Respiratory Care

As part of our ongoing analysis of respiratory care services at the Cleveland Clinic Foundation (CCF), we reviewed the differences in volume and costs of providing respiratory care services over a six-year period, comparing a time period before our respiratory care protocol service was available (1991) to a time after this service was widely used (1996).

The Respiratory Therapy Consult Service (RTCS) was first implemented hospitalwide for use at physician discretion in February 1992 and was mandated for most nonintensive care unit (non-ICU) adult inpatient care in August 1994. Using true variable and fixed costs for providing respiratory care services and a management information system that tallies all respiratory care services delivered, we calculated the volume and cost associated with the five highest-volume adult non-ICU respiratory care services at the Cleveland Clinic Hospital: aerosol medication delivery (SVN), metered dose inhalers (MDI), oxygen therapy, bronchopulmonary hygiene (BPH), and incentive spirometry. To assess the impact of the RTCS on volume and costs of respiratory care services, 1991 data were compared with 1996 data.

Despite a stable hospital census between 1991 (16,989 patients) and 1996 (16,556 patients), the total number of these five therapies administered decreased (202,728 in 1991 to 147,101 in 1996). The accompanying decrease in cost for these services was $460,666 over this interval. The mean cost per patient for providing the five therapies was reduced from $94 in 1991 to $69 in 1996. Most of the savings were associated with a decline in the volume of time-consuming services (ie, SVN and BPH) by 46,623 treatments, producing a cost decrease of $368,339. Delivery of aerosolized bronchodilators (SVN, MDI) decreased by 16,673 treatments, coupled with an 11% increase in the proportion of bronchodilator therapies administered by MDIs (less costly than SVNs), which rose from 25% of all bronchodilators (22,513) in 1991 to 36% (26,371) in 1996. This 11% increase in MDI treatments along with the total reduction in bronchodilator treatments administered resulted in a cost savings of $153,824. Oxygen therapy was reduced by 9,751 patient-days over the six-year period, resulting in cost savings of $9,556.

We conclude that between 1991 and 1996, changing patterns of use for the highest-volume respiratory care services delivered to non-ICU adult inpatients were associated with a substantial decrease in the number of therapies and associated costs and that implementation of the RTCS during this interval was associated with a cost savings, though this temporal correlation does not establish causality, ie, that the RTCS caused this savings. On the other hand, the lack of a tenable alternative explanation for this trend strengthens our belief that use of the RTCS is, at least, a contributing factor.

The prevalence and characteristics of chronically ventilator-assisted individuals (VAI) in the United States are largely unknown. There have been recent changes in the sites and methods of caring for VAIs, as exemplified in the increase in dedicated VAI hospitals and the use of noninvasive positive pressure ventilation (NPPV). To determine the changing prevalence and characteristics of VAIs in Minnesota, we conducted a cross-sectional survey of all VAIs in Minnesota in 1986, 1992, and 1997.

All providers of care for VAIs responded to similar questionnaires about each VAI in each survey year. Information obtained about VAIs included: age, respiratory diagnosis(es), location, duration of assistance, and need for full or partial support. The 1997 survey included a determination of patients receiving NPPV with a backup rate.

At a time when state population increased from 4.26 million (1986) to 4.47 million (1992, +4.9%) to 4.69 million (1997, +5.1%), the number of VAIs in Minnesota increased from 103 VAIS in 1986 to 216 in 1992 (+110%) to 306 in 1997 (+42%). The predominant reason for requiring assistance was ventilatory muscle dysfunction from polio, muscular dystrophy, cervical trauma, or amyotrophic lateral sclerosis (ALS). The most prevalent age groups are <11 and >70 years old. Polio, chronic obstructive pulmonary disease (COPD) and ALS VAIS were older, while those with muscular dystrophy and cervical trauma were younger. There was a bimodal distribution of VAIS in duration of ventilation: those with obstructive and restrictive lung diseases were assisted shorter periods, while the long-term patients (ventilated for >5 years) were those with ventilatory muscle dysfunction. Noninvasive ventilation accounted for 47% of the increase in VAIs between 1992 and 1997.

The number of VAIs in Minnesota continues to increase at a relatively constant rate (≈18/yr), driven by equivalent rises in the number of noninvasive and intubated patients. Ventilatory muscle dysfunction is the predominant disability requiring long-term assistance, while the obstructive-restrictive disease VAIs had a shorter duration of ventilatory assistance.