Trends in Non-Invasive and Invasive Mechanical Ventilation and at the End of Life (RP515)

• Published in: Journal of pain and symptom management 2020-07, Vol.60 (1), p.237-237
• Main Authors: Sullivan, Donald, MD MA MCR, Bunker, Jennifer, MPH, Kim, Hyosin, PhD, Teno, Joan, MD MS
• Format: Article
• Language: English
• Subjects: Anesthesia; Beneficiaries; Cancer; Chronic obstructive pulmonary disease; Comorbidity; Dementia; End of life decisions; Hospitalization; Mechanical ventilation; Medical diagnosis; Medicare; Myocardial infarction; Non-invasive; Ostomy; Pain Medicine; Palliative care; Pneumonia; Race; Sepsis; Tracheotomy; Trends; Ventilation; Ventilators
• ISSN: 0885-3924; 1873-6513
• DOI: 10.1016/j.jpainsymman.2020.04.107

Objectives Understand trends in non-invasive and invasive mechanical ventilation use at the end of life. Explain potential reasons for differences in noninvasive and invasive mechanical ventilation at the end of life by patient subgroup, with an emphasis on use intended for palliation at the end of life. Importance. Non-Invasive ventilation (NIV) has been suggested as a palliative approach to avoid invasive mechanical ventilation (IMV) use in dying persons. Objective(s). Characterize the use of NIV and IMV among decedents between 2000 and 2015 with hospitalization in the last 30 days of life. Method(s). Based on validated procedure codes that identify use of NIV and IMV, we examined trends in the use of NIV and IMV between 2000 and 2015 among 20% sample FFS Medicare Beneficiaries decedents. Multivariable regression models examined increase in NIV and IMV adjusting for age, gender, race, admitting diagnosis, comorbidities and Charlson comorbidity index. Exclusions: primary admitting diagnosis of cardiac arrest or pre-existing tracheostomy. Results. Between 2000 and 2015, 2.1 million hospitalizations (44.6% male, mean age 82.4, admitting diagnosis was pneumonia/sepsis 24.4%, cancer 10.5%, CHF 6.5%) occurred within 30 days of death. Overall, use of NIV increased from 0.8% to 7.4% while IMV use was stable from 13.6% to 13.1% from 2000 to 2015. The adjusted odds ratio (AOR) NIV increase compared to 2000 for 2005 was 2.5 (95% CI: 2.182.97), 2010 was 6.9 (95% CI: 5.84-8.09), and 2015 was 12.2 (95% CI: 10.41-14.36). A similar analysis of IMV found no striking increase in the use of IMV. In sub-analyses, a trend in increased NIV use was found among those with CHF (AOR 13.7, 95% CI: 11.1716.78) and COPD (AOR 8.34, 95% CI: 6.42-10.83) from 2000-2015. NIV use also increased among persons with advanced dementia (AOR 12.8, 95% CI: 9.91-16.42) from 2000-2015. Conclusion(s). Overall, there is a striking increase in the use of NIV in Medicare decedents without a reciprocal decrease in the use of IMV at the end of life. Among patients with CHF or COPD NIV may be intended to extend life, while use among persons with advanced dementia may be for palliation. Impact. Rapid growth in the use of NIV at the end of life necessitates trials to evaluate the effects.