Hospital Patterns of Mechanical Ventilation for Patients with Exacerbations of COPD

摘要

>Rationale: Randomized trials have shown that noninvasive ventilation (NIV) can reduce the need for intubation and improve the survival of patients with severe exacerbations of chronic obstructive pulmonary disease (COPD); however, it is not known whether hospitals with greater use of NIV achieve lower rates of intubation and better patient outcomes.>Objectives: To describe patterns of mechanical ventilation use for patients with COPD across a large sample of hospitals, and to analyze the relationship between use of NIV and other outcomes.>Methods: Cross-sectional analysis of 77,576 patients hospitalized for COPD between June 2009 and June 2011 at 386 U.S. hospitals.>Measurements and Main Results: Using hierarchical modeling, we estimated hospital risk-standardized percentages of ventilator starts that were noninvasive (RS-NIV%). We examined the association between RS-NIV% and other outcomes, including risk-standardized rates of invasive ventilation and NIV failure, total ventilation, in-hospital mortality, length of stay, and costs. At the hospital level, the median RS-NIV% was 75.1% (range: 9.2–94.1%). Smaller hospitals and those located in rural areas had higher RS-NIV%. When stratified into quartiles on the basis of the RS-NIV%, hospitals in the highest quartile had lower risk-standardized rates of invasive mechanical ventilation (Q4 vs. Q1: 4.0% vs. 13.3%, P < 0.01) and modestly higher risk-standardized total rates of ventilation (Q4 vs. Q1: 23.9% vs. 22.0%, P = 0.03). Hospitals with the highest RS-NIV% had lower risk-standardized mortality among ventilated patients who received ventilation (Q4 vs. Q1: 8.5% vs. 9.0%, P = 0.01) and marginally lower mortality rates among all patients with COPD (Q4 vs. Q1: 2.2% vs. 2.3%, P = 0.03) compared with hospitals with the lowest RS-NIV%. Higher RS-NIV% was associated with lower hospital costs (Q4 vs. Q1: $11,148 vs. $14,032, P < 0.001), shorter length of stay (Q4 vs. Q1: 5.5 vs. 6.8 d, P < 0.001), and lower NIV failure rates (Q4 vs. Q1: 12.8 vs. 32.5%, P < 0.001).>Conclusions: Use of NIV as the initial ventilation strategy for patients with COPD varies considerably across hospitals. Institutions with greater use of NIV have lower rates of invasive mechanical ventilation and better patient outcomes.