更高的医院病例量可能会产生当地专业知识(“实践造就完美”),导致更好的患者结果。医院无创通气(NIV)病例量与慢性阻塞性肺疾病(COPD)急性加重患者的预后之间的关系尚不清楚。
本研究旨在确定所有适应症的医院NIV病例总量与COPD急性加重患者NIV失败和住院死亡率之间的关系。
使用2011年加利福尼亚州住院患者数据库和多变量分层逻辑回归,我们计算了COPD急性加重患者的NIV失败(从NIV进展到有创机械通气)和住院死亡率的医院级别风险校正率.
2011年,我们在加利福尼亚州的252家医院中确定了37,516例COPD急性加重住院。所有适应症的医院NIV使用总数为2至565例(中位数,64;四分位数间距,96).COPD急性加重的医院NIV失败率为3.7%至31.3%(中位数,8.5%;四分位数间距,4.2).在医院层面,在COPD急性加重的情况下,较高的总住院NIV病例量与较高的住院NIV失败率弱相关(r=0.13;P=0.03).较高的医院NIV失败率与COPD急性加重的较高的医院死亡率弱相关(r=0.15;P=0.02),但更高的总住院NIV病例量与COPD加重的住院死亡率无关(r=-0.11;P=0.08).在患者层面,高NIV与低NIV病例量医院住院的患者NIV失败的可能性更大(四分位数4与四分位数1调整后的赔率比[aOR],1.95;95%置信区间[CI],1.12-3.40)。与有创机械通气的初始治疗相比,NIV失败与较高的死亡几率相关(aOR,1.81;95%CI,1.35-2.44)。然而,高NIV与低NIV病例量医院的入院率与患者住院死亡率无显著相关(四分位数4与四分位数1aOR,0.76;95%CI,0.57-1.02)。
尽管有强有力的证据表明在COPD急性加重的治疗中使用NIV,我们观察到,在高NIV病例量的医院中,没有显著的死亡率获益和更高的NIV失败率.需要进一步研究与NIV失败相关的患者选择和医院因素,以最大程度地提高与使用NIV治疗COPD急性加重相关的患者预后。
Higher hospital
case volume may produce local expertise (\"practice makes perfect\"), resulting in better patient outcomes. Associations between hospital noninvasive ventilation (NIV)
case volume and outcomes for patients with acute exacerbations of chronic obstructive pulmonary disease (COPD) are unclear.
To determine associations between total hospital NIV
case volume for all indications and NIV failure and hospital mortality among patients with acute exacerbations of COPD.
Using the 2011 California State Inpatient Database and multivariable hierarchical logistic regression, we calculated hospital-level risk-adjusted rates for NIV failure (progression from NIV to invasive mechanical ventilation) and hospital mortality among patients with acute exacerbations of COPD.
We identified 37,516 hospitalizations for acute exacerbations of COPD in 252 California hospitals in 2011. Total hospital NIV use for all indications ranged from 2 to 565 cases (median, 64; interquartile range, 96). Hospital NIV failure rates for acute exacerbations of COPD ranged from 3.7 to 31.3% (median, 8.5%; interquartile range, 4.2). At the hospital level, higher total hospital NIV case volume was weakly associated with higher hospital NIV failure rates for acute exacerbations of COPD (r = 0.13; P = 0.03). Higher hospital NIV failure rates were weakly associated with higher hospital mortality rates for acute exacerbations of COPD (r = 0.15; P = 0.02), but higher total hospital NIV case volume was not associated with hospital mortality for exacerbations of COPD (r = -0.11; P = 0.08). At the patient level, patients admitted to high-NIV versus low-NIV
case-volume hospitals had greater odds of NIV failure (quartile 4 vs. quartile 1 adjusted odds ratio [aOR], 1.95; 95% confidence interval [CI], 1.12-3.40). Compared with initial treatment with invasive mechanical ventilation, NIV failure was associated with higher odds of death (aOR, 1.81; 95% CI, 1.35-2.44). However, admission to high-NIV versus low-NIV
case-volume hospitals was not significantly associated with patient in-hospital mortality (quartile 4 vs. quartile 1 aOR, 0.76; 95% CI, 0.57-1.02).
Despite strong evidence for use of NIV in the management of acute exacerbations of COPD, we observed no significant mortality benefit and higher rates of NIV failure in high-NIV case-volume hospitals. Further investigation of patient selection and hospital factors associated with NIV failure is needed to maximize favorable patient outcomes associated with use of NIV for acute exacerbations of COPD.