Evidence-based Utilization of Noninvasive Ventilation and Patient Outcomes

Abstract

Rationale: Strong evidence supports use of noninvasive ventilation (NIV) for patients with respiratory distress from chronic obstructive pulmonary disease and heart failure (strong evidence conditions [SECs]). 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 with being treated initially with IMV.

Objectives: To 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 an SEC 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 SECs and patient risk of NIV failure (need for IMV after NIV).

Results: Among 22,706 hospitalizations with NIV as the initial ventilatory strategy, 6,820 (30.0%) had SECs. Patients with SECs 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 SECs had lower risk of NIV failure (Quartile 4 vs. Quartile 1 adjusted odds ratio = 0.62; 95% CI = 0.49-0.80). Even patients without an SEC benefited from admission to hospitals that used NIV more often for patients with SECs (Quartile 4 vs. Quartile 1 adjusted odds ratio 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 an SEC, benefited from admission to hospitals with greater evidence-based utilization of NIV, suggesting a "hospital effect" that is synergistic with patient selection.

Keywords: chronic obstructive pulmonary disease; heart failure; invasive mechanical ventilation; noninvasive ventilation.

Figure 1.

Hospital variation in indications for noninvasive ventilation (NIV). The average hospital NIV–strong evidence condition (SEC) rate was 29.6% (x-axis; SD = 10.1), but ranged from 6.1 to 58.9%.

Figure 2.

Association of hospital noninvasive ventilation (NIV) for strong evidence condition (SEC) rate with hospital risk-adjusted NIV failure rates. Hospitals with higher NIV-SEC rates had lower risk-adjusted NIV failure rates (ρ = −0.27, P < 0.0001).

Figure 3.

Association of hospital risk-adjusted noninvasive ventilation (NIV) failure rates with NIV hospital case volume and strong evidence condition (SEC) rate. The data is presented as Whisker plots with the diamonds indicating the mean NIV failure rate. Group 1: low hospital NIV case volume and high hospital NIV-SEC rate (mean NIV failure rate = 13.4% [SD = 4.8%]). Group 2: low hospital NIV case volume and low hospital NIV-SEC rate (mean NIV failure rate = 14.6% [SD = 4.6%]). Group 3: high hospital NIV case volume and high hospital NIV-SEC rate (mean NIV failure rate = 14.0% [SD = 5.4%]). Group 4: high hospital NIV case volume and low hospital NIV-SEC rate (mean NIV failure rate = 17.0% [SD = 5.7%]). P = 0.003 for difference in mean risk-adjusted NIV failure rates across all four groups. *P < 0.05 in pairwise comparison of mean hospital NIV failure rates.