title: Hospital patterns of mechanical ventilation for patients with exacerbations of COPD.
abstract: BACKGROUND
  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.
  
  
  OBJECTIVE
  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.
  
  
  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.
authors: 1 Center for Quality of Care Research and.
authors: Peter K
authors: PK
authors: Lindenauer
authors: Mihaela S
authors: MS
authors: Stefan
authors: Meng-Shiou
authors: MS
authors: Shieh
authors: Penelope S
authors: PS
authors: Pekow
authors: Michael B
authors: MB
authors: Rothberg
authors: Nicholas S
authors: NS
authors: Hill
mesh_terms: D000368:Aged; D003430:Cross-Sectional Studies; D005260:Female; D005500:Follow-Up Studies; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D007902:Length of Stay / Q000639:trends; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D029424:Pulmonary Disease, Chronic Obstructive / Q000401:mortality / Q000628:therapy*; D012121:Respiration, Artificial; D012189:Retrospective Studies; D018570:Risk Assessment; D014481:United States / Q000453:epidemiology
keywords: COPD; costs and cost analysis; cross-sectional analysis; length of stay; outcomes research
references: Lancet. 1993 Jun 19;341(8860):1555-7
references: 8099639
references: Arch Intern Med. 2003 May 26;163(10):1180-6
references: 12767954
references: N Engl J Med. 1995 Sep 28;333(13):817-22
references: 7651472
references: Chest. 2006 May;129(5):1226-33
references: 16685013
references: Ann Intern Med. 2006 Jun 20;144(12):894-903
references: 16785478
references: Chest. 2008 Mar;133(3):756-66
references: 18321904
references: N Engl J Med. 2009 Apr 2;360(14):1418-28
references: 19339721
references: Ann Intern Med. 2009 May 19;150(10):696-704
references: 19451576
references: JAMA. 2010 May 26;303(20):2035-42
references: 20501925
references: J Clin Epidemiol. 2011 Jul;64(7):749-59
references: 21208778
references: Chest. 2012 Jan;141(1):87-93
references: 21757568
references: Am J Respir Crit Care Med. 2012 Jan 15;185(2):152-9
references: 22016446
references: J Hosp Med. 2013 Feb;8(2):76-82
references: 23335231
references: Ann Am Thorac Soc. 2013 Feb;10(1):10-7
references: 23509327
references: J Hosp Med. 2013 Apr;8(4):165-72
references: 23401469
references: Med Care. 2013 Jul;51(7):597-605
references: 23604015
references: J Hosp Med. 2013 Aug;8(8):428-35
references: 23913593
references: Lancet. 2000 Jun 3;355(9219):1931-5
references: 10859037
references: Intensive Care Med. 2001 Nov;27(11):1718-28
references: 11810114
references: BMJ. 2003 Jan 25;326(7382):185
references: 12543832
references: Am J Respir Crit Care Med. 1995 Jun;151(6):1799-806
references: 7767523