Estimated cost-savings from optimizing use of inhaled medications for inpatients with obstructive lung disease

Abstract

Objective:

The majority of hospitalized patients with asthma or chronic obstructive pulmonary disease (COPD) misuse their inhalers. In a published program, “Nebs no More after 24”, the authors found their program to be effective at reducing unnecessary nebulized treatments, increasing patient education, and decreasing costs. The objective of this study was to develop financial models, both internal to our hospital and more generalizable externally, of the cost impact of transitioning adults hospitalized with asthma or COPD to metered dose inhalers (MDIs) after 24 hours of scheduled nebulized medications (“nebs”), when appropriate, to help hospitals make cost-efficient decisions for inhaled medications.

Methods:

“Internal” and “external” cost models were developed using number of patients, medication costs, and labor costs for nebulized medications and education for inhalers. Cost-savings were calculated by subtracting costs of nebulized-only cases from costs of nebulizer-plus-MDI cases. Estimates for staffing costs were obtained from the United States Bureau of Labor Statistics.

Results:

Cost-savings were estimated at $12,136 or $20,783 in the internal model and $8,927 or $14,283 in the external model when 50% or 80% of patients transitioned from nebs to MDIs, respectively. The marginal cost saving for every additional five new patients (~1% of n=552) transitioning to MDIs was estimated at $187.50.

Conclusions:

Models representing transitions from all-nebulized to nebulizer-plus-MDI respiratory medications resulted in cost savings, largely from the reduction of labor cost of nebulizer administration with nebs-only treatment. Therefore, transitioning from nebs to MDIs can lead to cost savings and could allow greater opportunities for inhaler education.

INTRODUCTION

The vast majority of hospitalized patients with obstructive lung disease misuse their inhalers (1). Inhaler misuse is not only common but leads to worse health outcomes, particularly with certain critical errors (2), and when using multiple devices (3–6). Guidelines for obstructive lung disease recommend assessing and educating individuals regarding self-management skills, including inhaler technique at all health encounters, including hospitalizations (7,8).

Studies have shown that providing in-hospital education on inhaler technique can improve patients’ skills and health outcomes (9–13). In a multi-center study of individuals admitted with asthma, more than half of adults who are prescribed rescue respiratory medications received only nebulized therapy (14). Since these patients were not prescribed inhalers during their hospitalization, there was substantial missed opportunity to assess and educate patients on effective inhaler education during their hospitalization (14).

Further, since the COVID-19 pandemic began, there are also concerns about limiting the use of nebulized therapies due to their risk of aerosolizing viral particles (15–20). Therefore, understanding the cost implications of utilizing inhalers earlier in hospitals stays are particularly salient during this current pandemic.

To address the cost effects of transitioning hospitalized patients from nebulized to inhaler delivered respiratory medications as well as opportunities for enhanced education, one hospital tested a program called “Nebs no More after 24” (21). This program was effective at reducing unnecessary nebulized treatments, increasing patient education, and decreasing costs (21). Because this was a single-site study, our objective was to develop a financial model of the impact of transitioning to (MDI) after 24 hours of scheduled nebulized medications (“nebs”) when appropriate to help hospitals make cost-efficient decisions for inhaled medications.

MATERIALS AND METHODS

Study design and population:

This was a cost-modeling study to determine the cost-effects of switching patients from nebulizer-only versus nebulizer for 24 hours followed by metered-dose inhaler (MDI) delivered short-acting “rescue” respiratory medications for symptom relief (not controller medication). This was a sub-study of a larger quality improvement “choosing wisely” project (22). This larger project was formally determined to be quality improvement, not human subjects research, and was therefore, not overseen by the Institutional Review Board, per institutional policy. The “Choosing Wisely” intervention aimed to use a decision support “nudge” with a “Best Practice Alert” or “BPA” to prompt clinicians to consider ordering MDIs after 24 hours of nebulizer treatments for any adult patients aged 18 years or older with asthma or COPD who were on the general wards (not intensive care unit) who would be discharged home with MDIs (Figure 1). This intervention was modeled after the “Nebs No More After 24” program published in JAMA Internal Medicine (21). Inclusion criteria for the electronic health record (EHR)-based algorithm included inpatients on the general medicine services who required systemic corticosteroids and inhaled medications; exclusion criteria included those who were in the intensive care unit and had cystic fibrosis or history of lung transplantation. Upon receiving the EHR prompt, clinicians could either dismiss the prompt or use the prompt to make the switch from nebulizer treatments to MDI-based treatment. This report’s objective was to estimate costs and potential for cost-saving based on intention to treat for the number of general ward inpatients seen over a one-year period (November 2018 through October 2019). This paper does not evaluate the Choosing Wisely program or patient-specific results.

Figure 1: Nebs No More After 24 Best Practice Alert.

Our Choosing Wisely best practice alert (BPA) was based on the “Nebs No More After 24” program published in JAMA Internal Medicine (Moriates et al, 2013; https://pubmed.ncbi.nlm.nih.gov/23877555/).²¹ The BPA allowed for a one-click opt-in for the nebulizer to metered dose inhaler switch (two timing options) or a one-click opt-out to keep providing nebulizer therapy with an option to provide the reason for opting out. © 2021 Epic Systems Corporation

Models:

We planned to develop two simple and interactive spreadsheet-based cost models. The first model planned would be an internal model to support our Choosing Wisely quality improvement project which was labeled “internal model”. This model would use site-specific cost information. The second planned model which was labeled “external model” would allow for more generalizable variables not specific to our hospital site, such as costs of spacers and pharmacist time (Table 1).

Table 1:

Parameters of Internal and External Cost Models for Transitioning from Nebulized to Metered Dose Inhaler Therapy

Model	Rescue Treatment Delivery Mode (Neb/MDI)	Number of patients in model **	Medication cost^	Supply costs (spacer)#	Labor costs*	Average LOS~
Internal	Nebulized	552	$0.16 (Duoneb)	N/A	$29/hour 0.25hour/neb	4 days
	MDI		$21 (Albuterol MDI)	$0	$65/hour 35hour (teaching time)
External	Nebulized	552	$0.16 (Duoneb)	N/A	$29/hour 0.25hour/neb	4 days
	MDI		$21 (Albuterol MDI)	$4.7	$61/hour 0.25hour/patient

^*Labor Costs: Were obtained from the United States Bureau of Labor Statistics.⁶ Internal Model: costs included time for pharmacist to provide education and for respiratory therapist to deliver nebulized treatments. External Model: costs included time for pharmacist/others to provide education + respiratory therapist to deliver nebulized treatments

^#Supply costs (spacer): Internal Model: Provided free of cost to patient internal program. External Model: included the costs of spacers, estimated based on University of Chicago Medicine’s catalogue

^{^}Medication Costs: Assumed that all patients received 15 nebs (3.75/day) for those that received only nebulized therapy vs. 5 nebs for those that received nebulized therapy + metered dose inhaler (MDI) therapy (one MDI per patient)

^~Length of stay (LOS): based on average LOS at our institution

^**Number of Patients in Model: the number of general medicine inpatients in one year (November 2018 – October 2019)

The models included number of patients over a one-year period, medication costs, and labor costs for nebulized medications and education for MDIs (Tables 1 and 2). The ratio of patients with nebulizer-only or nebulizer plus MDI use could be adjusted within each model. Based on the average length of stay of 4 days at our hospital, the model assumed that all patients received 15 nebs (3.75 per day) for those who received nebulized medications only versus 5 nebs, approximately 24 hours of treatment, before switching to an MDI. Also, in the model, each patient who switched to an MDI received an individual MDI and spacer. The internal model assumed no costs for the spacer, as it is routinely provided for patients at our institution to allow for teaching while hospitalized; the external model accounted for the cost of spacers. Additionally, student pharmacists provided the majority of the patient education at no cost at our institution therefore, pharmacist time was accounted in the internal model only for student training. In the external model these aspects are accounted for and are adjustable allowing for variable costs and distribution of responsibilities for patient education.

Table 2:

Neb/MDI cost saving model - Overview

Parameters		#/$/hour	Input Value
Number of patients		#	552
Nebulizer parameters
	Number of administrations per patient (Neb only)	#	15
	Number of administrations per patient (Neb + MDI)	#	5
	Cost (Duoneb)	$	0.16
	RT time per administration	hour	0.25
	Hourly RT labor cost	$	29
Metered Dose Inhaler (MDI) parameters
	Number of administrations per patient	#	1
	Cost (Albuterol MDI)	$	21.0
	Cost (Spacer)	$	4.7
	Teaching time	hour	35
	Hourly teaching labor cost	$	65
	Number of administrations per patient	#	1
	Pharmacist time per administration	hour	0.25
	Hourly pharmacist labor cost	$	61

Cost estimates:

Cost saving was calculated by subtracting costs of nebulized-only cases from costs of nebulizer plus MDI cases. Estimates for staffing costs were obtained from the US Bureau of Labor Statistics (23).

RESULTS

There were 552 adult general ward patients seen between November 2018 through October 2019 at our hospital among thousands of admitted patients who met our inclusion criteria as described above in the methods section.

Models

Both the internal and external models included the 552 patients seen over the one-year period (Tables 1 and 2). The cost saving calculation for nebulizer only for both internal and external models that includes all cost inputs and three scenarios is shown in Table 3A. The cost saving calculation for nebulizer plus MDI for both internal and external models that includes all cost inputs and three scenarios is shown in Table 3B.

Table 3A:

Cost Saving Calculation: Only Nebulizer (Neb)

		unit	calculation	UChicago Medicine Internal Model			External Model			Reference
				Scenario 1	Scenario 2	Scenario 3	Scenario 1	Scenario 2	Scenario 3
Neb+MDI ratio				0%	50%	80%	0%	50%	80%
Only Nebulizer (Neb)
	Medication
	Number of patients	#	A	552	276	110	552	276	110	The number of patients who took neb from November 2018 to October 2019 at UChicago Medicine was 552.
	Number of administrations per patient	#	B	15	15	15	15	15	15	The average administration per patient from November 2018 to October 2019 at UChicago Medicine was 14.9.
	Cost (Neb)	$	C	0.16	0.16	0.16	0.16	0.16	0.16	The actual cost of neb per administration at UChicago Medicine.
	Sub total	$	d=a*b*c	1,314	657	263	1,314	657	263	--
	Labor (Respiratory Therapist; RT)
	Number of patients	#	e	552	276	110	552	276	110	The number of patients who took neb from November 2018 to October 2019 at UChicago Medicine was 552.
	Number of administrations per patient	#	f	15	15	15	15	15	15	The average administration per patient from November 2018 to October 2019 at UChicago Medicine was 14.9.
	RT time per administration	hour	g	0.25	0.25	0.25	0.25	0.25	0.25	Assume that Respiratory Therapist need 0.25 hour per administration.
	Hourly RT labor cost	$	h	29	29	29	29	29	29	US Bureau of Labor Statistics (data as of September 4, 2019)
	Sub total	$	i=e*f*g*h	59,515	29,758	11,903	59,515	29,758	11,903	--
Neb total cost		$	j=d+i	60,830	30,415	12,166	60,830	30,415	12,166	--

Table 3B:

Cost Saving Calculation: Nebulizer + Metered-dose inhalers (MDI)

		unit	calculation		UChicago Medicine Internal Model			External Model			Reference
					Scenario 1	Scenario 2	Scenario 3	Scenario 1	Scenario 2	Scenario 3
Nebulizer (Neb) + Metered-dose inhalers (MDI)
Neb
	Medication
	Number of patients	#	a’		0	276	442	0	276	442	--
	Number of administrations per patient	#	b’		5	5	5	5	5	5	Assume that number of neb administration per patient is 5 when transitioning to MDI after neb.
	Cost (Neb)	$	c’		0.16	0.16	0.16	0.16	0.16	0.16	The actual cost of neb per administration at UChicago Medicine.
	Sub total	$	d’=a’*b’*c’		0	221	353	0	221	353	--
	Labor (Respiratory Therapist; RT)
	Number of patients	#	e’		0	276	442	0	276	442	--
	Number of administrations per patient	#	f’		5	5	5	5	5	5	Assume that number of neb administration per patient is 5 when transitioning to MDI after neb.
	RT time per administration	hour	g’		0.25	0.25	0.25	0.25	0.25	0.25	Assume that Respiratory Therapist need 0.25 hour per administration.
	Hourly labor cost	$	h’		29	29	29	29	29	29	US Bureau of Labor Statistics (data as of September 4, 2019)
	Sub total	$	i’=e’*f’*g’*h’		0	9,998	15,997	0	9,998	15,997	--
Neb total cost		$	j’=d’+i’		0	10,219	16,350	0	10,219	16,350	--
MDI
	Medication										--
	Number of patients	#	k		0	276	442	0	276	442	--
	Number of administrations per patient	#	l		1	1	1	1	1	1	Assume that number of MDI medication to patient is one.
	Cost (Albuterol MDI)	$	m		21	21	21	21	21	21	The actual cost of Albuterol MDI per patient at UChicago Medicine.
	Cost (Spacer)	$	n		0	0	0	4.7	4.7	4.7	UChicago Medicine doesn’t use spacer for MDI.
	Sub total	$	o=k*l*(m+n)		0	5,785	9,256	0	7,085	11,336	--
	Labor
	Pharmacist teaching students										At UChicago Medicine students at Pharmacy school are engaged in training patients to use MDI.
		Teaching time	hour	p	0	35	35	0	0	0	Pharmacist spent 35 hours to teach students about how to train patients.
		Hourly teaching labor cost	$	q	0	65	65	0	0	0	Assume that pharmacist hourly salary is $65 at UChicago Medicine.
	Sub total	$	r=p*q		0	2,275	2,275	0	0	0
	Pharmacist										Assume that pharmacists don’t directly train patients about how to use MDI in the external model.
		Number of patients	#	s	0	0	0	0	276	442
		Number of administrations per patient	#	t	0	0	0	1	1	1	Assume that number of training per patient is one.
		Pharmacist time per administration	hour	u	0	0	0	0.25	0.25	0.25	Assume that pharmacist spends 0.25 hours per training.
		Hourly pharmacist labor cost	$	v	0	0	0	61	61	61	US Bureau of Labor Statistics (data as of September 4, 2019)
	Sub total	$	w=s*t*u*v		0	0	0	0	4,184	6,695	--
	Sub total	$	x=r+w		0	2,275	2,275	0	4,184	6,695	--
MDI total cost		$	y=o+x		0	8,060	11,531	0	11,269	18,031	--
Neb + MDI total cost		$	z=j’+y		0	18,279	27,881	0	21,488	34,381	--
Total cost		$	j+z		60,830	48,694	40,047	60,830	51,903	46,547	--
Reference
Total medication cost		$	d+d’+o		1,314	6,663	9,872	1,314	7,963	11,952	--
Total labor cost		$	i+i’+x		59,515	42,031	30,175	59,515	43,940	34,595	--
% of total medication cost		%	(d+d’+o)/(j+z)		2.2%	13.7%	24.7%	2.2%	15.3%	25.7%	--
% of total labor cost		%	(i+i’+x)/(j+z)		97.8%	86.3%	75.3%	97.8%	84.7%	74.3%	--

Cost outcomes

In the internal model, cost savings were estimated at $12,136 when 50% of patients (276/552) transitioned from nebs to MDIs after 24 hours and at $20,783 when 80% of patients (442/552) transitioned from nebs to MDIs. The marginal cost saving for every additional 5 patients (about 1% of 552) transitioning to MDIs was estimated as $288.20 (Table 4). In the external model, the cost saving was estimated as $8,927 when 50% of patients transitioned from nebs to MDIs and as $14,283 when 80% of patients transitioned from nebs to MDIs (Table 4). The marginal cost saving for every additional 5 new patients (about 1% of 552) transitioning to MDIs was estimated as $187.50 (Table 4). When 80% of patients transitioned from nebs to MDIs, in the internal and external models, the percentage of total labor cost was 75.3% and 74.3% respectively compared to 97.8% in the nebulized-only case.

Table 4:

Summary of Cost Saving Results for Internal and External Models of Transitioning from Nebulized to Metered Dose Inhaler Therapy

Model	N	% Transitionin^	Cost savings	Marginal cost saving*
Internal	552			$288.20
		50%	$12,136
		80%	$20,738
External	552			$187.50
		50%	$8,927
		80%	$14,283

^*For every 5 additional patients (~1% of n=552)

^{^}Transitioning from nebulized therapy to metered dose inhalers after 24 hours

DISCUSSION

Transitioning hospitalized patients with obstructive lung disease such as asthma or COPD from nebulizer-only to nebulizer plus MDIs during hospitalization resulted in cost savings. These cost-savings were found in both the internal and external models, enhancing generalizability for use in planning across other institutions. The cost savings were largely from the reduction of labor cost of nebs administration by replacing this care with MDI prescribing as related labor costs are lower for MDIs. This may be surprising to some as there is a perception that nebulizer therapy is less expensive than respiratory inhalers. In the outpatient setting, refills of medications used with a nebulizer machine are less expensive than individual inhalers. However, in the inpatient setting, since nebulized therapies require delivery with and by respiratory therapists, respiratory inhalers are less costly at the institutional level. That said, there can be waste from inpatient MDI use as patients are not able to take these home upon discharge. Two potential ways to reduce waste are to use 60-dose MDIs instead of 200-dose products or to implement a shared canister model (24–26). The shared canister model uses one MDI to administer medication to multiple patients with patient-specific spacers. This allows the full canister to be used prior to discarding but typically requires staff support, adding to costs. Therefore, additional society-level and environmental factors need to be considered when implementing inpatient MDI use.

Cost-savings from neb to neb plus MDI transitions partnered with patient assessment and education of inhaler technique has the potential to lead to higher value care that is more aligned with clinical guidelines (7, 8, 21). In fact, when providing effective inhaler education during hospitalization, prior studies have found acute care utilization can decrease(10, 12), which could lead to further cost-savings. An additional clinical indication for health systems increasing opportunities for MDI-delivered therapies as opposed to nebulizer delivered treatments is related to the safety concerns of using nebs during the COVID-19 pandemic (15,16).

While the models used adjustable variables and particularly the external model is broadly generalizable, limitations of the study exist. The limitations are largely related to the specific staffing models and within-institution program costs; hence the cost-savings themselves could vary institution to institution. Additional limitations relate to this study focusing on cost-implications of a system-level BPA intervention only; hence patient-level data are not evaluated or reported for this study. Finally, limitations exist with respect to nuances in types of spacers, i.e., valved holding chambers (VHC), and nebulizer machines, both of which can have varying characteristics depending on which VHC or nebulizer is used. Future work is needed to determine the effectiveness of the BPA at the patient-level, both for transitioning effectively and safely from nebulizer to MDI treatments and to determine whether the intervention increased inhaler education and/or improved inhaler technique.

CONCLUSIONS

Given similar cost-savings found in the real-world program “Nebs no More after 24” published by Moriates et al in 2013 (21), and the cost-savings in both our internal and external models, consideration of transitioning to MDIs for adult inpatients with asthma and COPD could be beneficial- both for the system (cost-savings) and the patient (opportunity to be taught correct technique). In the era of focusing on value-added health care approaches, this transition from nebulizer to inhaler-based treatment among eligible hospitalized patients is an ideal approach, both for cost-efficiency and potentially at the patient-level should future work determine that this BPA-based approach to transition from nebulizer to MDI treatments improves access to inhaler education and/or improves patients’ inhaler technique.