Chest
Volume 108, Issue 2, August 1995, Pages 475-481
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Clinical Investigations in Critical Care; Articles
Financial Implications of Noninvasive Positive Pressure Ventilation (NPPV)

https://doi.org/10.1378/chest.108.2.475Get rights and content

Noninvasive positive pressure ventilation (NPPV) is effective in the treatment of acute and chronic respiratory failure. However, the costs and financial balance between costs and diagnosis-related group (DRG) reimbursement for patients with moderate to severe respiratory failure treated with NPPV are unknown. We examined the costs and DRG reimbursement for 27 patients receiving Medicare referred with moderately severe respiratory failure for NPPV to the ventilator rehabilitation unit (VRU) at Temple University Hospital. This unit is one of four Health Care Financing Administration chronic ventilator-dependent demonstration sites that evaluates patients for NPPV, instructs them in home NPPV use, emphasizes rehabilitation, and uses strict cost accounting methods. Nineteen patients were treated with NPPV in the ICU and then referred to the VRU, and 8 patients were directly admitted for NPPV to the VRU. Patients were (mean±SE) 69±9 years age, 14 had severe COPD, and 13 had various restrictive disorders. All were hypercapneic at the time of hospital admission (restrictive 60 ±15; obstructive 67 ±3 mm Hg, PaCO2) with impaired lung mechanics and limited functional status. Patients averaged 8± 15 days in the ICU, or 8±4.7 days on the medical floor prior to VRU transfer. The VRU length of stay averaged 20±18 days, for a total length of stay of 29±21 days. After implementation of NPPV, all patients had an improvement in gas exchange while spontaneously breathing and functional status that was maintained in follow-up. At 1 and 2 years of follow-up, 74% and 63% of patients were alive, respectively. Eleven patients were admitted with DRG 475 (respiratory system diagnosis with ventilator support); however, 16 of 27 patients were admitted across five different non-475 DRG codes with reimbursement rates ranging from $2,673 to $4,215. After DRG and outlier reimbursement, a total deficit of $261,948 remained (average deficit $9,701 per patient). However, individual patient deficits ranged from $1,113 to $32,892. Eighty-two percent of patients treated with NPPV incurred substantial financial losses that were underreimbursed across all assigned DRGs, including DRG 475, the highest-weighted DRG. We conclude that patients with moderate to severe respiratory failure receiving NPPV demonstrate an improvement in functional status and gas exchange that is maintained in follow-up. In addition, patients treated with NPPV incur high costs that are currently underreimbursed by the present DRG system. Newer DRG payment scales that recognize NPPV as specific treatment should be implemented.

(CHEST 1995; 108:475-81)

Section snippets

Enrollment Criteria

Prior to enrollment and admission to the VRU for NPPV, patients had to have maximization of medical therapy and fulfill at least two clinical and physiologic criteria for noninvasive ventilation as described in Table 1. All patients were first treated for 48 h with maximally effective doses of inhaled bronchodilators (eg, β-agonists, anticholinergic agents), systemic and inhaled corticosteroids, and supplemental oxygen. Following maximization of medical therapy, patients who then fulfilled the

Clinical Outcome

Baseline demographic data of the 27 patients demonstrated that 14 patients had COPD as the cause of respiratory failure and 13 patients had a variety of restrictive diseases (kyphoscoliosis [3], obesity-hypoventilation [5], neuromuscular [4], fibrothorax [1]).

Patient age was 69±9 years; 19 were females. Overall, patients were moderately to severely ill, with 48% (13/27) of patients demonstrating cor pulmonale by physical examination, chest radiograph, or ECG. Overall, patients spent 8±15 days

Discussion

Our data reinforce previous studies1, 2, 3, 4, 5, 6, 7, 8 and show that NPPV may have an important beneficial effect on gas exchange and functional status in patients with chronic respiratory failure. In addition, our data show that patients with chronic respiratory failure secondary to severe underlying disease have significant costs associated with their care when treated with NPPV. Moreover, our data show that the present DRG payment scale does not adequately reflect the costs incurred in

ACKNOWLEDGMENTS

We would like to acknowledge the efforts of Michael Beatrice and Herbert White in the compilation of financial data, the secretarial assistance of Darlene Macon, the illustration assistance of John Travaline, and the helpful comments of Gilbert d'Alonzo.

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    Supported in part by a grant 29-P-99401/3-01 from the Health Care Financing Administration (HCFA).

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