Hospital Variation in Non-Invasive Ventilation Use for Acute Respiratory Failure Due to COPD Exacerbation

Influenza-Associated Outcomes and Healthcare Utilization by Race and Ethnicity in the USA: a Retrospective Cohort Study Using the National Inpatient Sample Database

BACKGROUND

The influenza virus continues to be a public health concern every season. We aimed to evaluate influenza-associated outcomes and healthcare utilization by race and ethnicity.

METHODS

We conducted a retrospective cohort study using the National Inpatient Sample across 2019 and 2020. Influenza pneumonia was selected as the principal diagnosis. Outcomes included mortality, use of respiratory support ventilation, length of stay, and total hospitalization charge. Regression models were adjusted for age, gender, Charlson Comorbidity Index, hospitals' region, bed size, teaching status, insurance status, and median income.

RESULTS

We identified 73,098 individuals hospitalized with influenza pneumonia; 39,807 and 33,291 were admitted in 2019 and 2020, respectively. The sample included 49,829 (68%) White, 11,356 (15.5%) Black, 7526 (10%) Hispanic, 1860 (2.5%) Asian/Pacific, and 617 (0.84%) Native American patients. In-hospital mortality rates and respiratory support (non-invasive ventilation and invasive mechanical ventilation) in 2019 and 2020 were not significantly different across all the races. In 2019 and 2020, the adjusted odds ratios of in-patient mortality were not significantly different. Asians had higher odds of receiving NIV in 2019 but not in 2020 compared to White patients (adjusted odds ratio (aOR) 1.67, p value 0.04). The adjusted odds ratios for receiving IMV were not significantly different between the races in 2019 and 2020.

CONCLUSIONS

This study contributes valuable insight into influenza-associated outcomes and healthcare utilization patterns among diverse racial and ethnic groups. Disparities in healthcare utilization were observed among younger (< 65 years) individuals of Black and Hispanic ethnicity.

Association of rural living with COPD-related hospitalizations and deaths in US veterans

It is unclear whether the high burden of COPD in rural areas is related to worse outcomes in patients with COPD or is because the prevalence of COPD is higher in rural areas. We assessed the association of rural living with acute exacerbations of COPD (AECOPDs)-related hospitalization and mortality. We retrospectively analyzed Veterans Affairs (VA) and Medicare data of a nationwide cohort of veterans with COPD aged ≥ 65 years with COPD diagnosis between 2011 and 2014 that had follow-up data until 2017. Patients were categorized based on residential location into urban, rural, and isolated rural. We used generalized linear and Cox proportional hazards models to assess the association of residential location with AECOPD-related hospitalizations and long-term mortality. Of 152,065 patients, 80,162 (52.7%) experienced at least one AECOPD-related hospitalization. After adjusting for demographics and comorbidities, rural living was associated with fewer hospitalizations (relative risk-RR = 0.90; 95% CI: 0.89-0.91; P < 0.001) but isolated rural living was not associated with hospitalizations. Only after accounting for travel time to the closest VA medical center, neighborhood disadvantage, and air quality, isolated rural living was associated with more AECOPD-related hospitalizations (RR = 1.07; 95% CI: 1.05-1.09; P < 0.001). Mortality did not vary between rural and urban living patients. Our findings suggest that other aspects than hospital care may be responsible for the excess of hospitalizations in isolated rural patients like poor access to appropriate outpatient care.

Noninvasive positive pressure in acute exacerbations of chronic obstructive pulmonary disease

PURPOSE OF REVIEW

Noninvasive positive pressure ventilation (NIV) is standard of care for patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD). We review the most current evidence and highlight areas of uncertainty and ongoing research. We highlight key concepts for the clinician caring for patients with AECOPD which require NIV.

RECENT FINDINGS

Implementation of NIV in AECOPD is not uniform in spite of the evidence and guidelines. Initiation of NIV should be done early and following protocols. Low-intensity NIV remains the standard of care, although research and guidelines are evaluating higher intensity NIV. Scores to predict NIV failure continue to be refined to allow early identification and interventions. Several areas of uncertainty remain, among them are interventions to improve tolerance, length of support and titration and nutritional support during NIV.

SUMMARY

The use of NIV in AECOPD is the standard of care as it has demonstrated benefits in several patient-centered outcomes. Current developments and research is related to the implementation and adjustment of NIV.

The Association of Renin-Angiotensin System Blockades and Mortality in Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease and Acute Respiratory Failure: A Retrospective Cohort Study

Background

Acute respiratory failure (ARF) is a common cause of admission to the intensive care unit (ICU) for patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). There is still a lack of effective interventions and treatments. ACE inhibitors (ACEI)/ angiotensin II receptor blockers (ARB) were effective in COPD patients. We aimed to study the effect of ACEI/ARB use on AECOPD combined with ARF and evaluate the effect of in-hospital continuation of medication.

Methods

We included patients with AECOPD and ARF from the Medical Information Bank for Intensive Care (MIMIC-III) database. MIMIC III is a large cohort database from Boston, USA. Patients were divided into two groups according to the use of ACEI/ARB before admission. Propensity score matching (PSM) was used to reduce potential bias between the two groups. Cox regression and Kaplan-Meier curves compared 30-day mortality in ACEI/ARB users and non-users. We also defined and analyzed the use of in-hospital ACEI/ARB. Multiple models were used to ensure the robustness of the findings. Subgroup analysis was used to analyze the variability between groups.

Results

A total of 544 patients were included in the original study. After PSM, 256 patients were included in the matched cohort. Multivariate Cox regression showed 30-day mortality was significantly lower in ACEI/ARB users compared with controls (HR = 0.50, 95% CI: 0.29–0.86, p= 0.013). In PSM and inverse probability-weighted models, the results are stable Continued in-hospital use of ACEI/ARB remains effective (HR 0.40, 95% CI 0.22–0.74, p = 0.003). Kaplan-Meier showed a significant difference in survival between the two groups.

Conclusion

This study found that pre-hospital ACEI/ARB use was associated with reduced mortality in patients with AECOPD and ARF.

The Effect of Rurality and Poverty on COPD Outcomes in New Hampshire: An Analysis of Statewide Hospital Discharge Data

Purpose

Individuals in rural areas of the United States have a greater risk of chronic obstructive pulmonary disease (COPD) and have worse COPD outcomes. New Hampshire (NH) is split between non-rural and rural counties.

Methods

We examined differences in COPD exacerbation rates ([encounters per county/county population of 35 years of age and older] × 100), length of stay (LOS), and total charges by rurality, determined by the 2013 National Center for Health Statistics rural-urban classification. Linear regression analysis determined the association of rural status on COPD outcomes, adjusting for age, gender, insurance status, and county-level smoking prevalence.

Findings

A total of 15,916 encounters were analyzed, of which 5805 were inpatient and 10,111 were from the emergency department, 7058 (44%) were male, and the mean age was 65.6. A total of 31% were from large, fringe metro counties, 25.9% were from medium metro counties, 37.6% were from micropolitan counties, and 5.5% were from non-core counties. In multivariable regression, rural counties had higher COPD exacerbation rates compared to urban counties (non-core beta=0.18, [confidence interval (CI) 0.16, 0.20]; micropolitan beta=0.02, CI [0.01, 0.03]); medium metro counties (beta=-0.07, Cl [-0.09, -0.06]) had lower rates of COPD exacerbations (P < 0.001 for all). Compared to urban counties, encounters from rural counties had lower total charges (medium metro beta=-1695 [-2410, -980]; micropolitan beta=-2701 [-3315, -2088]; non-core beta=-4453 [-5646, -3260], all p<0.001). LOS did not differ by rurality.

Conclusions

Accounting for poverty and other sociodemographic factors, the rates of COPD exacerbation encounters were higher in rural versus non-rural NH counties. Additionally, non-rural areas carried higher total charges, potentially due to more resource availability. These results support the need for future interventions to improve outcomes in rural COPD patients.