Noninvasive positive pressure ventilation in the setting of severe, acute exacerbations of chronic obstructive pulmonary disease: More effective and less expensive

Objective: The use of noninvasive ventilation for patients with acute respi ratory failure has become increasingly popular over the last decade. Althou gh the literature provides good evidence for the effectiveness of noninvasi ve ventilation in addition to standard therapy compared with standard thera py alone in patients with chronic obstructive pulmonary disease (avoiding i ntubation and improving hospital mortality), the associated costs have not been rigorously measured. Adding noninvasive positive pressure ventilation (NPPV) to standard therapy in the setting of a severe, acute exacerbation o f chronic obstructive pulmonary disease (COPD) in patients with respiratory acidosis who are at high risk of requiring endotracheal intubation is both more effective and less expensive. Design: Economic evaluation based on theoretical model. Setting This analysis base case was modeled for a tertiary care, teaching h ospital. Patients or other Participants: Carefully selected patients with severe exa cerbations of COPD. Intervention: The two alternative therapies compared were standard therapy (oxygen, bronchodilators, steroids, and antibiotics) and standard therapy p lus NPPV. Measurements and Main Results: As the hypothesis was dominance, the main ou tcomes modeled and calculated were costs, mortality rate, and rates of intu bation between the two interventions. To determine clinical effectiveness, we used a metaanalysis of randomized trials evaluating the impact of NPPV o n hospital survival. A decision tree was constructed and probabilities were applied at each chance node using research evidence and a comprehensive re gional database. To provide data for this economic evaluation, MEDLINE lite rature searches were conducted. Bibliographies of relevant articles were re viewed, as were personal files. To estimate the costs of the alternative th erapeutic approaches, eight types of hospitalization days were costed using the London Health Sciences Center costing data. Sensitivity analyses were performed, varying all assumptions made. The metaanalysis yielded an odds r atio for hospital mortality in the NPPV arm, compared with standard therapy , of 0.22 (95% confidence interval, 0.10-0.66). By using baseline case assu mptions, we found a cost savings of $3,244 (1996, Canadian), per patient ad mission, if NPPV were adopted in favor of standard therapy. These findings present a scenario of clear dominance for treatment with NPPV. Sensitivity analyses did not alter the results appreciably. Conclusions: We conclude that from a hospital's perspective, NPPV and stand ard therapy for carefully selected patients with acute, severe exacerbation s of COPD are more effective and less expensive than standard therapy alone .