Evidence-Based Utilization of Non-Invasive Ventilation and Patient Outcomes.
Ann Am Thorac Soc. 2017 May 25;:
Authors: Mehta AB, Douglas IS, Walkey AJ
RATIONALE: Strong evidence supports use of non-invasive ventilation (NIV) for patients with respiratory distress from chronic obstructive pulmonary disease and heart failure (strong evidence conditions). Despite unclear benefits of NIV for other causes of acute respiratory failure, utilization for conditions with weaker evidence is increasing despite evidence demonstrating higher mortality for patients who suffer NIV failure (progression from NIV to invasive mechanical ventilation (IMV)) compared to being treated initially with IMV.
OBJECTIVE: Determine the association of hospital variation in evidence-based utilization of NIV with patient outcomes.
METHODS: Using the California State Inpatient Database 2011, we identified adult patients who received NIV. Patients were considered to have a strong evidence condition for NIV if they had an acute exacerbation of chronic obstructive pulmonary disease or heart failure. We used multivariable hierarchical logistic regression to determine the association between hospital rates of NIV use for strong evidence conditions and patient risk of NIV failure (need for invasive mechanical ventilation after NIV).
RESULTS: Among 22,706 hospitalizations with NIV as the initial ventilatory strategy, 6,820 (30.0%) had strong evidence conditions. Patients with strong evidence conditions had lower risk of NIV failure than patients with weak evidence conditions (8.1% vs 18.2%, p<0.0001). Regardless of underlying diagnosis, patients admitted to hospitals with greater use of NIV for strong evidence conditions had lower risk of NIV failure (Quartile 4 vs Quartile 1 aOR=0.62, 95% CI 0.49-0.80). Even patients without a strong evidence condition benefited from admission to hospitals that used NIV more often for patients with strong evidence conditions (Quartile 4 vs Quartile 1 aOR for NIV failure = 0.68, 95% CI 0.52-0.88).
CONCLUSIONS: Most patients who received NIV did not have conditions with strong supporting evidence for its use with wide institutional variation in patient selection for NIV. Surprisingly, we found that all patients, even those without a strong evidence condition, benefited from admission to hospitals with greater evidence-based utilization of NIV suggesting a 'hospital effect' that is synergistic with patient selection.
PMID: 28541747 [PubMed - as supplied by publisher]