COPD-Chronic Respiratory Failure Medicare Patients: Noninvasive Home Ventilation

In Medicare patients who are diagnosed with chronic obstructive pulmonary disease with chronic respiratory failure (COPD-CRF), the use of noninvasive ventilation at home (NIVH) is associated with lower risks for mortality, hospitalizations, and emergency room (ER) visits when instituted within 2 months of a CRF diagnosis. Results of the analysis were published in the journal Respiratory Medicine.

A retrospective cohort study was conducted using the Medicare Limited Data Set (LDS) between January 1, 2012, and December 31, 2018. The investigators sought to gain a greater understanding of the potential benefits of NIVH in a US population by evaluating the link between NIVH and the risks for mortality, hospitalizations, and ER visits among Medicare beneficiaries with COPD-CHR. The prespecified primary study endpoint was all-cause mortality following a diagnosis of CRF. Secondary outcomes included time to first hospital admission and time to first ER visit.

The study participants included patients who received NIVH within 2 months of a CRF diagnosis (treatment group), and individuals who had never received NIVH and were matched based on demographic and clinical characteristics (control group). ICD-9-CM and ICD-10-CM codes were used to identify a CRF diagnosis. Time to death, first hospitalization, and initial ER visit were estimated with the use of Cox regression time-to-event analysis.

The initial sample selection procedures yielded 517 patients with COPD-CRF who used NIVH and met all study criteria (ie, the treatment group) and an additional 44,281 patients with COPD-CRF patients without any evidence of NIVH utilization (ie, the unadjusted control group). The mean age in the treatment group was younger than that in the control group (70.6 years vs 75.1 years, respectively). Further, those in the treatment group were more likely than those in the control group to reside in the Western United States (23% vs 17%, respectively); to have lower total mean healthcare spending in the 6 months pre-index ($17,897 vs $32,370, respectively); and to have significantly lower rates of comorbidities.

Following matching, a total of 517 patients who received NIVH and 511 controls were compared. Results of the study showed that NIVH significantly reduced the risk for death (adjusted hazard ratio [aHR], 0.50; 95% CI, 0.36 to 0.65; P <.01), hospitalization (aHR, 0.72; 95% CI, 0.523; P <.01), and ER visits (aHR, 0.48; 95% CI, 0.38 to 0.58; P <.01) at the time of diagnosis. In fact, the NIVH risk reduction decreased over time for mortality and ER visits, but continued to accrue for hospitalizations.

At 1 year after COPD-CHR diagnosis, 28% of those in the treatment arm died, compared with 46% of those in the control arm. With respect to hospitalizations and ER visits at

1 year post-diagnosis, 55% and 72%, respectively, of those in the treatment group experienced an event, compared with 67% and 92%, respectively, of those in the control group. The relative risk reduction with NIVH was as follows: 39% for mortality, 17% for hospitalizations, and 22% for ER visits. The numbers needed to treat were 5.5, 9, and 5, in order to prevent a death, a hospitalization, or an ER visit, respectively, at 1 year following the initial diagnosis.

Limitations of the study includes concerns typical of retrospective study designs, immortal-time bias, and that the results of this study cannot be generalized to Medicare non-fee service populations.

The investigators concluded that the findings from the current study suggest that NIVH might prove to be an important treatment option for patients with COPD-CHR, with more individuals potentially benefiting from this therapy than the small number who are currently receiving it.

Reference

Frazier WD, Murphy R, van Eijndhoven E. Non-invasive ventilation at home improves survival and decreases healthcare utilization in Medicare beneficiaries with chronic obstructive pulmonary disease with chronic respiratory failure. Respir Med. Published online December 30, 2020. doi: 10.1016/j.rmed.2020.106291