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Influence of ICU Case-Volume on the Management and Hospital Outcomes of Acute Exacerbations of Chronic Obstructive Pulmonary Disease*

Dres, Martin MD1; Tran, Thi-Chien MSc2,3; Aegerter, Philippe MD, PhD2,3; Rabbat, Antoine MD1; Guidet, Bertrand MD4,5; Huchon, Gerard MD, PhD1; Roche, Nicolas MD, PhD1; on behalf of theCUB-REA Group

doi: 10.1097/CCM.0b013e31828a2bd8
Clinical Investigations

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.

1Service de Pneumologie et Soins Intensifs Respiratoires, Groupe Hospitalier Cochin Broca, Assistance Publique Hôpitaux de Paris, University Paris Descartes, Paris, France.

2Université Versailles-Saint Quentin, UPRES EA 2506, Paris, France.

3AP-HP, Hôpital Ambroise Paré, Département de Santé Publique, Boulogne, France.

4Service de Réanimation Médicale, Hôpital Saint Antoine, Assistance Publique Hôpitaux de Paris, University Pierre et Marie Curie, Paris, France.

5U707, Institut National de la santé et de la Recherche Médicale, Paris, France.

*See also p. 2038

Drs. Dres and Roche designed the analysis plan, interpreted the data, and wrote the manuscript. Ms. Tran and Dr. Aegerter performed statistical analyses. Drs. Guidet, Huchon, and Rabbat contributed to the analysis plan, interpretation of data, and manuscript review.

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Members of the CUB-REA Group are: F. Brivet (Hôpital Antoine Béclère, Clamart); J-P. Bedos (Hôpital André Mignot, Versailles); A. Vieillard-Baron (Hôpital Ambroise Paré, Boulogne); Y. Cohen (Hôpital Avicenne, Bobigny); J. Labrousse (Hôpital Boucicaut, Paris); M. Safar (Hôpital Broussais, Paris); C. Richard (Hôpital du Kremlin-Bicêtre, Kremlin- Bicêtre); M. Wolff (Hôpital Bichat, Paris); D. Caen (Centre Hospitalier Sud-Francilien); J.-P. Mira (Hôpital Cochin, Paris); F. Fraisse (Hôpital Delafontaine, Saint-Denis); P. Kalfon (Hôpital des Diaconesses, Paris); J.-Y. Fagon (Hôpital Européen Georges Pompidou, Paris); F. Blin (Hôpital de Gonesse, Gonesse); C. Brun-Buisson (Hôpital Henri Mondor, Créteil); A. Rabbat (Hôpital Hoˆtel-Dieu, Paris); G. Nitemberg (Institut Gustave Roussy, Villejuif); G. Dhonneur (Hôpital Jean Verdier, Bondy); D. Dreyfus (Hôpital Louis Mourier, Colombes); F. Baud (Hôpital Lariboisière, Paris); J.-M.Coulaud (Hôpital Intercommunal Le Raincy-Montfermeil); L. Pallot (Hôpital André Grégoire, Montreuil); H. Bismuth (Hôpital Paul Brousse, Villejuif); T. Similowski (Hôpital Pitié-Salpétrière, Paris); J. Chastre (Hôpital Pitié-Salpétrière, Paris); F. Bolgert (Hôpital Pitié -Salpétrière, Paris); J.-L. Ricome (Centre Hospitalier Intercommunal Poissy-Saint-Germain-en-Laye); H. Outin (Centre Hospitalier Intercommunal Poissy-Saint-Germain en Laye); D. Zarka (Hôpital Robert Ballanger, Aulnay sous Bois); D. Annane (Hôpital Raymond Poincaré, Garches), B. Guidet (Hôpital Saint-Antoine, Paris); B. Misset (Hôpital Saint-Joseph, Paris); B. Schlemmer (Hôpital Saint-Louis, Paris); L. Jacob (Hôpital Saint-Louis, Paris); A. Parrot (Hôpital Tenon, Paris); F. Bonnet (Hôpital Tenon, Paris); H. Mentec (Hôpital Victor Dupouy, Argenteuil).The authors have disclosed that they do not have any potential conflicts of interest.

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© 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins