Health & Medical intensive care

Influence of Case-Volume on Acute COPD Exacerbation Outcomes

Influence of Case-Volume on Acute COPD Exacerbation Outcomes

Abstract and Introduction

Abstract


Objectives: To study the relationship between case-volume and the use of noninvasive ventilation during acute exacerbations of chronic obstructive pulmonary disease in ICUs.
Design: A 13-year multicenter retrospective cohort study of prospectively collected data.
Setting: Medical ICUs.
Patients: From 1998 to 2010, patients with acute exacerbations of chronic obstructive pulmonary disease were identified through a regional database.
Interventions: The characteristics of hospitalization (including the type of mechanical ventilation) and demographic data of the patients were analyzed. ICUs were categorized into tertiles of the running mean annual volume of admissions. A logistic model performed a conditional multivariate analysis of prognostic factors after matching on a propensity score of being admitted to a high-volume unit and on the year of admission.
Measurements and Main Results: Fourteen thousand four hundred forty acute exacerbations of chronic obstructive pulmonary disease were identified. The Simplified Acute Physiology Score II and ICU mortality increased during the study period (36 to 41 and 12% to 14%, respectively). The proportion of patients receiving any mechanical ventilation support also increased during the study period (from 64% to 86%), with a marked increase in the use of noninvasive ventilation (from 18% to 49%) and a decrease in the use of invasive ventilation (from 34% to 19%). Participating units were distributed into low-volume (< 25 patients per year), medium-volume (26–47 patients per year), and high-volume (> 47 patients per year) tertiles. There was a significant association between case-volume and 1) the proportion of patients receiving noninvasive ventilation (highest vs lowest case-volume tertiles: odds ratio, 1.43 [95% CI, 1.23–1.66]) and 2) lower mortality.
Conclusions: Between 1998 and 2010, severity and mortality of acute exacerbations of chronic obstructive pulmonary disease admitted to Collège des Utilisateurs de Données en Réanimation ICUs increased. There was an increasing use of noninvasive ventilation and a decreasing use of invasive ventilation. Use of noninvasive ventilation was related to case-volume, suggesting that increasing experience favors the use of noninvasive ventilation and was associated with a strong trend toward decreased mortality.

Introduction


Chronic obstructive pulmonary disease (COPD), which is expected to become the third most common cause of death worldwide by 2020, is a slowly progressive lung disease resulting in a gradual loss of lung function. Acute exacerbations of COPD (AECOPD) are important causes of unscheduled physician visits and hospital admissions, especially to ICUs. Studies have reported highly variable in-hospital AECOPD mortality rates of 7% to 82%. The variations are mostly related to initial severity, age, comorbidities, and the context of care. The management of AECOPD in ICUs has changed considerably in the last 15 years, with increasing use of noninvasive ventilation (NIV). For this indication, NIV provides large benefits in terms of mortality, mostly by reducing the use of invasive ventilation (InV) with its associated complications. As a result, indications for InV are now restricted to a limited number of situations, including failure of NIV and multiple organ failure. However, despite its growing use, failure of NIV initiated as first-line ventilatory support is independently associated with a longer duration of mechanical ventilation (MV) and ICU stay. Even though the corresponding patients are probably more ill, this also suggests that NIV management needs experienced teams with appropriate skills and sufficient manpower.

Recently, many studies have focused on the relationship between case-volume and outcomes in various domains, including acute respiratory failure (ARF). Currently, funding authorities and consumer groups are increasingly concerned about the relationship between such markers and performance in terms of quality of care, patient safety, and efficiency. In the field of intensive care, some studies have shown better outcomes for various medical procedures in high-volume centers. However, no data are available on the relationship between case-volume, outcomes, and management in patients specifically admitted to the ICU for an AECOPD with ARF. As the use of NIV and InV requires a complex, well organized, and technically sophisticated level of care, outcomes could be related to case-volume in these patients. The main purpose of this study was to examine the relationship between ICU case-volume, NIV use, and survival, in critically ill patients with AECOPD. A secondary objective was to assess trends in patients' characteristics, outcomes, and management between 1998 and 2010.

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