Substitution of Metered-dose Inhalers for Hand-Held Nebulizers

Substitution of Metered-dose Inhalers for Hand-Held Nebulizers

clinical investigations Substitution of Metered-dose Inhalers for Hand-Held Nebulizers* Success and Cost Savings in a Large, Acute-care Hospital David...

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clinical investigations Substitution of Metered-dose Inhalers for Hand-Held Nebulizers* Success and Cost Savings in a Large, Acute-care Hospital David L. Bowton , M.D ., F.C .C.P. ;t William M. Goldsmith , R.R.T.; and Edward F. Haponik , M.D ., F.C.C.P.t Administration of p-agonist bronchodilators by metereddose inhaler (MOl) is as effective as administration by hand-held nebulizer (NEB). Recent studies have suggested that MOl therapy is less costly to administer and that routine substitution of MOl for NEB would result in considerable savings to patients and to hospitals. To our knowledge, the actual extent to which MOl therapy would replace NEB therapy or the cost savings realized has not been reported previously. We examined the success and impact on hospital costs of the routine substitution of MOl for NEB therapy in a large tertiary-care hospital. Following introduction of this strategy, more than 60 percent of all aerosol therapy was actually given as MOL The mean amount of time spent by therapists to provide aerosol

therapy was significantly reduced by MOl substitution, falling from 1,576 ± 131 hlmo, to 992 ± 116 hlmo (p<0.002). The total cost to deliver aerosol therapy fell from $27,600 ± $2,277/mo to $20,618 ± $2,086/mo (p =0.008). Potential cost savings of $83,000 annually were achieved by the hospital, and charges to patients were lowered by approximately $300,000 per year. Routine substitution of MOl therapy for NEB therapy can be accomplished with considerable , but not total, success. This approach results in significant reductions in the cost of health care provision.

R espiratory therapy represents a sign ifican t fract ion of hospital charges in mo st acute-care hospitals in th e Un ited States. Several recent inve stigations have confirmed that administration of 13-agonist bronchodilator by metered-dose inhaler (MOl) is as effective as administration by hand-held nebulizer (NE B).1.5 Furthermore, MOl th erapy is potentially les s costly, primarily because it requires less therapist time than NEB therapy to administer. Annual reductions in th e cost of delivery of inhaled 13-agonist bronchodilators of as little as $2,000 to more than $250 ,000 have been projected from these studies.v':" The widespread substitution of MOl therapy for NEB therapy in a large acute-ca re hospital should reduce hospital costs, but the actual feasibility and effe cts of this strategy have not b een reported previou sly. We examined the implementation of a policy of routine subs titution of MOl

therapy for NEB therapy: spec ifically, the percentage of aerosol therapy actually substitute d and its impact on hospital costs were assessed.

*From the Departments of Medi cine (Pulmonary and Critical Care Med icine) (D rs. Bowton and Haponik ), and Anesthesia (Critical Ca re) (D r. Bowton), th e Bowman Gra y School of Med icine of Wake Forest Univer sity, and th e Department of Respiratory Care (Drs. Bowton and Goldsmith), North Carolina Baptist Hospitals Inc, Winston- Salem , NC . t Associate Professor of Med icin e and Anesth esia. *Profes sor of Medicine. Manu script received February 5; revision accepted Jun e 24 Reprint requests : Dr. Bowton, Bowman Gray School of Medicine, Medical Center Blvd . Winston-Salem , NC 27157-1054

(Chest 1992; 101:305-08 ) MDI=metered-dose inhaler; NEB

=hand-held nebulizer


Th e cost-effectiveness and th e level of substitution actually achieved with a policy of routin e substitution of ~-agoni st MOl therapy for NEB therapy was examined in this 700-hed , tertiar ycar e , university hospital , which has approximately 175 critical care beds and 525 ~eneml care beds . From January 1, 1989 , through July 30 , 1989, the number of MOl and NEB treatm ents ord ered was rev iewed and tabul ated daily by a single respiratory therapy revie wer as part of an ongoing review of appropriaten ess of resp irator y th erapy ord er s. Patient char ges and hospital costs were obtained from respi ratory care charge data that are ente red by therapists, concurrent with th e administration of therapy, into a ce ntral Respiratory Care databa se . After April I , 1989, all ord ers for NEB ~-agonist therapy were routinely administered as MOl therapy unless a spec ific ph ysician ord er for " no su bstitution" was provided . In non mechanically ventilated patients, exce ptions to substitution were as follows: (I) the NE B orde r was written as no substitution; (2) the pati ent was not able to follow comm and s; or (3) in the judgment of the treatin g respirat ory th erapist , the patient could not perform the nece ssar y maneu vers to assure ade q uate delivery of the ~-agonist by MOL In mechanically ventilated patients, only the first exception appli ed . In those pati ents not receiving mechanical ventilatory support , all MOl therapy was given using a delivery enhance me nt "s pace r" de vice (Aerocha mbe r, Mon aghan Medi cal Corp, Platt sburgh , NY). In mechanically ventilated pati ent s an MOl adapte r ''T'' was placed in the inspiratory limb of th e ventilator y circuit just proximal to the CHEST I 101 I 2 I FEBRUARY, 1992


Table 1- Therapist Time (in Minutes·) Required to Deliver Aerosol Therapy ICU NEB MOl setup Ventilator No ventilator MOl follow-up Ventilator No ventilator

Aerosol Treatment Data (Mean ± SD)·



Total No.ofRx


Cost perRx


552±39 580±23 559±38 563±29 555±35 544±32 535±33

8,009 8,045 6,939 7,739 8,263 7,425 7,563

$28,862 $28,966 $24,971 $22,770 $22,035 $18,982 $18,684

$3.60 $3.60 $3.60 $2.94 $2.67 $2.56 $2.47

General Care



6 9

6 9

4 5

4 5

*Data rounded up to next whole minute. ICU = intensive care unit; MOl = metered-dose inhaler; and NEB = hand-held nebulizer. patient "Y:' In all patients, all treatments were supervised by a respiratory therapist. Unless otherwise ordered, three actuations (puffs) of the ordered p-agonist were given (or substituted for the ordered NEB p-agonist), with a L-min interval separating each actuation. In the general care areas of our hospital, therapists remain in the room for the entire NEB treatment, while in the intensive care units (ICUs; with their "open" architecture) therapists may administer more than one NEB treatment at a time. Estimates of therapist time spent administering each treatment were obtained from time-management studies routinely performed in this institution . For these time-management studies, the actual amount of time required by supervisory and inservice-training therapists to perform the initial setup and patient instruction and the subsequent (follow-up) visits in both spontaneously breathing and mechanically ventilated patients were examined (Table 1). These estimates are similar to times derived from previously published studies." The "therapist cost" was computed from these time estimates (rounding up to the next whole minute) using the institutional median therapist hourly wage, without shift differential, of $13.70. Equipment and drug costs were calculated based on an albuterol canister cost of $7 for each patient beginning MOl therapy. Additionally, for nonmechanically ventilated patients, an initial delivery enhancement device cost of $4.50 was included. For patients receiving mechanical ventilatory support, the $4 cost of the canister adapter ''T,'' which was changed every 48 h with the ventilator circuit, was incorporated. The NEB costs were derived from the $1 cost of the hand-held nebulizer, which was changed daily, and the unit dose medication charge for albuterol of $0.54 per treatment. Total patient charges were calculated from patient charges during the study period of $13 for NEB treatments, $16.50 for the initial MOl treatment (including initial patient instruction), and $5 for follow-up MOl treatments. Before initiation of the MOl substitution program, a concerted effort was made to educate respiratory therapists and medical staff regarding the equivalence of the two forms of therapy and the perceived benefits of routine substitution with regard to improved use of respiratory therapists' time. This was accomplished both by written memoranda and during inservice and conference time of the respiratory therapy and medical staffs. The mean costs of delivery of inhaled respiratory therapy before and after the introduction of MOl therapy were compared using the Student t test for unpaired data with two-tailed p

The average daily hospital census, the total number of aerosol treatments, the total cost of aerosol therapy throughout the hospital during each month of the study, and the effective cost per treatment (total cost! 306

Table 2-HOBpital CenBUII and Respiratory Care

*Census =average daily hospital census ; total No. of Rx = total number of hand-held nebulizer (NEB) and metered-dose inhaler (MOl) treatments during each month; cost = sum of costs of therapist time, drugs, and equipment to deliver MOl and NEB therapy.

number of treatments) are summarized in Table 2, Tables 3 and 4 detail separately the costs in the ICUs and general care areas, and the number of MOl and NEB treatments in each area. The total cost to deliver aerosol therapy was significantly less after the introduction of MOl ($20,618± $2,068Imo) (mean ± SO) therapy than before ($27,600±$2,277). This was true for the hospital as a whole (p=0.008), and for the general care areas (p = 0.022) and the ICU (p = 0.009). The mean monthly difference in the cost of delivery of inhaled medications throughout the hospital before and after the initiation of MOl therapy was $6,982 (95 percent confidence limits for a difference of $2,732 to $11 ,232), for an annual potential cost savings of $139,000. Alikely lower limit ofcost savings, estimated from the 95 percent confidence interval of the cost difference, is $32,000. The impact of MOl therapy on the amount of time therapists spent delivering aerosol therapy is presented in Figure 1, in which the total time spent in delivering aerosol therapy is listed for each month studied, Overlying these plots is the total number of aerosol treatments provided during each month. Despite the absence of change in the total number of treatments, there was a significant reduction in the amount of time spent by therapists delivering aerosol therapy after the introduction of a MOl, with a mean monthly time of 1,576± 131 h before the MOl and Table 3-ReBpiratory Therapy (RT) in the IntenBive Care uw· Month

No. of NEB


5,066 5,442 4,747 2,856 2,740 1,873 1,721

No. of MOl (%MOI) 0 0 0 2,696 3,064 3,293 4,093

(49) (53) (64) (70)

*NEB =hand-held nebulizer; MOl

Total No.ofRx

Total RT Cost

5,066 5,442 4,747 5,552 5,804 5,166 5,814

$17,738 $19,126 $16,685 $14,936 $14,698 $12,047 $12,778

=metered-dose inhaler.

MOlva Hand-heId Nebulizenl (Bowton, GoId8tnIftI. HaponIk)

Table 4-Respiratory Therapy (RT) in General Care Areal· No. of NEB


2,943 2,603 2,192 997 890




No. of MOl(% MOl) 0 0 0 1,190 1,569 1,416 1,082

Total No.ofRx

Total RT Cost

2,943 2,603 2,192 2,187 2,459 2,259 1,749

$11,124 $9,840 $8,286 $7,834 $7,337 $6,935 $5,906

(54) (64) (63) (62)

·NEB =hand-held nebulizer; MOl =metered-dose inhaler.

992 ± 116 h after MDI (p =0.(02). To gauge whether the time saved in delivering MDI therapy rather than NEB therapy was used productively, the total dollars billed for all respiratory therapy in the hospital for each study month was divided by the total number of therapists employed in that month. There was no apparent difference in this measure of therapist productivity before or after introduction of MDI therapy. Prior to MDI, "productivity" was $8,618 ± $950 per therapist; after MDI, it decreased only to $8,244±$1,684 (p=0.7). This finding, together with the relative stability of the total number of aerosol treatments delivered, suggests that the time saved in switching to MDI treatments was used to deliver other chargeable therapy. (/)










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FIGURE 1. On the lower half of the graph, the therapist time spent delivering aerosol therapy is plotted for each month in general care areas (open circles), the intensive care unit (open squares), and the total hospital (closed squares). On the upper half, the total number of treatments throughout the hospital (triangles) is plotted for each month. Despite the absence of change in the total number of treatments monthly, the time spent delivering therapy was significantly less following metered-dose inhaler substitution (p =0.002).

The patient charges for aerosol therapy during the MDI substitution period (April to July) averaged $67,656 ± $6,709 monthly, of which approximately 60 percent was given as MDI. If all therapy had been given as NEB , the monthly mean patient charges would have been $100,717±$4,770. This represents an annual savings to patients of $396,000. Importantly, no adverse sequelae were reported as a result of this change in therapy. There were no physician reports of the substitution of MDI for NEB resulting in a compromise in the patient care delivered . DISCUSSION

Routine substitution of MDI for NEB therapy in a large, tertiary-care hospital can be done successfully and result in considerable potential cost savings. While previous projections of cost savings have tacitly assumed that complete substitution of MDI for NEB was feasible, this was not achieved in practice. Within the first three months of our MDI substitution program, more than 60 percent of all aerosol therapy was being delivered by MDI, and this percentage has remained stable to date . The fact that only 60 percent of therapy was delivered as MDI, far from representing a failure of the substitution program, is, rather, an acknowledgment that MDI therapy is not appropriate for all patients. However, a majority of patients can be treated with MDI instead of NEB . The projected savings in this hospital amounted to $83,000 annually and probably not less than $32,000 annually. This is in the range of previous estimates of the potential savings that might be achieved by substituting MDI for NEB therapy" This represents a "potential" cost savings. Actual cost savingsare difficult to assess accurately and are likely to be less than the potential savings for a number of reasons. Accurate assessment of actual cost savingswould require knowledge of the amount of therapist time saved that was spent in additionalrevenue-generating activities. Failing this, if it can be demonstrated that therapists' productivity did not change following institution of MDI therapy, one may assume that time not spent in delivery of NEB was productively spent in other activities. Therapist productivity, calculated as dollars billed per therapist, was not changed over the course of the study. No changes were made in the charges for the most commonly administered respiratory therapies; hence, the stability of this expression of productivity was not a reflection of changes in the billed costs of specific respiratory care procedures. Because the patient charges for MDI therapy in our hospital are less than those for comparable NEB therapy, MDI substitution resulted in considerable savingsto patients receiving respiratory therapy. Based on patient charges for the year 1989 in our hospital, a CHEST I 101 12 I FEBRUARY, 1992


reduction in charges to patients in excess of $300,000

was observed compared with the patient charges that

would have resulted from all therapy being given by NEB. While patient charges will vary considerably among institutions, if similar reductions in patient charges were realized in other institutions, the resultant savings nationwide would be substantial. In our tertiary-care institution, more respiratory therapy is ordered than can be completed with the available personnel. Hence, as more therapist time becomes available, it is generally put to productive use . However, if in switching from NEB to MDI therapy the savings in therapist time cannot be redirected productively, then to realize any of the potential savings, a reduction in the work force commensurate with the reduction in the work load must take place. Thus, the relative volume, case mix, and scope of services offered by the Respiratory Care Department will determine the real impact of this treatment strategy in other institutions. An additional area that was not specifically addressed by this study was that of employee satisfaction. Prior to initiation of MDI therapy in this institution, a considerable amount of ordered respiratory therapy could not be delivered. This placed a considerable burden on staff therapists, who frequently felt overwhelmed by the knowledge that they could never complete all ordered therapy, and who were uncomfortable being placed in the role of triage officer to determine which therapy would be performed. It is our unsubstantiated opinion (based on staff turnover rates and exit interviews) that staff satisfaction has increased, at least in part, as a consequence of better use of therapists' time . This unforeseen impact of MDI therapy on the Respiratory Care Department has proved important for departmental function, and has been maintained since the time of the study. Several practical factors contributed to the successful implementation of this program. Comprehensive educational programs directed at respiratory therapists and physicians before beginning MDI substitution were of paramount importance. The respiratory therapist education ensured that therapists were comfortable with this approach, and that they understood


the rationale for the change as well as the potential limitations of MDI therapy. The fact that therapists have significant input in selecting the method by which each patient is treated provides a sense of responsibility that is reflected in their generally positive attitudes toward the substitution program. Similarly, the educational program for physicians stressed the similar efficacy of MDI and NEB therapy and the savings in therapist time that we hoped to realize. Physicians, eager to have their patients receive all ordered respiratory therapy, and to have that therapy delivered in as cost effective a manner as possible, view the program as a step toward that goal. As third-party reimbursement for health-care costs is increasingly fixed for specific disease states and severity of illness (eg, MedicarelDRG), the careful examination of alternative, more cost-effective therapies will be increasingly important to hospitals and their medical staffs. Substitution of MDI for NEB therapy can be done successfully in a large , acutecare hospital and with a favorable impact on hospital costs. While the actual dollar savings realized by a hospital as a result of this change will vary, a reduction in the cost of health care delivery and better utilization of respiratory therapy personnel will likely occur. REFERENCES

1 Berry RB, Shinto RA, Wong FH , Despars jA, Light Rw. Nebulizer vs spacer for bronchodilator delivery in patients hospitalized for acute exacerbations of COPD. Chest 1989; 96:1241-46 2 Gay PC, Patel HG , Nelson SB, Gilles B, Hubmayr RD. Metered dose inhalers for bronchodilator delivery in intubated mechanically ventilated patients. Chest 1991;99:66-71 3 Summer \v, Elston R, Tharpe L, Nelson S, Haponik EF. Aerosol bronchodilator delivery methods. Arch Intern Med 1989; 149:618-23 4 Berenberg MJ,Cupples LA, Baigelman \v, Pearce L. Comparison of metered-dose inhaler attached to an Aerochamber with an updraft nebulizer for the administration of metaproterenol in hospitalized patients. J Asthma 1985; 22:87-92 5 Salzman GA, Steele MT, Pribble Jf, Elenbaas RM, Pyszczynslti DR. Aerosolized metaproterenol in the treatment of asthmatics with severe airflow obstruction : comparison of two delivery methods. Chest 1989; 95:1017-20 6 Jasper AC, Mohsenifar Z, Kahan S, Goldberg HS, Koerner SIC. Cost-benefit comparison of aerosol bronchodilator delivery methods in hospitalized patients. Chest 1987;91:614-18

MOlva Hand-held NebuHzers (Bawton, GoId4tnIth. HeponIk)