Center for Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA.
Department 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.
Int J Chron Obstruct Pulmon Dis. 2021 Nov 17;16:3157-3166. doi: 10.2147/COPD.S321053. eCollection 2021.
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.
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.
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 (=0.047), but hospital mortality did not differ between the two groups.
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.
因 COPD 加重（AECOPD）导致急性呼吸衰竭而入院的患者，其接受无创机械通气（NIV）治疗的情况在各医院间存在显著差异。然而，既往文献并未考虑到患者的疾病严重程度。我们的目的是在调整疾病严重程度后，考察 NIV 使用的风险标准化差异。
我们回顾性分析了 2011 年至 2017 年期间美国 106 家退伍军人事务部（VA）急性护理医院收治的 AECOPD 住院患者。我们根据患者入院后 24 小时内接受通气支持的患者中接受 NIV 治疗的比例，将医院分为四组，比较患者特征。我们使用分层模型计算了风险标准化的 NIV%，并调整了合并症和疾病严重程度。然后，我们根据风险标准化的 NIV%将医院分为四组，并比较了各组间的医院特征。我们还比较了农村和城市医院间的风险标准化的 NIV%。
在 6 年间的 42048 例 AECOPD 住院患者中，中位风险标准化初始 NIV%为 57.3%（四分位距[IQR]=41.9-64.4%）。风险标准化 NIV%最高的四分位组的医院收治了更多的农村患者，较少使用有创呼吸机，住院时间更长，但与最低四分位组的医院相比，死亡率没有差异。农村医院的风险标准化 NIV%为 65.3%（IQR=34.2-84.2%），城市医院为 55.1%（IQR=10.8-86.6%）（P=0.047），但两组医院的死亡率没有差异。
NIV 使用在各医院间存在显著差异，农村医院的风险标准化 NIV%高于城市医院。进一步的研究应调查农村和城市医院间 NIV 使用差异的具体机制。
