Published on *jems.com* (http://www.jems.com)

Saturday, July 12, 2008

Keith Wesley, MD, FACEP

Keith Wesley, MD, FACEP

**Review of:** Hubble MW, Richards ME and Wilfong DA: "Estimates of cost-effectiveness of prehospital continuous positive airway pressure in the management of acute pulmonary edema." Prehospital Emergency Care. 12(3):277-85, 2008.

**The Science
**his study is by the same authors who showed that prehospital CPAP reduced mortality by 18% and intubation by 16%. They follow that study with this assessment of the financial implications of instituting prehospital CPAP. The study accurately lists the cost of this implementation in their system. It then goes far beyond that to examine the cost of hospitalization across the nation as it's reported in many articles.

In this paper, the authors conservatively overestimate that the cost to implement CPAP during one year -- including the cost of equipment, supplies and training -- was $10,686. They used CPAP 120 times a year, or about four times per 1,000 patient transports, at a cost of $89. This resulted in 0.75 lives saved for every 1,000 patients treated at a cost of $490.

Their criteria were that non-intubated patients had an average hospital stay of about five days versus 10 days for the intubated patient (five days of which are spent in the ICU at a cost of three to four times that of the general ward) Using this criteria, the hospital cost savings was $499,717. This resulted in a total savings of $489,031, after accounting for the cost of equipment, supplies and training. In their system, they used CPAP 120 so that equated to a savings of $4,075 per CPAP use.

They further conclude the number needed to treat (NNT) to avoid an intubation is 6. Their final conclusion is that prehospital CPAP is a cost-effective treatment.

**The Street
**Finally we're getting research that will make "cents" to those that come up with the inane rules and regulations that haunt our existence in EMS. We need to prove that what we do saves not only lives, but more importantly for others we need to prove that what we do saves

The authors have provided an honest and unbiased approached that I challenge every system to mirror when implementing a new strategy of care. In fact, they were overly conservative in their estimates. Despite the phenomenal reduction they experienced in mortality and intubation, they recognized many systems haven't seen that same degree of reduction and therefore took a conservative estimate of hospital length-of-stay reduction. Using their more aggressive intubation reduction model, they estimate that the hospital savings would have been $1,118,050. This would result in a cost savings of $9,317 per CPAP use.

If you're finding it hard to fund the cost of CPAP, look to your receiving hospital. Ask them the following questions: How many patients with pulmonary edema did you bring to them last year? How many were intubated on arrival or shortly after arrival? How many went to the ICU? Ask them about the patients' average lengths of stay, and have them separate out ICU and general ward days. What was the average hospital charge? What was the hospital mortality rate? Then provide them with this paper and the ones listed in the bibliography.

On another note, I hope someone in Washington is reading this or has read this paper and recognizes that EMT-basics who use CPAP are providing ALS skills. Therefore, they should be able charge on the ALS fee screen to bill for the cost of the CPAP circuit, because the data shows they're saving Medicare money by decreasing hospital length-of-stay.

**JEMS.com Editor's Note:** Dr. Wesley further discusses adding CPAP to the EMT-B scope of practice in his article, "The 'Basic' Skill of CPAP." To read it, click here to download a pdf of the October 2007*JEMS* supplement, "State of the Science".