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By Dean R. Hess, PhD, RRT
Three forces are driving health care as we move into the 21st century: access to care, quality of care, and cost of care. These were major issues facing the American voter in the recent Presidential campaigns, as topics such as prescription drug benefits and the Patient’s Bill-of-Rights were debated by the candidates. Managed care has become an increasing force in the delivery of health care in the United States.1 Simply defined, managed care is any system that manages the delivery of heath care in a way such that cost is controlled. First, with the implementation of the Medicare Diagnosis-Related Groups (DRG) prospective fixed-payment system, and now with the increasing penetration of managed care, the business of health care has shifted from revenue-generating to cost-control. Survival in this environment depends heavily on the ability to manage the costs of providing care.
In the United States, respiratory care makes up about 7% of total health care costs and about 10% of total prescription costs.1 Respiratory care is the sixth largest disease category in terms of dollars spent. Because much of respiratory care is provided in acute and critical care environments, efforts to control its costs have direct effect on the provision of critical care services. Although the effect of this has been felt most acutely by respiratory therapists, it has nonetheless affected everyone whose work is related to critical care—physicians, nurses, patients, and families.
When the environment changes, survival requires adaptation and selection forces favor those who can adjust to fit the new climate. With increasing pressure to provide high quality at low cost, a careful examination of the necessity for some forms of respiratory care has occurred. This has happened at the same time that evidence-based medicine has become increasingly fashionable—in other words, providing health care is consistent with the high-level evidence that supports effective therapy.
Four methods can reduce the costs of respiratory care: elimination of unproven therapy, reduction of misallocation of therapy, transfer of patients to lower cost sites of care, and use of guidelines and protocols.
Elimination of Unproven Therapy
Overordering of respiratory therapy is nearly as old as the profession itself. Respiratory therapists have known for many years that many respiratory treatments are unnecessary or have unproven value. It is also known that much of this therapy can be eliminated without affecting patient outcomes. For example, Zibrak et al2 implemented a program in which they were able to dramatically reduce the volume of respiratory treatments without any evidence of adverse patient outcomes (e.g., mortality or hospital stay). This program resulted in a reduction of aerosolized medication treatments and incentive spirometry of about 50%. In a revenue-generating business model, such as existed at the time of Zibrak et al’s publication, there was no financial incentive to reduce the prescription of unnecessary or unproven therapy.
Incentive spirometry is commonly used in postoperative patients to facilitate deep breathing. The physiologic basis for this is sound. Postoperative patients have a monotonous shallow breathing pattern that promotes atelectasis, secretion retention, and pneumonia. Providing the patient with an incentive to deep breathe periodically should decrease these complications. Unfortunately, the evidence does not support this benefit. In fact, it might be argued that incentive spirometry simply moved into the niche vacated when the postoperative use of intermittent positive pressure breathing (IPPB) therapy became unfashionable. This was recently investigated by Gosslink et al3 in a randomized controlled trial (RCT) of 67 patients following thoracic surgery. Incentive spirometry with deep-breathing and coughing was compared to deep-breathing and coughing alone. There was no difference in postoperative pulmonary complications, ICU stay, or hospital stay between the two groups. This RCT thus failed to demonstrate a benefit for use of routine incentive spirometry in this patient population.
Chest physiotherapy is a time-consuming, costly, and potentially dangerous (at least for some patients) therapy that is commonly used for hospitalized patients. Despite its popularity, there is little evidence to support its use in most hospitalized patients. Alexander et al4 reported their experience with a strategy to reduce use of chest physiotherapy without compromising patient care. They did a 30-year review of the literature to identify appropriate indications for chest physiotherapy: patients who produce copious amounts of sputum (> 30 mL/d), patients with segmental or lobar atelectasis, lung abscess, and a diagnosis of cystic fibrosis or bronchiectasis. Although commonly accepted, these indications are largely anecdotal due to the paucity of RCTs demonstrating benefit for chest physiotherapy. In a series of 177 patients who were ordered to receive chest physiotherapy, Alexander et al 4 identified 72 who fit the identified indications. The remaining 105 patients (i.e., those in whom chest physiotherapy was judged inappropriate) were randomized to receive the therapy as ordered or to not receive the ordered chest physiotherapy. Hospital length-of-stay and mortality were no different between the patients who were randomized to receive chest physiotherapy and those who were randomized not to receive it. This was associated with a reported cost savings of $319,000.
Reduce Misallocation of Therapy
Misallocation of respiratory therapy refers to over-ordering and under-ordering.5 Overordering results in therapy for patients who do not require the therapy or are unlikely to benefit from the therapy. Underordering is failing to prescribe respiratory care for those likely to benefit from receiving the treatment. Misallocation of respiratory therapy occurs commonly, is associated with a number of therapies, and occurs in both academic and nonacademic hospitals. Stoller has suggested three possible factors that affect misallocation of respiratory therapy: 1) respiratory disorders are commonly misdiagnosed, resulting in prescription of inappropriate therapy, 2) respiratory treatments are prescribed in a more cavalier manner than drugs, and 3) physicians empowered to prescribe respiratory therapy sometimes lack sufficient training about respiratory therapy to order it appropriately.5
Kester and Stoller6 studied misallocation of respiratory therapy at a large academic medical center. From an audit of 170 patients’ charts, they reported that 25% of the prescribed respiratory therapy was not indicated. On the other hand, 10% of the patients were not ordered to receive therapy that was indicated. Similar patterns of misallocation have been reported by others, as reviewed by Stoller.5 Use of guidelines and protocols has been suggested as a strategy to improve allocation of respiratory therapy. This approach empowers respiratory therapists to identify and provide the appropriate respiratory therapy. The available evidence suggests that respiratory therapists are indeed able to improve the allocation of respiratory therapy.
Guidelines and Protocols
Clinical practice guidelines (CPGs) are systematically developed statements to assist clinicians with appropriate care for specific clinical circumstances. CPGs came into vogue in the 1990s and have been promulgated by governmental agencies and professional societies. For example, about 50 CPGs have been published by the American Association for Respiratory Care (AARC) in the past 10 years and are readily available on the Internet (Web address www.rcjournal.com/online_resources/cpgs/cpg_index.html). The principal motivations for CPGs have been to improve the quality of care, decrease the cost of care, and reduce regional variability in care. Guidelines describe the most appropriate care based upon the available evidence. Pathways, which have become popular in nursing practice, define the best practice along a specific timeline and provide a framework for data collection and documentation. Protocols dictate specific instructions for clinical care and have become popular in respiratory care practice. Therapist-driven protocols are medical staff-approved respiratory care plans in which the physician orders a protocol rather than a specific therapy, the respiratory therapist determines the care plan within the parameters of the protocol, the therapist implements the care plan and modifies it (including discontinuation) within the boundaries of the protocol.
In a RCT, Stoller et al7 studied physician-directed vs. therapist protocol-directed respiratory therapy for adult non-ICU patients. The respiratory therapist protocols were consistent with the CPGs published by the AARC. They reported that respiratory therapist directed respiratory care was slightly less expensive than physician-directed respiratory care and without adverse events. Perhaps more important, misallocation was less with the therapist directed care. Based upon these results, therapist-driven protocols were made mandatory for prescribing respiratory care to most adult non-ICU inpatients at Stoller et al's hospital (Cleveland Clinic Foundation).
Kollef et al8 reported the results of a quasi-randomized clinical study of the effect of therapist-driven protocols on patient outcomes and resource management for non-ICU inpatients. They also reported that respiratory care managed by therapist-driven protocols was safe and resulted in less misallocation of respiratory therapy than physician-directed respiratory care. They further reported that respiratory therapist directed care resulted in a significant reduction in the overall use of respiratory therapy, which resulted in a significant cost savings.
In the critical care setting, respiratory therapists are intimately involved in care of patients receiving mechanical ventilation. Several recent studies have reported an important role for respiratory therapist protocols in the assessment for extubation readiness and for weaning of patients from mechanical ventilation.9 Ely et al10 reported a study in which respiratory therapists screened mechanically ventilated patients for extubation readiness daily, performed a spontaneous breathing trial if indicated, and notified the physician if the patient successfully completed the spontaneous breathing trial. Patients were randomized to this intervention or to a daily screen only. They reported decreased ventilator days, decreased costs, and no adverse outcomes associated with the intervention. In a follow-up study, Ely et al11 reported successful large-scale implementation of a therapist driven weaning protocol. Kollef et al12 randomly assigned mechanically ventilated patients to receive physician-directed or protocol-directed weaning (protocol implemented by respiratory therapists and nurses), and reported that use of the protocol resulted in weaning patients safely and more quickly than traditional physician-directed weaning. Marelich et al13 reported a RCT comparing physician-directed weaning and protocol-directed weaning by respiratory therapists and nurses. Similar to the findings of Ely and Kollef, they reported that protocol-directed weaning resulted in reduced duration of mechanical ventilation without any adverse effects.
Transfer to Lower Cost Sites of Care
Caring for patients in acute care hospitals is expensive. If the patient’s severity of acute illness allows, it would seem cost-effective to transfer the patient to lower cost sites of care such as weaning centers, extended care facilities, and the home. Until recently, reimbursement strategies (DRG exemption) had favored transfer of long-term mechanically ventilated patients to weaning centers. However, favorable reimbursement strategies for such centers are disappearing. This produces a catch-22 scenario for cost-effective health care. On one hand, it is less costly to care for these patients in long-term care facilities. On the other hand, long-term care facilities cannot accept transfer of these patients if reimbursement is unfavorable.
Managed care has challenged the health care delivery system to identify and implement cost-effective strategies to reduce costs. For respiratory care, a number of strategies can be used to reduce costs. Some of these have been subjected to RCTs, which have reported high-level benefit for these strategies.
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