Changing Patterns of Respiratory Care Service use in the Era of Respiratory Care Protocols: An Observational Study

Abstract

Background

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).

Methods

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.

Results

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.

Conclusions

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.