Elsevier

Journal of Critical Care

Volume 30, Issue 6, December 2015, Pages 1217-1221
Journal of Critical Care

Mechanical Ventilation
Epidemiological trends in invasive mechanical ventilation in the United States: A population-based study,☆☆

https://doi.org/10.1016/j.jcrc.2015.07.007Get rights and content

Abstract

Purpose

Epidemiological trends for invasive mechanical ventilation (IMV) have not been clearly defined. We sought to define trends for IMV in the United States and assess for disease-specific variation for 3 common causes of respiratory failure: pneumonia, heart failure (HF), and chronic obstructive pulmonary disease (COPD).

Methods

We calculated national estimates for utilization of nonsurgical IMV cases from the Nationwide Inpatient Sample from 1993 to 2009 and compared trends for COPD, HF, and pneumonia.

Results

We identified 8 309 344 cases of IMV from 1993 to 2009. Utilization of IMV for nonsurgical indications increased from 178.9 per 100 000 in 1993 to 310.9 per 100 000 US adults in 2009. Pneumonia cases requiring IMV showed the largest increase (103.6%), whereas COPD cases remained relatively stable (2.5% increase) and HF cases decreased by 55.4%. Similar demographic and clinical changes were observed for pneumonia, COPD, and HF, with cases of IMV becoming younger, more ethnically diverse, and more frequently insured by Medicaid. Outcome trends for patients differed based on diagnosis. Adjusted hospital mortality decreased over time for cases of pneumonia (odds ratio [OR] per 5 years, 0.89; 95% confidence interval [CI], 0.88-0.90) and COPD (OR per 5 years, 0.97; 95% CI, 0.97-0.98) but increased for HF (OR per 5 years, 1.10; 95% CI, 1.09-1.12).

Conclusion

Utilization of IMV in the US increased from 1993 to 2009 with a decrease in overall mortality. However, trends in utilization and outcomes of IMV differed markedly based on diagnosis. Unlike favorable outcome trends in pneumonia and COPD, hospital mortality for HF has not improved. Further studies to investigate the outcome gap between HF and other causes of respiratory failure are needed.

Introduction

Respiratory support with invasive mechanical ventilation (IMV) remains a cornerstone of critical care medicine. Although frequently a lifesaving intervention, nonsurgical patients requiring IMV have hospital mortality exceeding 35% [1], [2], [3], [4], [5]. In addition, survivors of IMV may experience significant long-term morbidity with substantially reduced functional status and ability to complete activities of daily living [6], [7]. Patients requiring IMV represent 2.8% of hospital admissions but contribute to 12% of hospital costs at $27 billion per year [8].

Despite high mortality, morbidity, and costs, trends in utilization and outcomes of IMV in the United States are unclear. Point prevalence studies have suggested that hospital mortality for IMV is improving internationally [1], [2], [9]. Prior studies have analyzed trends in specific subsets of the IMV population and shown decreasing mortality among patients with acute respiratory failure (ARF) of any etiology [10], acute respiratory distress syndrome [11], and chronic obstructive pulmonary disease (COPD) [10], [12], [13], [14]. However, studies investigating longitudinal trends in IMV in the United States and outcomes for other common causes of respiratory failure, such as pneumonia and heart failure (HF), are lacking.

Given the mortality and costs associated with IMV, understanding changing trends may better inform quality improvement measures and resource allocation. For example, identifying divergent trends in disease-specific outcomes would warrant further study into practice pattern variations across diagnoses. As such, we sought to investigate population-based trends for all nonsurgical patients receiving IMV as well as trends in outcomes for COPD, HF, and pneumonia, the 3 most common causes of ARF [10], using a representative, population-based sample of hospitalizations in the United States.

Section snippets

Study population and outcomes

Our data source was the US Agency for Healthcare and Research Quality's Healthcare Cost and Utilization Project's Nationwide Inpatient Sample (NIS). The NIS is a 20% stratified probability sample of all nonfederal US acute care hospitalization that contains deidentified clinical and resource utilization data extrapolated from records for 5 to 8 million hospital discharges per year [15]. In 1993, the NIS contained data from 17 states, increasing to 44 states by 2009.

We identified adult patients

Trends in IMV utilization

We identified 8 309 344 survey-weighted (1 675 914 unweighted) nonsurgical patients who received IMV from 1993 to 2009. Utilization of IMV increased from 178.8 cases per 100 000 US adults (341 164 cases) in 1993 to 310.9 per 100 000 (723 310 cases) in 2009 (AAPC, 3.5%; P < .0001). During the study period, COPD, HF, and pneumonia accounted for 33.5% of all nonsurgical IMV cases. Use of IMV for pneumonia showed the greatest growth between 1993 and 2009, doubling from 30.5 to 62.1 cases per 100 000 US

Discussion

We investigated trends in incidence and outcomes for nonsurgical patients receiving IMV in the United States from 1993 to 2009. Our study demonstrates a large increase in the incidence of IMV for hospitalized adults. Epidemiological trends in IMV differed substantially based upon the etiology of respiratory failure. Use of IMV for patients with pneumonia appeared to drive the increase in IMV utilization, whereas use of IMV for COPD remained relatively stable and use of IMV for patients with HF

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    No authors listed have any financial, professional, or personal conflicts of interest.

    ☆☆

    Supported in part by National Institutes of HealthT32 86308 (ABM) and National Institutes of Health's National Heart, Lung, and Blood InstituteK01HL116768 (AJW).

    1

    Primary study design, statistical analysis, and principal writer.

    2

    Database design.

    3

    Database design and revising/editing final drafts of manuscript for intellectual content.

    4

    Study design, statistical analysis, revising/editing all drafts of manuscript, and study supervision.

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