The Failure of an Auto-Substitution Protocol of Short-Acting Nebulizers for Long-Acting Inhalers to Reduce Cost of Care in a Quaternary Teaching Hospital.

Abstract

Background: COPD is a common diagnosis driving in-patient admissions. A major component of in-patient COPD management involves nebulized or inhaled bronchodilators. In many hospitals, the in-patient pharmacy limits medication availability and may auto-substitute short-acting nebulized bronchodilators (SANBs) for long-acting inhalers (LAIs) to cut costs; the effect of such policy change on patient care is unknown. Methods: We performed a retrospective, observational study at a quaternary teaching hospital to analyze respiratory therapy utilization in subjects with COPD on home LAI, who were admitted between December 1, 2022-February 28, 2023. We compared resource utilization between the following groups: SANB only, LAI + as-needed SANB, and LAI + scheduled SANB. Results: We reviewed 302 admissions. There were 97 in SANB group, 99 in LAI + as-needed SANB group, and 106 admissions in LAI + scheduled SANB group. Subjects in LAI + as-needed SANB category utilized significantly fewer treatments overall than SANB or LAI + scheduled SANB groups (1.6/d vs 4.2/d vs 4.5/d, respectively, P < .001) and suffered fewer missed treatments (0.2/d vs 1.7/d vs 1.3/d, respectively, P < .001). There was no significant difference in the length of stay between the 3 groups. Furthermore, overall costs were lowest in LAI + as-needed SANB compared to the SANB and LAI + scheduled SANB groups ($117.62/admission vs $219.71/admission vs $375.35/admission, respectively, P < .001). Within the SANB group, we found that only 36.1% of admissions included orders that complied with the auto-substitution policy. Conclusions: In conclusion, for patients with COPD on home LAI admitted to the hospital, substituting scheduled SANB for LAI resulted in higher costs, more frequent treatment utilization, and more missed doses than the alternative regimens. Moreover, most scheduled SANB orders were not reflective of the actual auto-substitution policy.