COPD is the fourth, and soon to be third, leading cause of death in the US and is the only cause among the top seven that is moving up the ladder. While major advances in preventing death from heart disease and cancer— the first and second leading causes—have occurred, the same cannot be said for COPD.
In efforts to improve outcomes in COPD, there has been a growing interest in using non-invasive ventilation at home (NIVH) to treat the sub-group of patients with COPD who develop chronic respiratory failure (COPD-CRF). Although a few small, European clinical trials have suggested that NIVH use in this patient population reduces morbidity and mortality, no recent studies using currently available ventilator technology have been conducted in a US population. To address this data gap, my colleagues and I performed a retrospective study using Medicare claims data from 2012-2018 to investigate the association of NIVH use with clinical outcomes in patients with COPD-CRF. WDF.
Our study, published in Respiratory Medicine, showed a highly statistically significant reduction in mortality, hospitalizations, and emergency room visits in patients with COPD-CRF who received NIVH within 2 months of their CRF diagnosis (n=517), when compared with similar patients who did not (n=511). More than 1,000 patients (mean age, 70.6; 44% male) were included in the analysis, and the treatment and control groups were closely matched on multiple clinical and demographic factors using propensity score matching techniques.
Adjusted hazard ratios showed that mortality was reduced by 50% (95% CI, 0.36-0.65), hospitalizations by 72% (95% CI, 0.52-0.93), and emergency department (ED) visits by 48% (95% CI, 0.38-0.58) at diagnosis in the group using NIVH when compared with a statistically comparable group not afforded this treatment. Risk reductions with NIVH became smaller over time for mortality and ED visits but continued to accrue through the study period for hospitalizations. At 1 year following CRF diagnosis, mortality rates were 28% for those who received NIVH and 46% for those who did not. Hospitalization and ED visit rates were 55% and 72%, respectively for those who received NIVH, compared with rates of 67% and 92%, respectively for controls. Relative risk reduction rates with NIVH were 39% for mortality, 17% for hospitalizations, and 22% for ED visits. The numbers needed to treat for NIVH therapy were five and one-half to prevent a death, nine to prevent a hospitalization, and five to prevent an ED visit (Table).
While the use of NIVH in patients with COPD-CRF has been growing, fewer than 5% of eligible patients in the US are currently using this therapy. Hypothetically, our data suggest that providing NIVH to the entire Medicare fee-for-service population of patients with COPD-CRF could reduce deaths by 135,000, hospitalizations by 64,000, and ED visits by 151,000 annually.
The major limitation of our study was its retrospective design. Ideally, prospective randomized trials are needed to confirm our findings, but we are unaware of any such trials currently underway. Future research goals for NIVH also include determining if any specific phenotype of COPD-CRF—such as hypercapnic or hypoxic CRF—benefits more from NIVH than does any other. Additional questions awaiting definitive answers include the minimum level of compliance with NIVH necessary to provide benefit, as well as the best ventilator devices and best settings needed to optimize patient outcomes.