Chronic obstructive pulmonary disease (COPD) is the nation's 4th leading cause of death and exacerbations result in more than 500,000 annual hospital admissions. Usual care for hospitalized patients consists of bronchodilators, corticosteroids, antibiotics, and supplemental oxygen. Historically, patients who failed these treatments have been sedated, endotracheally intubated, placed on a ventilator, and transferred to an intensive care unit, where the risk of a prolonged stay, complications and death has been high. Randomized trials conducted in the 1990s found that noninvasive ventilation (NIV) reduced the need for invasive mechanical ventilation and improved hospital survival by 50%. More than a decade later, little is known about the use or outcomes of NIV outside of the clinical trial environment. If the experience of other biomedical innovations holds true, then the diffusion of NIV into routine clinical practice is likely occurring slowly and unevenly. The goal of this proposal is to examine the use and outcomes of NIV in a large and representative sample of US hospitals, and to identify contextual factors and strategies associated with its effective implementation. The proposed series of investigations will be carried out in two phases. The first phase will employ an extremely large dataset containing detailed information about the treatment and outcomes of patients at over 600 US hospitals to assess the use of NIV and its effectiveness. Successful completion of this phase will close major gaps in our understanding of the diffusion of NIV into routine clinical practice over the period 2001-2010, will offer novel insights into the patient and hospital level factors influencing adoption, and will assess the degree to which the benefits of NIV reported in efficacy studies are being achieved in routine practice. These investigations will also help us identify a group of high performing hospitals-that deliver noninvasive ventilation to a large proportion of COPD patients and that experience a beneficial effect of noninvasive ventilation on patient outcomes. The second phase of the project involves the application of mixed qualitative and quantitative methods to identify the contextual factors and strategies associated with effective implementation of NIV. Guided by a well-established conceptual framework used to explain why complex innovations are more successfully implemented in some organizations than in others, we will refine our hypotheses through interviews with a diverse group of clinicians at a sample of high performing institutions. We will then test these hypotheses using survey methods within the remaining network hospitals. The identification of effective strategies for implementing NIV is the first step toward improving the outcomes of COPD patients and will help shape the intervention for a future multi-center implementation trial. This proposal is highly responsive to the 3rd goal of the NHLBI's Strategic Plan, specifically to """"""""To generate an improved understanding of the processes involved in translating research into practice and [to] use that understanding to enable improvements in public health and to stimulate further scientific discovery.""""""""

Public Health Relevance

For the roughly 500,000 individuals hospitalized each year in the US for exacerbations of chronic obstructive pulmonary disease, the discovery of noninvasive forms of mechanical ventilation in the 1990s represented a treatment breakthrough that offered an alternative to being placed on an invasive mechanical ventilator in the intensive care unit, where the risks of prolonged hospitalization, complications, and death are substantial. Yet nearly a decade after its discovery, little is known about the use or outcomes of noninvasive ventilation in routine clinical setting, and if the experience of other biomedical innovations holds true, there are reasons to be concerned that translation of these research findings into day-to-day practice may be occurring slowly and unevenly. Through statistical analyses of records from a representative sample of more than 600 US hospitals, and through interviews and surveys with a diverse set of hospital personnel, we will close the gap in our understanding of the adoption of noninvasive ventilation in the US, and will identify effective strategies that can help speed the implementation process.

Agency
National Institute of Health (NIH)
Institute
National Heart, Lung, and Blood Institute (NHLBI)
Type
Research Demonstration and Dissemination Projects (R18)
Project #
5R18HL108810-03
Application #
8519524
Study Section
Special Emphasis Panel (ZHL1-CSR-Z (M2))
Program Officer
Punturieri, Antonello
Project Start
2011-08-03
Project End
2016-07-31
Budget Start
2013-08-01
Budget End
2014-07-31
Support Year
3
Fiscal Year
2013
Total Cost
$417,767
Indirect Cost
$119,210
Name
Baystate Medical Center
Department
Type
DUNS #
079237988
City
Springfield
State
MA
Country
United States
Zip Code
01199
Lindenauer, Peter K; Shieh, Meng-Shiou; Stefan, Mihaela S et al. (2017) Hospital Procalcitonin Testing and Antibiotic Treatment of Patients Admitted for Chronic Obstructive Pulmonary Disease Exacerbation. Ann Am Thorac Soc 14:1779-1785
Stefan, Mihaela S; Pekow, Penelope S; Shieh, Meng-Shiou et al. (2017) Hospital Volume and Outcomes of Noninvasive Ventilation in Patients Hospitalized With an Acute Exacerbation of Chronic Obstructive Pulmonary Disease. Crit Care Med 45:20-27
Fisher, Kimberly A; Mazor, Kathleen M; Goff, Sarah et al. (2017) Successful Use of Noninvasive Ventilation in Chronic Obstructive Pulmonary Disease. How Do High-Performing Hospitals Do It? Ann Am Thorac Soc 14:1674-1681
DiNino, Ernest; Stefan, Mihaela S; Priya, Aruna et al. (2016) The Trajectory of Dyspnea in Hospitalized Patients. J Pain Symptom Manage 51:682-689.e1
Stefan, Mihaela S; Nathanson, Brian H; Lagu, Tara et al. (2016) Outcomes of Noninvasive and Invasive Ventilation in Patients Hospitalized with Asthma Exacerbation. Ann Am Thorac Soc 13:1096-104
Stefan, Mihaela S; Nathanson, Brian H; Higgins, Thomas L et al. (2015) Comparative Effectiveness of Noninvasive and Invasive Ventilation in Critically Ill Patients With Acute Exacerbation of Chronic Obstructive Pulmonary Disease. Crit Care Med 43:1386-94
Lindenauer, Peter K; Stefan, Mihaela S; Shieh, Meng-Shiou et al. (2015) Hospital patterns of mechanical ventilation for patients with exacerbations of COPD. Ann Am Thorac Soc 12:402-9
Stefan, Mihaela S; Shieh, Meng-Shiou; Pekow, Penelope S et al. (2015) Trends in mechanical ventilation among patients hospitalized with acute exacerbations of COPD in the United States, 2001 to 2011. Chest 147:959-968
Lindenauer, Peter K; Shieh, Meng-Shiou; Pekow, Penelope S et al. (2014) Use and outcomes associated with long-acting bronchodilators among patients hospitalized for chronic obstructive pulmonary disease. Ann Am Thorac Soc 11:1186-94
Lindenauer, Peter K; Stefan, Mihaela S; Shieh, Meng-Shiou et al. (2014) Outcomes associated with invasive and noninvasive ventilation among patients hospitalized with exacerbations of chronic obstructive pulmonary disease. JAMA Intern Med 174:1982-93

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