Economic impact and chronic obstructive pulmonary disease outcomes of a comprehensive inhaler to nebulization therapy protocol implementation in a large multi-state healthcare system

Abstract

Objective: There are currently 39 FDA-approved metered-dose (MDI) or dry-powder inhalers (DPI) on the US market. Most are high cost with significantly more drug in the device than needed for a typical average length of stay in acute care hospitals, which leads to significant waste. The objective was to assess the financial impact and chronic obstructive pulmonary disease (COPD) outcomes of a comprehensive inhaler to nebulization protocol implemented in a large multi-state US health system. Methods: The retrospective study evaluated respiratory drug costs at 28 hospitals in the health system after a phased implementation of the automatic inhaler to nebulization protocol. Purchasing data was collected for all respiratory medications impacted by the protocol for the twelve months preceding as well as the two subsequent twelve-month periods following implementation at each facility. COPD length of stay (LOS) and 30 day readmissions were also reviewed. An attempt was made to evaluate the impact on respiratory therapy (RT) department workload. Results: Compared to pre-implementation, system-wide drug expenditures declined $1,561,011 (38.5%) and $1,646,411 (40.6%) in post-implementation year 1 (PY1) and post-implementation year 2 (PY2), respectively. COPD LOS and 30 day readmissions were not adversely affected and remained relatively stable in comparative periods. Objective impact on RT productivity and labor statistics was not ascertained due to complicated variables and multiple service lines. Conclusions: In an era of increased drug costs incurred by hospitals, a comprehensive inhaler to nebulization protocol significantly decreased costs without incurring any negative observed trends in COPD LOS or readmissions.

Systemic Steroid and Nebulized Budesonide Combination Therapy Versus Systemic Steroid Monotherapy in Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease in a Community Hospital: A Retrospective Cohort Study

“…The significant reduction in respiratory drug costs have previously been reported secondary to the implementation of our inhaler to nebulization protocol as well as the high percentage of overall nebulized budesonide costs throughout the health system. 7 Our institution also observed annual nebulized budesonide expenditures of $175 924, accounting for 52% of our overall inhaler and nebulized medication drug costs of $338 532 in 2018. The significant occurrence of duplicative therapy of ICS and systemic corticosteroids in our respiratory patients ultimately led to the development, approval, and implementation of the automatic budesonide discontinuation protocol, as stated.…”

“…5,6 Another study has illustrated significant hospitalized ICS medication costs in COPD treatment. 7 If ICS medications can be discontinued without incurring negative effects to the patient and LOS while patient’s are on systemic steroids, a closer look into combined use of systemic and inhaled corticosteroids is warranted.…”

Estimating Tiotropium Wasted Doses After Adding Revefenacin to an Inpatient Formulary: A Single-Center Cross-Sectional Study

“…It is plausible that additional resources, specifically respiratory therapists, may be required to administer and supervise the increase in nebulized medication orders described in this study; however, previous studies describing similar expansions of medication formularies and nebulizer protocols did not identify a need to hire more staff based on their findings. 10,23 Nonetheless, the direct cost savings attributable to revefenacin must be carefully weighed against indirect caregiving costs attributable to and direct wages incurred by its caregiving burden on respiratory therapists.…”

<p>Nebulized Therapies in COPD: Past, Present, and the Future</p>

“…Compared with preimplementation, system-wide drug expenditures declined by approximately 40% in post-implementation years 1 and 2. 35 On the other hand, a cohort study at a single US hospital showed that reducing nebulizer use, and implementing MDIs in the hospital resulted in significant savings annually. However, some limitations of this study included a lack of control group and possible overestimation of cost-savings since some of the costs were semifixed.…”