title: Hospital variation in noninvasive positive pressure ventilation for acute decompensated heart failure.
abstract: BACKGROUND
  Although noninvasive positive pressure ventilation (NIPPV) for patients with acute decompensated heart failure was introduced almost 20 years ago, the variation in its use among hospitals remains unknown. We sought to define hospital practice patterns of NIPPV use for acute decompensated heart failure and their relationship with intubation and mortality.
  
  
  RESULTS
  We conducted a cross-sectional study using a database maintained by Premier, Inc., that includes a date-stamped log of all billed items for hospitalizations at >400 hospitals. We examined hospitalizations for acute decompensated heart failure in this database from 2005 to 2010 and included hospitals with annual average volume of >25 such hospitalizations. We identified 384 hospitals that encompassed 524 430 hospitalizations (median annual average volume: 206). We used hierarchical logistic regression models to calculate hospital-level outcomes: risk-standardized NIPPV rate, risk-standardized intubation rate, and in-hospital risk-standardized mortality rate. We grouped hospitals into quartiles by risk-standardized NIPPV rate and compared risk-standardized mortality rates and risk-standardized intubation rates across quartiles. Median risk-standardized NIPPV rate was 6.2% (interquartile range, 2.8%-9.3%; 5th percentile, 0.2%; 95th percentile, 14.8%). There was no clear pattern of risk-standardized mortality rates across quartiles. The bottom quartile of hospitals had higher risk-standardized intubation rate (11.4%) than each of the other quartiles (9.0%, 9.7%, and 9.1%; P<0.02 for all comparisons).
  
  
  CONCLUSIONS
  Substantial variation exists among hospitals in the use of NIPPV for acute decompensated heart failure without evidence for differences in mortality. There may be a threshold effect in relation to intubation rates, with the lowest users of NIPPV having higher intubation rates.
authors.affiliation: From the Yale University School of Medicine, New Haven, CT (V.T.K.); Sections of General Medicine (N.K.) and Cardiovascular Medicine (B.B., J.T., D.L.D., H.M.K.), Department of Internal Medicine, Yale University School of Medicine, New Haven, CT; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, CT (Y.D., K.D., B.B., H.M.K.); Robert Wood Johnson Clinical Scholars Program, and Department of Health Policy and Administration, Yale School of Public Health, New Haven, CT (H.M.K.); Division of Cardiology, Columbia University Medical Center, New York, NY (K.D.); Center for Quality of Care Research and Division of General Internal Medicine, Baystate Medical Center, Springfield, MA (P.K.L.); Department of Medicine, Tufts University School of Medicine, Boston, MA (P.K.L.); and Department of Medicine, Brigham and Women's Hospital, Boston, MA (K.C.S.).
authors.forename: Vivek T
authors.initials: VT
authors.lastname: Kulkarni
authors.affiliation: From the Yale University School of Medicine, New Haven, CT (V.T.K.); Sections of General Medicine (N.K.) and Cardiovascular Medicine (B.B., J.T., D.L.D., H.M.K.), Department of Internal Medicine, Yale University School of Medicine, New Haven, CT; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, CT (Y.D., K.D., B.B., H.M.K.); Robert Wood Johnson Clinical Scholars Program, and Department of Health Policy and Administration, Yale School of Public Health, New Haven, CT (H.M.K.); Division of Cardiology, Columbia University Medical Center, New York, NY (K.D.); Center for Quality of Care Research and Division of General Internal Medicine, Baystate Medical Center, Springfield, MA (P.K.L.); Department of Medicine, Tufts University School of Medicine, Boston, MA (P.K.L.); and Department of Medicine, Brigham and Women's Hospital, Boston, MA (K.C.S.).
authors.forename: Nancy
authors.initials: N
authors.lastname: Kim
authors.affiliation: From the Yale University School of Medicine, New Haven, CT (V.T.K.); Sections of General Medicine (N.K.) and Cardiovascular Medicine (B.B., J.T., D.L.D., H.M.K.), Department of Internal Medicine, Yale University School of Medicine, New Haven, CT; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, CT (Y.D., K.D., B.B., H.M.K.); Robert Wood Johnson Clinical Scholars Program, and Department of Health Policy and Administration, Yale School of Public Health, New Haven, CT (H.M.K.); Division of Cardiology, Columbia University Medical Center, New York, NY (K.D.); Center for Quality of Care Research and Division of General Internal Medicine, Baystate Medical Center, Springfield, MA (P.K.L.); Department of Medicine, Tufts University School of Medicine, Boston, MA (P.K.L.); and Department of Medicine, Brigham and Women's Hospital, Boston, MA (K.C.S.).
authors.forename: Ying
authors.initials: Y
authors.lastname: Dai
authors.affiliation: From the Yale University School of Medicine, New Haven, CT (V.T.K.); Sections of General Medicine (N.K.) and Cardiovascular Medicine (B.B., J.T., D.L.D., H.M.K.), Department of Internal Medicine, Yale University School of Medicine, New Haven, CT; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, CT (Y.D., K.D., B.B., H.M.K.); Robert Wood Johnson Clinical Scholars Program, and Department of Health Policy and Administration, Yale School of Public Health, New Haven, CT (H.M.K.); Division of Cardiology, Columbia University Medical Center, New York, NY (K.D.); Center for Quality of Care Research and Division of General Internal Medicine, Baystate Medical Center, Springfield, MA (P.K.L.); Department of Medicine, Tufts University School of Medicine, Boston, MA (P.K.L.); and Department of Medicine, Brigham and Women's Hospital, Boston, MA (K.C.S.).
authors.forename: Kumar
authors.initials: K
authors.lastname: Dharmarajan
authors.affiliation: From the Yale University School of Medicine, New Haven, CT (V.T.K.); Sections of General Medicine (N.K.) and Cardiovascular Medicine (B.B., J.T., D.L.D., H.M.K.), Department of Internal Medicine, Yale University School of Medicine, New Haven, CT; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, CT (Y.D., K.D., B.B., H.M.K.); Robert Wood Johnson Clinical Scholars Program, and Department of Health Policy and Administration, Yale School of Public Health, New Haven, CT (H.M.K.); Division of Cardiology, Columbia University Medical Center, New York, NY (K.D.); Center for Quality of Care Research and Division of General Internal Medicine, Baystate Medical Center, Springfield, MA (P.K.L.); Department of Medicine, Tufts University School of Medicine, Boston, MA (P.K.L.); and Department of Medicine, Brigham and Women's Hospital, Boston, MA (K.C.S.).
authors.forename: Kyan C
authors.initials: KC
authors.lastname: Safavi
authors.affiliation: From the Yale University School of Medicine, New Haven, CT (V.T.K.); Sections of General Medicine (N.K.) and Cardiovascular Medicine (B.B., J.T., D.L.D., H.M.K.), Department of Internal Medicine, Yale University School of Medicine, New Haven, CT; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, CT (Y.D., K.D., B.B., H.M.K.); Robert Wood Johnson Clinical Scholars Program, and Department of Health Policy and Administration, Yale School of Public Health, New Haven, CT (H.M.K.); Division of Cardiology, Columbia University Medical Center, New York, NY (K.D.); Center for Quality of Care Research and Division of General Internal Medicine, Baystate Medical Center, Springfield, MA (P.K.L.); Department of Medicine, Tufts University School of Medicine, Boston, MA (P.K.L.); and Department of Medicine, Brigham and Women's Hospital, Boston, MA (K.C.S.).
authors.forename: Behnood
authors.initials: B
authors.lastname: Bikdeli
authors.affiliation: From the Yale University School of Medicine, New Haven, CT (V.T.K.); Sections of General Medicine (N.K.) and Cardiovascular Medicine (B.B., J.T., D.L.D., H.M.K.), Department of Internal Medicine, Yale University School of Medicine, New Haven, CT; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, CT (Y.D., K.D., B.B., H.M.K.); Robert Wood Johnson Clinical Scholars Program, and Department of Health Policy and Administration, Yale School of Public Health, New Haven, CT (H.M.K.); Division of Cardiology, Columbia University Medical Center, New York, NY (K.D.); Center for Quality of Care Research and Division of General Internal Medicine, Baystate Medical Center, Springfield, MA (P.K.L.); Department of Medicine, Tufts University School of Medicine, Boston, MA (P.K.L.); and Department of Medicine, Brigham and Women's Hospital, Boston, MA (K.C.S.).
authors.forename: Peter K
authors.initials: PK
authors.lastname: Lindenauer
authors.affiliation: From the Yale University School of Medicine, New Haven, CT (V.T.K.); Sections of General Medicine (N.K.) and Cardiovascular Medicine (B.B., J.T., D.L.D., H.M.K.), Department of Internal Medicine, Yale University School of Medicine, New Haven, CT; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, CT (Y.D., K.D., B.B., H.M.K.); Robert Wood Johnson Clinical Scholars Program, and Department of Health Policy and Administration, Yale School of Public Health, New Haven, CT (H.M.K.); Division of Cardiology, Columbia University Medical Center, New York, NY (K.D.); Center for Quality of Care Research and Division of General Internal Medicine, Baystate Medical Center, Springfield, MA (P.K.L.); Department of Medicine, Tufts University School of Medicine, Boston, MA (P.K.L.); and Department of Medicine, Brigham and Women's Hospital, Boston, MA (K.C.S.).
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Testani
authors.affiliation: From the Yale University School of Medicine, New Haven, CT (V.T.K.); Sections of General Medicine (N.K.) and Cardiovascular Medicine (B.B., J.T., D.L.D., H.M.K.), Department of Internal Medicine, Yale University School of Medicine, New Haven, CT; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, CT (Y.D., K.D., B.B., H.M.K.); Robert Wood Johnson Clinical Scholars Program, and Department of Health Policy and Administration, Yale School of Public Health, New Haven, CT (H.M.K.); Division of Cardiology, Columbia University Medical Center, New York, NY (K.D.); Center for Quality of Care Research and Division of General Internal Medicine, Baystate Medical Center, Springfield, MA (P.K.L.); Department of Medicine, Tufts University School of Medicine, Boston, MA (P.K.L.); and Department of Medicine, Brigham and Women's Hospital, Boston, MA (K.C.S.).
authors.forename: Daniel L
authors.initials: DL
authors.lastname: Dries
authors.affiliation: From the Yale University School of Medicine, New Haven, CT (V.T.K.); Sections of General Medicine (N.K.) and Cardiovascular Medicine (B.B., J.T., D.L.D., H.M.K.), Department of Internal Medicine, Yale University School of Medicine, New Haven, CT; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, CT (Y.D., K.D., B.B., H.M.K.); Robert Wood Johnson Clinical Scholars Program, and Department of Health Policy and Administration, Yale School of Public Health, New Haven, CT (H.M.K.); Division of Cardiology, Columbia University Medical Center, New York, NY (K.D.); Center for Quality of Care Research and Division of General Internal Medicine, Baystate Medical Center, Springfield, MA (P.K.L.); Department of Medicine, Tufts University School of Medicine, Boston, MA (P.K.L.); and Department of Medicine, Brigham and Women's Hospital, Boston, MA (K.C.S.). harlan.krumholz@yale.edu.
authors.forename: Harlan M
authors.initials: HM
authors.lastname: Krumholz
mesh_terms: D000208:Acute Disease; D016507:Cardiology Service, Hospital / Q000706:statistics & numerical data*; D003430:Cross-Sectional Studies; D006333:Heart Failure / Q000401:mortality / Q000628:therapy*; D017052:Hospital Mortality; D006801:Humans; D007442:Intubation, Intratracheal / Q000706:statistics & numerical data; D063087:Noninvasive Ventilation / Q000706:statistics & numerical data*; D011175:Positive-Pressure Respiration / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D015996:Survival Rate
keywords: heart failure; mortality; ventilation