Breath-Actuated Nebulizers for Asthma and Chronic Obstructive Pulmonary Disease Exacerbation: A Monte Carlo Simulation Demonstrating National Cost Savings and Length of Stay Reduction.

Objectives: Breath-actuated nebulizers (BANs) deliver medication only during inspiration, and prior studies have demonstrated their increased efficacy for asthma and chronic obstructive pulmonary disease (COPD) exacerbations compared to continuous nebulizers. However, the widespread adoption of BAN has been limited by its higher per-unit cost. Our primary objective was to estimate the annual national net cost and emergency department (ED) bed-hour savings of switching to BAN for pediatric and adult patients presenting to the ED with asthma or COPD exacerbation. Methods: We estimated the prevalence of ED visits for asthma and COPD requiring nebulizer treatment using publicly available datasets. We created a Monte Carlo model and ran 1000 trials to determine the marginal cost of a BAN-first approach. We modeled the cost savings from decreased ED bed hours and averted inpatient admissions among eligible patients nationally and by common annual ED visit volumes. Results: Adoption of a BAN-first strategy nationally is estimated to incur an additional $6,059,000 (±$1,024,000) in supply costs, with total savings of $744,610,000 (±$141,922,000) and a reduction of 178,000 (±77,000) ED bed hours. An ED with 30,000 annual visits would save $206,000 (±$38,000) annually with a supply cost of $1400 (±$260). For 60,000 visits, savings would be $551,000 (±$99,600) with a supply cost of $3700 (±$680). At 130,000 visits, savings would reach $896,000 (±$168,000) with a supply cost of $5900 (±$1100). Conclusion: BAN may yield significant cost savings driven primarily by a decreased likelihood of admission for COPD exacerbation. Further research is needed to validate clinical efficacy and address barriers to adoption.