Metered-dose Inhalers in the Emergency Department

Source: Doan Q, Shefrin A, Johnson D. Cost-effectiveness of metereddose inhalers for asthma exacerbations in the pediatric emergency department. Pediatrics. 2011; 127(5): e1105– e1111; doi: 10.1542/peds.2010-2963To compare the cost-effectiveness of two modes of beta-agonist delivery in the treatment of children with an acute exacerbation of asthma, investigators obtained asthma-related costs from two tertiary Canadian children’s hospitals (British Columbia and Alberta). In development of a decision model, cost data were combined with asthma outcomes as published in a Cochrane systematic review (SR)1 that compared metered-dose inhaler (MDI) with wet nebulization. Outcome data from children who were aged 2 to 18 years with a mild to moderate acute exacerbation of asthma in the emergency department (ED) who did not require intensive care unit treatment were extracted from the SR. Costs were analyzed from a hospital perspective based on health care utilization within two days of an ED visit, with ED discharge considered a success, and hospital admission considered a failure.A range of costs were projected based on two treatment protocols. Both protocols included three to six treatments of albuterol with MDI and spacer (500–1,000 mcg) versus three to six treatments of nebulized albuterol (2.5–5.0 mg), all given at 20-minute intervals. In the second protocol, three treatments of ipratropium at 20-minute intervals via MDI or nebulization were assumed in the cost calculations. Cost values were established in Canadian dollars for nursing hours, pharmacologic costs (one MDI per patient), daily hospital stay (including physician fees, nursing, and pharmacologic costs), and device costs (eg, spacers or nebulizer tubing) using hospital data. Mode of delivery of albuterol was assumed to be associated with neither a differential labor cost in the ED nor hospital admission length of stay. The incremental cost-effectiveness ratio (ICER) was calculated per hospital admission averted, representing the difference in costs associated with delivery mode divided by the difference in probability of admission for a child treated with either mode. Sensitivity analyses were performed and Monte Carlo simulations were calculated around the baseline ICER to account for variability of model variables and costs.Although the point estimate favored the MDI mode of delivery, there was no statistically significant difference in the probability of admission between delivery modes. However, a net cost savings of nearly $155 (Canadian) per patient was observed with the MDI protocol. The MDI protocol also resulted in a greater likelihood of preventing hospital admissions with reduced cost, resulting in about a −$2,500 (Canadian) ICER per averted admission. In Monte Carlo simulations and sensitivity analysis, the ICER favored the MDI protocol in 90% to 98% of points or runs, respectively, even with inclusion of ipratropium in the protocols.The authors conclude that delivery of albuterol using MDIs with spacers to children with mild to moderate exacerbations would result in both a reduced risk of hospitalization and cost savings in most cases. The authors are careful to state that the cost savings are driven in large part by the lower risk of hospitalization with the use of the MDI protocols, despite the lower costs for nebulized drugs and associated devices.Dr Stevenson has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.An estimated 10 million children in the United States have asthma,2 and many will unfortunately experience an exacerbation resulting in an ED visit. Systemic corticosteroids and beta-agonists remain the mainstay of therapy. A significant body of literature supports MDIs as a delivery mode that is both faster than and at least as efficacious as wet nebulization, particularly for mild to moderate exacerbations, as summarized in the SR.1 Cost of the inhalers and spacers, especially associated with ipratropium delivery (which is indicated for moderate to severe exacerbations),3 has been a significant barrier to adoption of the MDI as the preferred delivery device in many pediatric EDs.4This carefully modeled study addresses the critical cost issue and shows that even under the worst case scenarios (very high costs of albuterol and ipratropium MDIs) the MDI delivery mode is a superior strategy, resulting in both a reduced risk of hospitalization and cost savings for hospitals and potentially, as the authors note, families and the health care system. Although cost variability in the United States may be greater due to the mix of payers, the sensitivity analyses suggest that the MDI strategy would be favored in most markets.

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