Hospital Variation in Non-Invasive Positive Pressure Ventilation for Acute Decompensated Heart Failure

Background—Although non-invasive positive pressure ventilation (NIPPV) for patients with acute decompensated heart failure (ADHF) was introduced almost 20 years ago, the variation in its use among hospitals remains unknown. We sought to define hospital practice patterns of NIPPV use for ADHF and their relationship with intubation and mortality. Methods and Results—We conducted a cross-sectional study using a database maintained by Premier, Inc., that includes a date-stamped log of all billed items for hospitalizations at over 400 hospitals. We examined hospitalizations for ADHF in this database from 2005-2010 and included hospitals with annual average volume of greater than 25 such hospitalizations. We identified 384 hospitals that encompassed 524,430 hospitalizations (median annual average volume: 206). We used hierarchical logistic regression models to calculate hospital-level outcomes: risk-standardized NIPPV rate (RS-NIPPV), risk-standardized intubation rate (RSIR), and in-hospital risk-standardized mortality rate (RSMR). We grouped hospitals into quartiles by RS-NIPPV and compared RSMRs and RSIRs across quartiles. Median RS-NIPPV was 6.2% (interquartile range, 2.8-9.3%; 5 percentile, 0.2%; 95 percentile, 14.8%). There was no clear pattern of RSMRs across quartiles. The bottom quartile of hospitals had higher RSIR (11.4%) than each of the other quartiles (9.0%, 9.7%, and 9.1%; P<0.02 for all comparisons). Conclusion—Substantial variation exists among hospitals in the use of NIPPV for ADHF without evidence for differences in mortality. There may be a threshold effect in relation to intubation rates, with the lowest utilizers of NIPPV having higher intubation rates.