Disclosures: Sullivan and Iyer report receiving grants from the National Institute on Aging of the NIH. Sullivan reports receiving grants from the National Cancer Institute. Iyer reports receiving grants from the Agency for Healthcare Research. Please see the study for all other authors’ relevant financial disclosures.
October 27, 2020
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Use of noninvasive ventilation rapidly increased in Medicare beneficiaries at end of life

Disclosures: Sullivan and Iyer report receiving grants from the National Institute on Aging of the NIH. Sullivan reports receiving grants from the National Cancer Institute. Iyer reports receiving grants from the Agency for Healthcare Research. Please see the study for all other authors’ relevant financial disclosures.
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Use of noninvasive ventilation among Medicare beneficiaries who were hospitalized in the last 30 days of life increased from 2000 to 2017, especially among those with cancer and dementia, researchers reported.

Donald R. Sullivan, MD, MA, MCR, physician-scientist in the division of pulmonary and critical care medicine at Oregon Health & Science University, Portland, and colleagues conducted a population-based cohort study to assess trends in end-of-life use of noninvasive ventilation and mechanical ventilation. Their findings were published in JAMA Internal Medicine.

Study details increase in end-of-life use of noninvasive ventilation over time.

The researchers evaluated a random sample of 2,470,435 Medicare beneficiaries (mean age, 82.2 years; 54.8% women) with an acute care hospitalization in the last 30 days of life who died from 2000 to 2017.

Researchers reviewed procedure codes to identify noninvasive ventilation use, invasive mechanical ventilation use, use of both or no use. They further identified four Medicare subgroups using primary admitting diagnosis codes: COPD, congestive heart failure, cancer and dementia.

Use of end-of-life noninvasive ventilation increased over time. Compared with use in 2000, the adjusted OR for the increase in noninvasive ventilation use was 2.63 (95% CI, 2.46-2.82; percent receipt: 0.8% vs. 2%) for 2005 and 11.84 (95% CI, 11.11-12.61; percent receipt: 0.8% vs. 7.1%) for 2017.

When the researchers analyzed changes in invasive mechanical ventilation over time, compared with 2000, the adjusted OR for the increase in invasive mechanical ventilation was 1.04 (95% CI, 1.02-1.06; percent receipt: 15% vs. 15.2%) for 2005 and 1.63 (95% CI, 1.59-1.66; percent receipt: 15% vs. 18.2%) for 2017.

Sullivan and colleagues observed a similar trend of increased use of noninvasive ventilation from 2000 to 2017 among patients with congestive heart failure (aOR = 14.14; 95% CI, 11.77-16.98; percent receipt: 1.4% vs. 14.2%), COPD (aOR = 8.22; 95% CI, 6.42-10.52; percent receipt: 2.7% vs. 14.5%). The researchers reported “reciprocal stabilization” in invasive mechanical ventilation use in these subgroups: patients with congestive heart failure (aOR = 1.07; 95% CI, 0.95-1.19; percent receipt: 11.1% vs. 7.8%) and COPD (aOR = 1.03; 95% CI, 0.88-1.21; percent receipt: 2.7% vs. 14.5%).

Among decedents with cancer and dementia, the aOR for increased noninvasive ventilation use was 10.82 (95% CI, 8.16-14.43; percent receipt: 0.4% vs. 3.5%) and 9.62 (95% CI, 7.61-12.15; percent receipt: 0.6% vs. 5.2%), respectively, and the aOR for increased invasive mechanical ventilation use was 1.4 (95% CI, 1.26-1.55; percent receipt: 6.2% vs. 7.6%) and 1.28 (95% CI, 1.17-1.41; percent receipt: 5.7% vs. 6.2%), respectively.

Researchers observed lower rates of in-hospital death (50.3% vs. 76.7%) and hospice enrollment in the last 3 days of life (57.7% vs. 63%) and higher rates of hospice enrollment overall (41.3% vs. 20%) among decedents who received noninvasive ventilation compared with invasive mechanical ventilation.

“Given the rapid growth, the potential for patient harm and distress, and the substantial health care resources associated with noninvasive ventilation use, further research is warranted to evaluate its outcomes and to inform discussions about the goals of this therapy between clinicians and patients and their health care proxies so that they can make patient-centered choices,” the researchers wrote.

In a related editorial, Anand S. Iyer, MD, MSPH, pulmonologist with the division of pulmonary, allergy and critical care medicine, the Lung Health Center and the Center for Palliative and Supportive Care at the University of Alabama at Birmingham, said the rapid proliferation in use of noninvasive ventilation reported in this study is “concerning,” given the absence of evidence supporting noninvasive ventilation use as palliative ventilatory support in this population.

“Future research on terminal respiratory failure in these vulnerable populations and their bereaved caregivers should explore in more detail the feasibility, acceptability and palliative benefits of noninvasive ventilation, especially in comparison to high-flow nasal cannula oxygenation,” Iyer wrote. “Although the use of this newer modality may be limited in smaller centers due to equipment availability, the recent proliferation of high-flow nasal cannula oxygenation could alter some of the trends seen in the current analysis and radically change the evidence for noninvasive ventilation use in subgroups of seriously ill older adults with terminal respiratory failure.”

Reference:

Iyer AS. JAMA Intern Med. 2020;doi:10.1001/jamainternmed.2020.5648.