Mechanical ventilation survivorship: A tale of two countries

Nearly 1 million Americans undergo mechanical ventilation annually, of whom up to one-third die during their hospitalizations. Historically, the success of mechanical ventilation has been measured by patient survival. However, in more recent years, as advances in therapeutics and technologies have led to improvements in mortality associated with critical illness, attention has shifted to survivorship outcomes. The many morbidities associated with surviving mechanical ventilation lead to substantial healthcare use after episodes of acute care, such as use of nonacute inpatient care and subsequent rehospitalization. Measures of resource use—length of inpatient stay, discharge disposition, and hospital readmission, for example—are not only important to hospitals and policymakers; they are also endorsed by patients and their families as important patient-centered outcomes.

Patterns of care for mechanical ventilation survivors across different countries are not well described. It is known that patients admitted to ICUs, as are most mechanically ventilated patients, remain in acute care hospitals for shorter durations in the United States than in other countries . However, whether this difference translates into actual differences in healthcare use and overall outcomes is unknown. In this issue of AnnalsATS, Wunsch and colleagues report the results of a retrospective observational study of postacute care and outcomes in two contemporary cohorts: mechanical ventilation survivors admitted to hospitals from 2010 through 2012 in New York State and in Ontario. They found that although initial hospital length of stay was similar in the two populations overall, length of stay was consistently shorter in New York than in Ontario among patient subgroups of comparable acuity. Furthermore, more patients in New York were discharged to nonhome destinations and had higher 30-day hospital readmission rates. Subgroup analyses demonstrated particularly strong associations with 30-day hospital readmissions in New York among patients with new tracheostomies, patients who required hemodialysis during hospitalization, and patients discharged to nonhome destinations. Interestingly, they also found that hospital-free days out to 2 months after the initial hospitalization (i.e., days alive and not admitted to an acute care hospital during that period) did not differ between New York and Ontario, even in most subgroup analyses. As the authors note, this finding suggests the possibility of an “equilibrium” in post–acute care resource use between New York and Ontario, despite apparent differences in initial acute care.

National Heart, Lung,and Blood Institute (NHLBI)