU rather than a
general ward. For example, in the studies by Elpern
and associates13 and the first study by Krieger and
coworkers,14 the focus ofthe cost analysis was exclu¬
sively on ventilated patients (and in the latter study14
only Medicare patients were considered). However,
a large proportion of patients admitted to their TCUs
were not represented by their economic evaluation
(61% and 80%, respectively). In the second study by
Krieger and colleagues,15 private patients, compris¬
ing 14% of admissions, were excluded from the
analysis. Of the remaining patients, the cost savings
were considerably less for the nonventilated patients
when compared to those patients who were venti¬
lated. One would suspect that as the proportion of
nonventilated patients in a TCU of this type in¬
creases, the overall cost savings would decrease or
disappear. Careful planning prior to opening a TCU
would allow better estimation of the institution's
needs and hopefully avoid future unnecessary costs
176
related to inappropriate admissions. The interpreta¬
tion of potential cost savings for the institution must
also be closely scrutinized. The claim that costs per
patient will be less with introduction of a TCU must
be coupled with the acknowledgment that overall
costs to the institution will increase unless ICU beds
are closed at the same time. Therefore, from the
perspective of the hospital, the total budget could
possibly increase rather than decrease. Krieger and
coworkers15 suggested closing ICU beds in their
study, but it is not clear whether ICU beds were
actually closed.
In addition to careful planning of a TCU prior to
its opening, continuous monitoring of the appropri¬
ateness of patient admissions and discharge must be
conducted. A trend may develop toward admitting
patients to a TCU rather than a general ward bed
who are less sick than proposed in initial planning.
admission creep. Alternatively patients may be dis¬
charged from the ICU to TCUs who are well enough
for a regular ward bed.ICU discharge creep. These
drifts in admissions policies in addition to another
possible trend.keeping patients in the TCU longer
than necessary.would all lead to unanticipated
additional costs. We have summarized in Table 5
some of the important factors to consider when
assessing or attempting to control costs of a TCU.
In conclusion, we were unable to find evidence
from our systematic review of the literature that
supports TCUs being cost-effective. We believe that
the cost-effectiveness of any new technology should
be rigorously assessed prior to adoption. This was not
performed for TCUs. There remains a need to
conduct economic evaluations using the appropriate
viewpoint to determine the conditions under which
TCUs may be cost-effective. Ideally, these studies
would be conducted as randomized, controlled trials
comparing the costs and outcomes of patients
treated in various types of TCUs to similar patients
treated in the appropriate alternative setting, insti¬
tutions with ICU and general ward beds alone.
However, alternative study designs, such as a before-
Table 5.Factors Influencing Cost of TCU Care
Factors
1. Nurse: patient ratio
2. Degree of support available (ventilation, etc)
3. Use of protocols in patient care (weaning protocol may lead to
early discharge)
4. No. of beds relative to need (increased bed availability may lead
to lower acuity admissions)
5. Flexibility of admission policy
6. Flexibility of discharge policy
Periodic review of admission/discharge process
7.
8. Periodic review of process of care.reassess/develop protocols
Clinical Investigations in Critical Care
after design or cluster randomization, may be more
pragmatic. The results of these economic evaluations
would allow us to answer the question: are noncar¬
diac TCUs truly cost-effective?
References
1 Henning RJ, McClish D, Daly B, et al. Clinical characteristics
and resource utilization of ICU patients: implications for
organization intensive care. Crit Care Med 1987; 15:264-69
of
2 Knaus WA, Thibault GE. Intensive care units today. In:
McNeil BJ, Cravalho EG, eds. Critical issues in medical
technology. Boston: Auburn House, 1982; 193-215
3 Critical care in the United States. Anaheim, Calif: Society of
Critical Care Medicine, 1992
4 Jacobs P, Noseworthy TW. National estimates of intensive
care utilization and costs: Canada and the United States. Crit
Care Med 1990; 18:1282-86
5 Thibault GE, Mulley Ag, Barnett GO, et al. Medical intensive
care: indications, interventions, and outcomes. N Engl J Med
1980; 302:938-42
6 Knaus WA, Wagner DP, Draper EA, et al. The range of
intensive care services today. JAMA 1981; 246:2711-16
7 Wagner DP, Knaus WA, Draper EA. Identification of low-
risk monitor admissions to medical-surgical ICUs. Chest
1987; 92:423-28
8 Knaus WA, Le Gall JR, Wagner DP, et al. A comparison of
intensive care in the USA and France. Lancet 1982; 2:642-46
9 Zimmerman JE, Knaus WA, Judson JA, et al. Patient selection
for intensive care: a comparison of New Zealand and United
States hospitals. Crit Care Med 1988; 16:318-26
10 Bone RC, Balk RA. Noninvasive respiratory care unit: a
cost-effective solution for the future. Chest 1988; 93:390-94
11 Silver MR, Elpern EH, Balk RA, et al. Noninvasive respira¬
tory care units as an innovative alternative to ICUs: how
hospitals cut costs without compromising quality of care. J
Crit Illness 1990; 5:1279-87
12 Patterson PA, Elpern EH, Silver MR. Advances in patient
care management: the NRCU. Crit Care Nurse 1991; 11:
42-45
13 Elpern EH, Silver MR, Rosen RL, et al. The noninvasive
respiratory care unit: patterns of use and financial implica¬
tions. Chest 1991; 99:205-08
14 Krieger BP, Ershowsky P, Spivack D, et al. Initial experience
with a central respiratory monitoring unit as a cost-saving
alternative to the intensive care unit for Medicare patients
who require long-term ventilator support. Chest 1988; 93:
395-97
15 Krieger BP, Ershowsky P, Spivack D. One year's experience
with a noninvasively monitored intermediate care unit for
pulmonary patients. JAMA 1990; 264:1143-46
16 Drummond MF, Stoddart GL, Torrance GW. Methods for
the economic evaluation of health care programmes. Oxford,
UK: Oxford University Press, 1987; 18-38
17 Udvarhelyi IS, Colditz GA, Rai A, et al. Cost-effectiveness
and cost-benefit analyses in the medical literature: are the
methods being used correctly? Ann Intern Med 1992; 116:
238-44
18 Task Force on Principles for Economic Analysis of Health
Care Technology. Economic analysis of health care technol¬
ogy: a report on principles. Ann Intern Med 1995; 123:61-70
19 Russell LB, Gold MR, Siegel JE, et al. The role of cost-
effectiveness analysis in health and medicine. JAMA 1996;
276:1172-77
20 Weinstein MC, Siegel JE, Gold MR, et al. Recommendations
of the panel on cost-effectiveness in health and medicine.
JAMA 1996; 276:1253-58
21 Siegel JE, Weinstein MC, Russell LB, al. Recommenda¬
et
tions for reporting cost-effectiveness analyses. JAMA 1996;
276:1339-41
22 Indihar FJ, Forsberg DP. Experience with a prolonged
respiratory care unit. Chest 1982; 81:189-92
23 Indihar FJ, Walker NE. Experience with a prolonged respi¬
ratory care unit.revisited. Chest 1984; 86:616-20
24 Indihar FJ. A 10-year report of patients in a prolonged
respiratory care unit. Minn Med 1991; 74:23-27
25 Scheinhorn DJ, Artinian BM, Catlin JL. Weaning from
prolonged mechanical ventilation: the experience at a re¬
gional weaning center. Chest 1994; 105:534-39
26 Franklin CM, Rackow EC, Mamdani B, et al. Decreases in
mortality on a urban medical service by facilitating
large
access to critical care: an alternative to rationing. Arch Intern
Med 1988; 148:1403-05
27 Vitacca M, Clini E, Scalvini S, et al. Cardiopulmonary
intermediate intensive unit: time course of 2 years activity.
Monaldi Arch Chest Dis 1993; 48:296-300
28 Byrick RJ, Power JD, Yeas JO, et al. Impact of an interme¬
diate care area on ICU utilization after cardiac surgery. Crit
Care Med 1986; 14:869-72
29 Byrick RJ, Mazer CD, Caskennette GM. Closure of an
intermediate care unit: impact on critical care utilization.
Chest 1993; 104:876-81
30 Maclntyre ML, Savoy-Bird S. Creating a step-down unit
opens a door to the future. Dimens Health Serv 1989;
66:25-27
31 Hilton G, Madayag M, Shagoury C. Development of a
surgical/trauma intermediate care unit. Clin Nurse Specialist
1993; 7:274-79
32 United States Congress Office of Technology Assessment.
Life sustaining technologies and the elderly. OTA-BA-306.
Washington, DC: US Government Printing Office, July 1987;
225
33 Wagner DP. Economics of mechanical ventilation. Am Rev
Respir Dis 1989; 140:S14-18
34 Douglass PS, Rosen RL, Butler PW, et al. DRG payment for
long-term ventilator patients: implications and recommenda¬
tions. Chest 1987; 91:413-17
35 Finkler SA. The distinction between cost and charges. Ann
Intern Med 1982; 96:102-09
36 Gyldmark M. A review of cost studies of intensive care units:
problems with the cost concept. Crit Care Med 1995; 23:
964-72
37 Spicher JE, White DP. Outcome and function following
prolonged mechanical ventilation. Arch Intern Med 1987;
147:421-25
38 Morganroth ML, Morganroth JL, Nett LM, et al. Criteria for
weaning from prolonged mechanical ventilation. Arch Intern
Med 1984; 144:1012-16
39 Davis H, Lefrak SS, Miller D, et al. Prolonged mechanically
assisted ventilation: an analysis of outcome and charges.
JAMA 1980; 243:43-45
40 Gracey DR, Gillespie D, Nobrega F, et al. Financial impli¬
cations of prolonged ventilator care of Medicare patients
under the prospective payment system: a multicenter study.
Chest 1987; 91:424-27
41 Dickersin K. The existence of publication bias and risk factors
for its occurrence. JAMA 1990; 263.1385-89
42 Cook DJ, Guyatt GH, Ryan G, et al. Should unpublished data
be included in meta-analyses? Current convictions and con¬
troversies. JAMA 1993; 269:2749-53
CHEST / 113 / 1 / JANUARY, 1998 177