title: Hospitals' Patterns of Use of Noninvasive Ventilation in Patients With Asthma Exacerbation.
abstract: BACKGROUND
  Limited data are available on the use of noninvasive ventilation in patients with asthma exacerbations. The objective of this study was to characterize hospital patterns of noninvasive ventilation use in patients with asthma and to evaluate the association with the use of invasive mechanical ventilation and case fatality rate.
  
  
  METHODS
  This cross-sectional study used an electronic medical record dataset, which includes comprehensive pharmacy and laboratory results from 58 hospitals. Data on 13,558 patients admitted from 2009 to 2012 were analyzed. Initial noninvasive ventilation (NIV) or invasive mechanical ventilation (IMV) was defined as the first ventilation method during hospitalization. Hospital-level risk-standardized rates of NIV among all admissions with asthma were calculated by using a hierarchical regression model. Hospitals were grouped into quartiles of NIV to compare the outcomes.
  
  
  RESULTS
  Overall, 90.3% of patients with asthma were not ventilated, 4.0% were ventilated with NIV, and 5.7% were ventilated with IMV. Twenty-two (38%) hospitals did not use NIV for any included admissions. Hospital-level adjusted NIV rates varied considerably (range, 0.4-33.1; median, 5.2%). Hospitals in the highest quartile of NIV did not have lower IMV use (5.4% vs 5.7%), but they did have a small but significantly shorter length of stay. Higher NIV rates were not associated with lower risk-adjusted case fatality rates.
  
  
  CONCLUSIONS
  Large variation exists in hospital use of NIV for patients with an acute exacerbation of asthma. Higher hospital rates of NIV use does not seem to be associated with lower IMV rates. These results indicate a need to understand contextual and organizational factors contributing to this variability.
authors.affiliation: Center for Quality of Care Research, Baystate Medical Center, Springfield, MA; Division of Hospital Medicine, Baystate Medical Center, Springfield, MA; Department of Medicine, Tufts University School of Medicine, Boston, MA. Electronic address: mihaela.stefan@baystatehealth.org.
authors.forename: Mihaela S
authors.initials: MS
authors.lastname: Stefan
authors.affiliation: OptiStatim LLC, Longmeadow, MA.
authors.forename: Brian H
authors.initials: BH
authors.lastname: Nathanson
authors.affiliation: Center for Quality of Care Research, Baystate Medical Center, Springfield, MA.
authors.forename: Aruna
authors.initials: A
authors.lastname: Priya
authors.affiliation: Center for Quality of Care Research, Baystate Medical Center, Springfield, MA; School of Public Health & Health Sciences, University of Massachusetts Amherst, Amherst, MA.
authors.forename: Penelope S
authors.initials: PS
authors.lastname: Pekow
authors.affiliation: Center for Quality of Care Research, Baystate Medical Center, Springfield, MA; Division of Hospital Medicine, Baystate Medical Center, Springfield, MA; Department of Medicine, Tufts University School of Medicine, Boston, MA.
authors.forename: Tara
authors.initials: T
authors.lastname: Lagu
authors.affiliation: Division of Pulmonary and Critical Care, Baystate Medical Center, Springfield, MA.
authors.forename: Jay S
authors.initials: JS
authors.lastname: Steingrub
authors.affiliation: Division of Pulmonary and Critical Care Medicine, Tufts University School of Medicine, Boston, MA.
authors.forename: Nicholas S
authors.initials: NS
authors.lastname: Hill
authors.affiliation: Department of Quantitative Health Sciences, UMass Medical School, Worcester, MA.
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Goldberg
authors.affiliation: Institute for Clinical Research and Health Policy Studies, Tufts University School of Medicine, Boston, MA.
authors.forename: David M
authors.initials: DM
authors.lastname: Kent
authors.affiliation: Center for Quality of Care Research, Baystate Medical Center, Springfield, MA; Division of Hospital Medicine, Baystate Medical Center, Springfield, MA; Department of Medicine, Tufts University School of Medicine, Boston, MA.
authors.forename: Peter K
authors.initials: PK
authors.lastname: Lindenauer
mesh_terms: D001249:Asthma / Q000453:epidemiology / Q000628:therapy*; D001993:Bronchodilator Agents / Q000627:therapeutic use; D015897:Comorbidity; D003430:Cross-Sectional Studies; D016208:Databases, Factual; D018450:Disease Progression; D057286:Electronic Health Records; D005260:Female; D005938:Glucocorticoids / Q000627:therapeutic use; D006276:Health Facility Size / Q000706:statistics & numerical data*; D006760:Hospitalization; D006780:Hospitals, Rural / Q000706:statistics & numerical data*; D006784:Hospitals, Teaching / Q000706:statistics & numerical data*; D006786:Hospitals, Urban / Q000706:statistics & numerical data*; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D063087:Noninvasive Ventilation / Q000379:methods*; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D012121:Respiration, Artificial / Q000379:methods; D014481:United States
chemical_list: D001993:Bronchodilator Agents; D005938:Glucocorticoids
keywords: CPAP; asthma; mechanical ventilation; noninvasive ventilation
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