Hospital Variation in Non-Invasive Ventilation Use for Acute Respiratory Failure Due to COPD Exacerbation

Spyridon Fortis,1,2 Yubo Gao,1,3 Amy M J O’Shea,1,3 Brice Beck,1 Peter Kaboli,1,3 Mary Vaughan Sarrazin1,3 1Center for Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; 2Department of Internal Medicine, Division of Pulmonary, Critical Care and Occupation Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA; 3Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USACorrespondence: Spyridon FortisDepartment of Internal Medicine, Division of Pulmonary, Critical Care and Occupation Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, University of Iowa Hospitals and Clinics, 200 Hawkins Drive – C33 GH, Iowa City, IA, 52242, USAEmail spyridon-fortis@uiowa.eduBackground: Non-invasive mechanical ventilation (NIV) use in patients admitted with acute respiratory failure due to COPD exacerbations (AECOPDs) varies significantly between hospitals. However, previous literature did not account for patients’ illness severity. Our objective was to examine the variation in risk-standardized NIV use after adjusting for illness severity.Methods: We retrospectively analyzed AECOPD hospitalizations from 2011 to 2017 at 106 acute-care Veterans Health Administration (VA) hospitals in the USA. We stratified hospitals based on the percentage of NIV use among patients who received ventilation support within the first 24 hours of admission into quartiles, and compared patient characteristics. We calculated the risk-standardized NIV % using hierarchical models adjusting for comorbidities and severity of illness. We then stratified the hospitals by risk-standardized NIV % into quartiles and compared hospital characteristics between quartiles. We also compared the risk-standardized NIV % between rural and urban hospitals.Results: In 42,048 admissions for AECOPD over 6 years, the median risk-standardized initial NIV % was 57.3% (interquartile interval [IQI]=41.9– 64.4%). Hospitals in the highest risk-standardized NIV % quartiles cared for more rural patients, used invasive ventilators less frequently, and had longer length of hospital stay, but had no difference in mortality relative to the hospitals in the lowest quartiles. The risk-standardized NIV % was 65.3% (IQI=34.2– 84.2%) in rural and 55.1% (IQI=10.8– 86.6%) in urban hospitals (p=0.047), but hospital mortality did not differ between the two groups.Conclusion: NIV use varied significantly across hospitals, with rural hospitals having higher risk-standardized NIV % rates than urban hospitals. Further research should investigate the exact mechanism of variation in NIV use between rural and urban hospitals.Keywords: pulmonary disease, chronic obstructive, epidemiology, non-invasive ventilation