5.Intensive care recommendations

5.1Intensive Care Working Group membership

The Committee formed a Working Group to consider intensive care services. The Intensive Care Working Group (ICUWG) included the members listed in Table 4.

Table 4. Intensive Care Working Group members

Name Position/Organisation Interests declared
A/Prof Andrew
Turner*
(Chair)
Director, Department of Critical Care Medicine,
Royal Hobart Hospital
None
Ms Eileen Jerga AM* Consumer Representative None
A/Prof George
Skowronski
Senior Staff Specialist, St George Intensive Care
Unit
Former President, Australian and New Zealand
Intensive Care Society
Former Chairman, Intensive Care Specialist
Advisory Committee, Royal Australasian
College of Physicians
None
Dr Mark Nicholls Senior Staff Specialist, Intensive Care, St
Vincent's Hospital, Sydney
Chair, Practice and Economics Committee,
Australian and New Zealand Intensive Care
Society
None
Dr Matthew Anstey* Intensive Care Specialist and Director of ICU
Research, Sir Charles Gairdner Hospital
Medical Advisor, Australian Commission on
Safety and Quality in Health Care
Board Member, Choosing Wisely Australia
None
Prof Michael Parr* Intensive Care Unit, Liverpool Hospital,
University of New South Wales
None
Dr Simon Towler* Clinical Co‐Lead, Fiona Stanley Hospital,
Medical Co‐Director, WA Department of
Health
None
Prof Stephen Bernard* Director of Intensive Care, Knox Private
Hospital
Chair, Medical Advisory Committee, Knox
Private Hospital
Honorary Senior Intensive Care Physician, The
Alfred
Adjunct Professor, Monash University
Department of Epidemiology and Preventive
Medicine
Senior Medical Advisor, Ambulance Victoria
None
A/Prof Sally McCarthy* Senior Emergency Physician, Prince of Wales None
(Committee Chair) Hospital
Medical Director, Emergency Care Institute
NSW
Clinical Lead, NSW Whole of Hospital Program
NSW Health
Former President, Australasian College for
Emergency Medicine
None

*Also a member of the Committee.

It is noted that the majority of Committee members share a common conflict of interest in reviewing items that are a source of revenue for them (i.e., Committee members claim the items under review). This conflict is inherent in a clinician‐led process, and having been acknowledged by the Committee and the Taskforce, it was agreed that this should not prevent a clinician from participating in the review.

The ICUWG developed the following recommendations, which were unanimously endorsed by the Committee.

5.2Intensive care daily management items (13870 and 13873) and the invasive pressure monitoring item (13876)

Table 5: Item introduction table for items 13870, 13873 and 13876

Item Descriptor Schedule
fee
Volume of
services
FY2014/15
Total
benefits
FY2014/15
Services 5‐
year‐
average
annual
growth
13870 Management of a patient in an Intensive
Care Unit by a specialist or consultant
physician who is immediately available and
exclusively rostered for intensive care –
including initial and subsequent
attendances, electrocardiographic
monitoring, arterial sampling and bladder
catheterisation – management on the first
day.

(H)
$362.10 64,863 $17,616,540 8.3%
13873 Management of a patient in an Intensive
Care Unit by a specialist or consultant
physician who is immediately available and
exclusively rostered for intensive care –
including all attendances,
electrocardiographic monitoring, arterial
sampling and bladder catheterisation –
management on each day subsequent to the
first day.

(H)
$268.60 190,443 $38,362,962 6.2%
13876 Central venous pressure, pulmonary arterial
pressure, systemic arterial pressure or
cardiac intracavity pressure, continuous
monitoring by indwelling catheter in an
intensive care unit and managed by a
specialist or consultant physician who is
immediately available and exclusively
rostered for intensive care – once only for
each type of pressure on any calendar day
(up to a maximum of 4 pressures).

(H)
$76.90 278,678 $16,079,720 4.9%
Recommendation 3
  • ΔLeave items 13870, 13873 and 13876 unchanged.

Rationale

This recommendation is based on the following observations.

  • ΔThe Committee noted that item 13876 reflects intervention on sicker patients, and therefore has always been intended to function, additionally, as a surrogate for complexity.
  • – ICU daily management items 13870 and 13873 were initially developed to reflect Intensivist attendance equivalent to three Physician consults: a morning ward round, an evening ward round and one further attendance to the patient. For this reason, only procedures integral to such a consult (for example, ECG monitoring, arterial sampling and bladder catherisation) are bundled. No other provisions account for differences in professional involvement based on the complexity of the patient’s clinical condition.
  • ΔThe Committee felt that item 13876 reflects contemporary intensive care practice and is an accurate and scalable surrogate for complexity. As a result, it concluded that there was no compelling reason for altering the existing arrangements. The Committee agreed on the following points:
  • – Hypoxia and vasopressor requirements are an appropriate surrogate for complexity in the ICU context.
  • – Item 13876 can be claimed up to four times per day—depending on the number of different pressure types monitored (for example, central venous pressure or cardiac intra‐cavity pressure)— and therefore functions as a scalable proxy for complexity.
  • – Use of invasive pressure monitoring is both simple and auditable, reducing the chances of item misuse (such as upcoding to higher complexity items, which may occur with alternative systems that account for complexity but do not unambiguously differentiate between clinical situations).
  • – There is no evidence of misuse or over‐servicing of item 13876.
    • Australian ICUs are intended to handle a case‐mix that requires invasive monitoring. In this context, the usage rates are within the expected range (co‐claimed in 75 per cent of instances where item 13870 is provided, and 70 per cent where item 13873 is provided; Figure 5).
    • Intensive Care Specialists are vigilant in removing unnecessary invasive devices as soon as possible in order to minimise the risk of complications, such as bloodstream infection. Furthermore, ICUs are required to report central line‐associated blood stream infection (CLABSI) to the Australia and New Zealand Intensive Care Society’s (ANZICS) Centre for Outcome and Resource Evaluation (CORE) registry in order to receive and maintain accreditation.
    • Although item 13876 may appear to incentivise overuse of invasive pressure monitoring, there is no evidence that this risk has materialised. Invasive pressure monitoring allows real time adjustments of physiological parameters, enabling organ perfusion to be maximized to provide patients with the best chance of recovery. However, all invasive lines are associated with risk of complications that necessitate removal when no longer required.
  • ΔTo date, an alternative and superior way of accounting for differences in patient complexity has not been identified. The Committee noted the following:
  • – Bundling an average requirement for invasive pressure monitoring into items 13870 and 13873 would result in an inappropriate funding transfer from facilities with high‐complexity case‐mixes to facilities with low‐complexity case‐mixes.
  • – Disease severity scoring systems are not a viable method of accounting for differences in patient complexity as they do not provide an accurate reflection of the level of professional involvement required.
    • For example, the Acute Physiology and Chronic Health Evaluation (APACHE) is only validated for use as an admission score (in the first 24 hours in ICU). The physiological parameters are not a meaningful indicator of the level of clinical input required once these parameters are being maintained by clinical interventions.
  • – Indication‐based items—for example, those based on major diagnostic categories (such as major cardiac surgery), similar to the MBS Relative Value Guide for anaesthetics items—are both complex and inadequate. Such a system would require providers to use a significantly larger number of items, as well as requiring the MBS to maintain these items. Although these items may adequately account for case‐mix variation between facilities, it is likely that the categories would not be able to account for provider‐level case‐mix variation.
  • – International approaches do not offer alternatives that adequately account for complexity whilst also addressing the perceived potential for incentivising over‐servicing.
    • In the United States, both Medicare and commercial payors use current procedural terminology (CPT) codes on a fee‐for‐service basis, with critical care attendance items tiered by time, and additional procedures billed via separate codes (for example, for ventilation or insertion of extracorporeal membrane oxygenation [ECMO] cannulae).
    • In Canada, both Ontario and British Columbia use per‐diem payments.
    • In the United Kingdom, National Health Service Physicians are salaried staff.
    • In New Zealand, ICU services are provided in public hospitals by salaried Intensive Care Physicians.

Figure 5: Use of item 13876 in conjunction with ICU daily management items 13870 and 13873

Figure 5 shows the use of item 13876 in conjunction with ICU daily management items 13870 and 13873. Ranked alongside top 10 items numbers co-claimed in cojunction with item 13870, it is ranked at 1st, being co-claimed at 75%. When ranked alongside top 10 items numbers co-claimed in cojunction with item number 13873, it is also ranked 1st, being co-claimed at only 69%.

5.3Management of counterpulsation by intraaortic balloon (items 13847 and 13848)

Table 6: Item introduction table for items 13847 and 13848

Item Descriptor Schedule
fee
Volume of
services
FY2014/15
Total
benefits
FY2014/15
Services 5‐
year‐
average
annual
growth
13847 Counterpulsation by intraaortic balloon
management on the first day including initial
and subsequent consultations and
monitoring of parameters.

(Anaes.)
$156.10 298 $34,874 ‐0.1%
13848 Counterpulsation by intraaortic balloon
management on each day subsequent to the
first, including associated consultations and
monitoring of parameters.
$131.05 781 $76,678 ‐0.8%
Recommendation 4
  • ΔRemove the differential fees for the first day and subsequent days of managing counterpulsation by intraaortic balloon:
  • – Remove item 13847 (for the management of counterpulsation by intraaortic balloon on the first day) from the MBS.
  • – Revise item 13848 (for the management of counterpulsation by intraaortic balloon on each day subsequent to the first) to apply to management on any day (including the first).
  • The proposed item descriptor and explanatory notes are provided below.

Item 13848

COUNTERPULSATION BY INTRAAORTIC BALLOON management on each day, including associated consultations and monitoring of parameters.

Explanatory note for item 13848:

Item 13858 covers management of counterpulsation by intraaortic balloon and includes initial and subsequent consultations and monitoring of parameters. “Management” of counterpulsation of intraaortic balloon means full haemodynamic assessment and management on several occasions during the day.

Insertion of the intraaortic balloon is covered under item 38609.

Rationale

This recommendation focuses on enhancing value for the patient and the health system, and on simplifying the MBS. It is based on the following observation.

  • ΔThere is no significant difference in the amount of clinical input required on the first day and on subsequent days of management, other than that already reflected in the separate item covering insertion of an intraaortic balloon pump (item 38609).

5.4Circulatory support items (13851 and 13854) and coverage of ventricular assist devices and extracorporeal life support

Table 7: Item introduction table for items 13851 and 13854

Item Descriptor Schedule
fee
Volume of
services
FY2014/15
Total
benefits
FY2014/15
Services 5‐
year‐
average
annual
growth
13851 Circulatory support device, management of,
on first day.
$493.65 103 $38,181 12.2%
13854 Circulatory support device, management of,
on each day subsequent to the first.
$114.85 656 $57,204 14.6%
Recommendation 5
  • ΔConsider an expedited MSAC assessment for listing MBS items for extracorporeal life support.
  • The proposed item descriptors and explanatory notes are provided below.
  • – For veno‐arterial cardiopulmonary extracorporeal life support:
    • Item AAAAA:
    • Peripheral Cannulation for Veno‐arterial Cardiopulmonary Extracorporeal Life Support, including any use of imaging to assist in the procedure.
    • Item BBBBB:
    • Veno‐arterial Cardiopulmonary Extracorporeal Life Support, management of, on the first day.
    • Item CCCCC:
    • Veno‐arterial Cardiopulmonary Extracorporeal Life Support, management of, on each day subsequent to the first.
  • – For veno‐venous pulmonary extracorporeal life support:
    • Item XXXXX:
    • Peripheral Cannulation for Veno‐venous Pulmonary Extracorporeal Life Support, including any use of imaging to assist in the procedure.
    • Item YYYYY:
    • Veno‐venous Pulmonary Extracorporeal Life Support, management of, on the first day.
    • Item ZZZZZ:
    • Veno‐venous Pulmonary Extracorporeal Life Support, management of, on each day subsequent to the first.
  • Explanatory notes
  • Items AAAAA, BBBBB, CCCCC, and items XXXXX, YYYYY and ZZZZZ cover extracorporeal life support in an ICU. Benefits are payable only once per calendar day for a patient, irrespective of the number of medical practitioners involved.
  • ΔRevise items 13851 and 13854 to clarify that they are intended to cover ventricular assist devices (VADs), but only if and when MBS items are introduced for extracorporeal life support.
  • Item descriptors and explanatory notes are provided below.
    • Item 13851:
    • Ventricular Assist Device, management of, on first day, where the ICU admission relates to device implantation or complication.
    • Item 13854:
    • Ventricular Assist Devices, management of, on a day subsequent to the first, where the ICU admission relates to device implantation or complication.
    • Explanatory notes for items 13851 and 13854:
    • Items 13851 and 13854 cover the management of ventricular assist devices in an ICU. Benefits are payable only once per calendar day for a patient, irrespective of the number of medical practitioners involved.

Rationale

This recommendation focuses on making item descriptors clearer and supporting access to best‐ practice health services. It is based on the following observations.

  • ΔItems 13851 and 13854 were originally introduced to cover management of VADs. However, the items are vaguely worded and are currently used to cover ECMO services. The items could be misinterpreted as covering other circulatory support devices (such as intra‐aortic balloon pumps, which are already covered under MBS items 13847 and 13848).
  • ΔThe Committee noted that extracorporeal life support through ECMO is an established clinical procedure currently in use in Australia. The procedure is not experimental or novel. However, the evidence for use is indication‐specific. As such, the MSAC may wish to review these indications and modify the proposed item descriptors accordingly.
  • ΔThe level of clinical input required for the management of an ICU patient does not necessarily differ significantly for a patient with a VAD (for example, in the case of a long‐term implanted VAD). The circulatory support items 13851 and 13854 should therefore only be used if the clinical issue requiring ICU admission relates in some way to management of the VAD.
  • ΔVeno‐arterial extracorporeal life support is considerably more complex to manage than veno‐ venous extracorporeal life support, particularly in the weaning stage of therapy, due to embolic and ischemic risks, among others.

5.5Vascular catheterisation items (13815 and 13842) and use of ultrasound

Table 8: Item introduction table for items 13815, 13839 and 13842

Item Descriptor Schedule
fee
Volume of
services
FY2014/15
Total
benefits
FY2014/15
Services 5‐
year‐
average
annual
growth
13815 Central vein catheterisation by percutaneous
or open exposure not being a service to
which item 13318 applies.

(Anaes.)
$85.25 18,523 $1,203,563 9.7%
13839 Arterial puncture and collection of blood for
diagnostic purposes.
$23.05 9,850 $189,830 1.1%
13842 Intra‐arterial cannulation for the purpose of
taking multiple arterial blood samples for
blood gas analysis.
$69.30 6,896 $359,476 8.5%
Recommendation 6
  • ΔThe Committee requests that the MBS Review Taskforce and Diagnostic Imaging Clinical Committee consider making recommendations to revise item descriptors for item 13815 (for central vein catheterisation) and item 13842 (for intra‐arterial cannulation) to include the following text: “under ultrasound guidance, where clinically appropriate.”
  • – MBS benefits for ultrasound services should not be payable separately from items 13815 and 13842.
  • – The above should apply to all providers, regardless of specialty.
  • ΔLeave item 13839 unchanged.

Rationale

These recommendations focus on supporting best‐practice health services and enhancing value for patients and the community. They are based on the following observations.

  • ΔWhere used, ultrasound guidance is an integral component of the services covered by items 13815 and 13842, and it should not be separately billed.
  • – Although clinical practice is evolving to include ultrasound as part of the standard of care, mandatory use of ultrasound may not provide value for patients or the health system in instances where insertion without ultrasound guidance is equally safe. Specifically, there is poorer evidence regarding the value of ultrasound use for experienced operators.
  • – There is no significant difference in the service provided between Intensivists, Emergency Physicians and other appropriately qualified provider types.
  • ΔThe Committee agreed that MBS benefits for arterial puncture and the collection of blood for diagnostic purposes (item 13839) and intra‐arterial cannulation for blood gas analysis (item 13842) did not need to be amended.
  • – At present, MBS benefits for arterial puncture and the collection of blood for diagnostic purposes (item 13839) are not payable separately from ICU daily management items (13870 and 13873) as the services are bundled. However, intra‐arterial cannulation for blood gas analysis (item 13842) is not bundled and MBS benefits remain payable separately.
  • – The explanatory notes for ICU daily management items state: “Medicare benefits are not payable for sampling by arterial puncture under Item 13839 in addition to Item 13870 (and 13873) on the same day. Benefits are payable under Item 13842 (Intra‐arterial cannulation) in addition to Item 13870 (and 13873) when performed on the same day.”
  • – The Committee agreed that arterial puncture and the collection of blood for diagnosis purposes is a common procedure in the ICU, and it remains integral to the standard of care. The Committee therefore concluded that MBS benefits should not be payable separately, in line with current item specifications.
  • – The Committee also agreed that intra‐arterial cannulation for blood gas analysis represents a distinct and substantive procedure requiring special skill, and that it should therefore continue to attract separate MBS benefits. The service is not routinely performed (Figure 6).

Figure 6: Use of item 13842 in conjunction with ICU daily management items 13870 and 13873

Figure 6 shows the use of item 13842 in conjunction with ICU daily management items 13870 and 13873. Ranked alongside top 10 items numbers co-claimed in cojunction with item 13870, it is ranked at 3rd, being co-claimed at 5%. When ranked alongside top 10 items numbers co-claimed in cojunction with item number 13873, it is ranked 10th, being co-claimed at only 1% .

5.6An item for goals‐of‐care services provided by Intensive Care Physicians

Recommendation 7
  • ΔIntroduce an MBS item for the discussion and documentation of goals of care by an Intensive Care Specialist.

The proposed item descriptors and explanatory notes are provided below.

Item ABCD1:

Professional attendance by an Intensive Care Specialist for the discussion and documentation of goals of care:

(a) For a patient

  • Experiencing either a life‐threatening acute illness, or an acute illness in the context of a high baseline risk for end‐of‐life within the next 12 months, and
  • For whom alternatives to active management are reasonably thought to be an appropriate clinical choice, and
  • For whom an appropriate documentation of goals of care does not already exist or these goals are reasonably expected to change substantially due to new clinical circumstances;

(b) Including

  • Assessment of the patient’s capacity to make goals of care decisions, and
  • Comprehensive evaluation of the patient’s medical, physical, psychological and social issues, including identification of major issues requiring goals of care to be defined, and
  • Discussion with the patient (or surrogate), which must include proactive offering of treatment alternatives, including alternatives to intensive or escalated care; and, where appropriate, with the patient’s family, carers and other health practitioners, and
  • Agreement on the goals of care, between the provider and the patient or their guardian, and in relation to all major medical issues identified in the comprehensive assessment, and
  • Documentation of the goals of care in a way that facilitates timely retrieval by subsequent healthcare providers for the patient, and includes what interventions should and should not be pursued, with
  • At least 60 minutes of dedicated professional involvement;

(c) Claimable

  • Once only per inpatient admission (including instances of use of corresponding items 51K and 51L), unless precipitated by a subsequent ICU referral or Cardiac Arrest / Medical Emergency Team (“MET”) call where the clinical circumstances change substantively with a resultant expectation that the original goals of care require amendment,
  • For the medical practitioner taking overall responsibility for the agreement and documentation of goals of care.

Explanatory notes for items ABCD1:

  • Patients could be assessed for “high baseline risk” (and suspicion that alternatives to active management may be an appropriate clinical choice) through the use of tools that assist in predicting end‐of‐life, such as the SPICT tool.
  • “Proactive offering of treatment alternatives” means that the patient must be provided with reasonable alternatives to continued intensive / active treatment or escalation of care, including where the patient has not directly asked for such information (in recognition that patients may not ask if they are not aware of such alternatives).
  • “Documentation” should be undertaken using standard forms (where available) appropriate to the facility in which a patient is receiving care.
  • Providers of this service should be appropriately trained to provide end‐of‐life care options and goals of care discussions.
  • The item should not be claimed where the goals of care are defined only in relation to a sub‐set of the patient’s major issues.

Rationale

This recommendation focuses on supporting access to a best‐practice health service that improves both the patient experience and enhances the value provided to the patient and the health system. It is based on the following observations.

  • ΔThe Committee noted that efforts to define a patient’s goals of care are inconsistent and are often undertaken at a later stage than is clinically useful.
  • – Patients attended by Intensive Care Specialists often have not had goals of care defined in advance by their primary GP or their in‐hours “home team.”
  • – The lack of advance decision‐making on goals of care may result in over‐treatment and / or excessive lengths of stay. In particular, there are patients who may not wish to proceed with active treatment but may feel that they have not been given alternative options to consider.
  • ΔAs a result, the Committee agreed that Intensive Care Physicians often bear responsibility for initiating discussion regarding the goals of care. These discussions occur upon referral to the ICU, or on hospital wards where an Intensive Care Specialist is requested to review the clinically deteriorating patient (for example, during a MET call or cardiac arrest call). The professional involvement required in such situations is significant due to the:
  • – Acuity of the situation.
  • – Importance of clarifying the goals of care prior to admission to the ICU, particularly where such an admission may be inappropriate.
  • – Need to undertake complex discussions and decision‐making for a patient with whom the provider is unfamiliar.
  • ΔBased on these observations, the Committee felt that there is a need for the MBS to better support discussion and documentation of goals of care in two situations:
  • – Prior to presentation in an ED or referral to an ICU.
  • – When Intensive Care and Emergency Physicians are required to undertake goals of care discussion and documentation because this has not previously occurred and an acutely unwell patient may otherwise embark on an undesirable course of intensive treatment (for example, surgery or admission to an ICU).

The Committee focused on the latter situation, but it supports the efforts of other Clinical Committees involved in the MBS Review to address the former situation.



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