Variation in Early Management Practices in Moderate-to-Severe ARDS in the United States: The Severe ARDS: Generating Evidence Study

doi:10.1016/j.chest.2021.05.047

Variation in Early Management Practices in Moderate-to-Severe ARDS in the United States: The Severe ARDS: Generating Evidence Study

,

Research output: Contribution to journal › Article › peer-review

40 Scopus citations

Abstract

Background: Although specific interventions previously demonstrated benefit in patients with ARDS, use of these interventions is inconsistent, and patient mortality remains high. The impact of variability in center management practices on ARDS mortality rates remains unknown. Research Question: What is the impact of treatment variability on mortality in patients with moderate to severe ARDS in the United States? Study Design and Methods: We conducted a multicenter, observational cohort study of mechanically ventilated adults with ARDS and PaO₂ to FIO₂ ratio of ≤ 150 with positive end-expiratory pressure of ≥ 5 cm H₂O, who were admitted to 29 US centers between October 1, 2016, and April 30, 2017. The primary outcome was 28-day in-hospital mortality. Center variation in ventilator management, adjunctive therapy use, and mortality also were assessed. Results: A total of 2,466 patients were enrolled. Median baseline PaO₂ to FIO₂ ratio was 105 (interquartile range, 78.0-129.0). In-hospital 28-day mortality was 40.7%. Initial adherence to lung protective ventilation (LPV; tidal volume, ≤ 6.5 mL/kg predicted body weight; plateau pressure, or when unavailable, peak inspiratory pressure, ≤ 30 mm H₂O) was 31.4% and varied between centers (0%-65%), as did rates of adjunctive therapy use (27.1%-96.4%), methods used (neuromuscular blockade, prone positioning, systemic steroids, pulmonary vasodilators, and extracorporeal support), and mortality (16.7%-73.3%). Center standardized mortality ratios (SMRs), calculated using baseline patient-level characteristics to derive expected mortality rate, ranged from 0.33 to 1.98. Of the treatment-level factors explored, only center adherence to early LPV was correlated with SMR. Interpretation: Substantial center-to-center variability exists in ARDS management, suggesting that further opportunities for improving ARDS outcomes exist. Early adherence to LPV was associated with lower center mortality and may be a surrogate for overall quality of care processes. Future collaboration is needed to identify additional treatment-level factors influencing center-level outcomes. Trial Registry: ClinicalTrials.gov; No.: NCT03021824; URL: www.clinicaltrials.gov

Original language	English
Pages (from-to)	1304-1315
Number of pages	12
Journal	Chest
Volume	160
Issue number	4
DOIs	https://doi.org/10.1016/j.chest.2021.05.047
State	Published - Oct 2021

Bibliographical note

Publisher Copyright:
© 2021

Funding

Author contributions: The study was designed by N. Q. P. K. P. R. R. B. and M. N. G. Data was acquired from individual sites by the following investigators: N. Q. R. R. B. C. L. H. M. J. L. V. M. B.-G. J.-T. C. S. G. D. G. M. W. S. N. H. J. K. A. D. A. K. K. R. K. A. K. S. Y. C. J. E. T. H. L. A. J. M. L. J. M. M. P. E. M. A. G. I. K. L. M. T. R. S. S. A. M. E. D. J. D. A. M. K. E. S. W. B. A. T. P. K. G. and S. H. R. R. B. and M. L. C. had full access to all of the data in the study and performed the data analyses. The initial manuscript was drafted by N. Q. and P. K. P. All authors provided critical input into manuscript revisions. P. K. P. is the guarantor of the paper. Financial/nonfinancial disclosures: None declared. ∗Severe ARDS: Generating Evidence (SAGE) Study Investigators (alphabetical, by center): Baystate Medical Center: Jay S Steingrub, Mark Tidswell; Beth Israel Deaconess Medical Center: Valerie M Banner-Goodspeed, Kristin Brierley, Julia L Larson, Ariel Mueller, Tereza Pinkhasova, Daniel Talmor; Brigham and Women's Hospital: Imoigele Aisiku, Rebecca Baron, Lauren Fredenburgh, Alissa Genthon, Peter Hou, Anthony Massaro, Raghu Seethala; Cleveland Clinic: Abhijit Duggal, Duncan Hite, Ashish K Khanna; Columbia University: Daniel Brodie, Irene K Louh, Briana Short; Duke University Medical Center: Raquel Bartz, Mary L Cooter, Jordan C Komisarow; East Carolina University: Anupama Tiwari; Emory University: William Bender, James Blum; Grady Memorial Hospital: Annette Esper, Greg S. Martin; Harborview Medical Center: Eileen Bulger, Catherine L Hough, Anna Ungar; Intermountain Medical Center: Samuel M Brown, Colin K Grissom, Eliotte L Hirshberg, Michael J Lanspa, Ithan D Peltan; Johns Hopkins University: Roy G Brower, Sarina K Sahetya, R Scott Stephens; Mayo Clinic Florida: Pramod K Guru; Mayo Clinic Rochester: John K Bohman, Hongchuan Coville, Ognjen Gajic, Rahul Kashyap, John C O'Horo; Montefiore Medical Center: Jorge-Bleik Ataucuri-Vargas, Jen-Ting Chen, Michelle N Gong, Fiore Mastroianni; Northwell Health System: Negin Hajizadeh, Jamie Hirsch, Michael Qui, Molly Stewart; Oregon Health Sciences University: Akram Khan, Ebaad Haq, Makrina Kamel, Olivia Krol, Kimberly Lerner; Regions Hospital: David J Dries, John Marini; St. Agnes Hospital: Valentina Chiara Bistolfi Amaral, Anthony Martinez; St. Joseph's Medical Center: Harry L Anderson, III, Jill Brown, Michael Brozik, Heidi Kemmer, Janet Obear; Temple University: Nina Gentile, Kraftin E Shreyer; University of Arizona - Banner Health: Charles Cairns, Cameron Hypes, Josh Malo, Jarrod Mosier, Bhupinder Natt; University of California Los Angeles: Steven Y Chang, Scott Hu, Ishan Mehta, Nida Qadir; University of Cincinnati: Richard Branson, Dina Gomaa, Betty Tsuei; University of Kentucky: Sanjay Dhar, Ashley Montgomery-Yates, Peter Morris; University of Michigan: Tina Chen, Sinan Hanna, Pauline K Park, Michael W Sjoding; University of Southern California: Alfredo Lee Chang, Perren Cobb, Janice M. Liebler; University of Utah: Estelle Harris, Nate Hatton, Gia Lewis, Stephen McKellar, Sanjeev Raman, Joseph Tonna; University of Washington: Ellen Caldwell, Sarah Dean, Shewit Giovanni. Additional information: The e-Appendixes, e-Figure, and e-Tables can be found in the Supplemental Materials section of the online article. FUNDING/SUPPORT: The authors have reported to CHEST that no funding was received for this study.

Funders	Funder number
St. Agnes Hospital
National Heart, Lung, and Blood Institute (NHLBI)	K23HL141596
National Heart, Lung, and Blood Institute (NHLBI)
Mayo Clinic Rochester
Oregon Health and Science University
Michigan Retirement Research Center, University of Michigan
University of Kentucky
University of Utah Health
The George Washington University
The Johns Hopkins University
University of Cincinnati University Research Council

Keywords

ARDS
corticosteroids
extracorporeal membrane oxygenation
mechanical ventilation
neuromuscular blockade
prone positioning

ASJC Scopus subject areas

Pulmonary and Respiratory Medicine
Critical Care and Intensive Care Medicine
Cardiology and Cardiovascular Medicine

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10.1016/j.chest.2021.05.047

Cite this

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title = "Variation in Early Management Practices in Moderate-to-Severe ARDS in the United States: The Severe ARDS: Generating Evidence Study",

abstract = "Background: Although specific interventions previously demonstrated benefit in patients with ARDS, use of these interventions is inconsistent, and patient mortality remains high. The impact of variability in center management practices on ARDS mortality rates remains unknown. Research Question: What is the impact of treatment variability on mortality in patients with moderate to severe ARDS in the United States? Study Design and Methods: We conducted a multicenter, observational cohort study of mechanically ventilated adults with ARDS and PaO2 to FIO2 ratio of ≤ 150 with positive end-expiratory pressure of ≥ 5 cm H2O, who were admitted to 29 US centers between October 1, 2016, and April 30, 2017. The primary outcome was 28-day in-hospital mortality. Center variation in ventilator management, adjunctive therapy use, and mortality also were assessed. Results: A total of 2,466 patients were enrolled. Median baseline PaO2 to FIO2 ratio was 105 (interquartile range, 78.0-129.0). In-hospital 28-day mortality was 40.7%. Initial adherence to lung protective ventilation (LPV; tidal volume, ≤ 6.5 mL/kg predicted body weight; plateau pressure, or when unavailable, peak inspiratory pressure, ≤ 30 mm H2O) was 31.4% and varied between centers (0%-65%), as did rates of adjunctive therapy use (27.1%-96.4%), methods used (neuromuscular blockade, prone positioning, systemic steroids, pulmonary vasodilators, and extracorporeal support), and mortality (16.7%-73.3%). Center standardized mortality ratios (SMRs), calculated using baseline patient-level characteristics to derive expected mortality rate, ranged from 0.33 to 1.98. Of the treatment-level factors explored, only center adherence to early LPV was correlated with SMR. Interpretation: Substantial center-to-center variability exists in ARDS management, suggesting that further opportunities for improving ARDS outcomes exist. Early adherence to LPV was associated with lower center mortality and may be a surrogate for overall quality of care processes. Future collaboration is needed to identify additional treatment-level factors influencing center-level outcomes. Trial Registry: ClinicalTrials.gov; No.: NCT03021824; URL: www.clinicaltrials.gov",

keywords = "ARDS, corticosteroids, extracorporeal membrane oxygenation, mechanical ventilation, neuromuscular blockade, prone positioning",

author = "Nida Qadir and Bartz, {Raquel R.} and Cooter, {Mary L.} and Hough, {Catherine L.} and Lanspa, {Michael J.} and Banner-Goodspeed, {Valerie M.} and Chen, {Jen Ting} and Shewit Giovanni and Dina Gomaa and Sjoding, {Michael W.} and Negin Hajizadeh and Jordan Komisarow and Abhijit Duggal and Khanna, {Ashish K.} and Rahul Kashyap and Akram Khan and Chang, {Steven Y.} and Tonna, {Joseph E.} and Anderson, {Harry L.} and Liebler, {Janice M.} and Mosier, {Jarrod M.} and Morris, {Peter E.} and Alissa Genthon and Louh, {Irene K.} and Mark Tidswell and Stephens, {R. Scott} and Esper, {Annette M.} and Dries, {David J.} and Anthony Martinez and Schreyer, {Kraftin E.} and William Bender and Anupama Tiwari and Guru, {Pramod K.} and Sinan Hanna and Gong, {Michelle N.} and Park, {Pauline K.} and Steingrub, {Jay S.} and Kristin Brierley and Larson, {Julia L.} and Ariel Mueller and Tereza Pinkhasova and Daniel Talmor and Imoigele Aisiku and Rebecca Baron and Lauren Fredenburgh and Peter Hou and Anthony Massaro and Raghu Seethala and Duncan Hite and Daniel Brodie",

note = "Publisher Copyright: {\textcopyright} 2021",

year = "2021",

month = oct,

doi = "10.1016/j.chest.2021.05.047",

language = "English",

volume = "160",

pages = "1304--1315",

number = "4",

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TY - JOUR

T1 - Variation in Early Management Practices in Moderate-to-Severe ARDS in the United States

T2 - The Severe ARDS: Generating Evidence Study

AU - Qadir, Nida

AU - Bartz, Raquel R.

AU - Cooter, Mary L.

AU - Hough, Catherine L.

AU - Lanspa, Michael J.

AU - Banner-Goodspeed, Valerie M.

AU - Chen, Jen Ting

AU - Giovanni, Shewit

AU - Gomaa, Dina

AU - Sjoding, Michael W.

AU - Hajizadeh, Negin

AU - Komisarow, Jordan

AU - Duggal, Abhijit

AU - Khanna, Ashish K.

AU - Kashyap, Rahul

AU - Khan, Akram

AU - Chang, Steven Y.

AU - Tonna, Joseph E.

AU - Anderson, Harry L.

AU - Liebler, Janice M.

AU - Mosier, Jarrod M.

AU - Morris, Peter E.

AU - Genthon, Alissa

AU - Louh, Irene K.

AU - Tidswell, Mark

AU - Stephens, R. Scott

AU - Esper, Annette M.

AU - Dries, David J.

AU - Martinez, Anthony

AU - Schreyer, Kraftin E.

AU - Bender, William

AU - Tiwari, Anupama

AU - Guru, Pramod K.

AU - Hanna, Sinan

AU - Gong, Michelle N.

AU - Park, Pauline K.

AU - Steingrub, Jay S.

AU - Brierley, Kristin

AU - Larson, Julia L.

AU - Mueller, Ariel

AU - Pinkhasova, Tereza

AU - Talmor, Daniel

AU - Aisiku, Imoigele

AU - Baron, Rebecca

AU - Fredenburgh, Lauren

AU - Hou, Peter

AU - Massaro, Anthony

AU - Seethala, Raghu

AU - Hite, Duncan

AU - Brodie, Daniel

PY - 2021/10

Y1 - 2021/10

N2 - Background: Although specific interventions previously demonstrated benefit in patients with ARDS, use of these interventions is inconsistent, and patient mortality remains high. The impact of variability in center management practices on ARDS mortality rates remains unknown. Research Question: What is the impact of treatment variability on mortality in patients with moderate to severe ARDS in the United States? Study Design and Methods: We conducted a multicenter, observational cohort study of mechanically ventilated adults with ARDS and PaO2 to FIO2 ratio of ≤ 150 with positive end-expiratory pressure of ≥ 5 cm H2O, who were admitted to 29 US centers between October 1, 2016, and April 30, 2017. The primary outcome was 28-day in-hospital mortality. Center variation in ventilator management, adjunctive therapy use, and mortality also were assessed. Results: A total of 2,466 patients were enrolled. Median baseline PaO2 to FIO2 ratio was 105 (interquartile range, 78.0-129.0). In-hospital 28-day mortality was 40.7%. Initial adherence to lung protective ventilation (LPV; tidal volume, ≤ 6.5 mL/kg predicted body weight; plateau pressure, or when unavailable, peak inspiratory pressure, ≤ 30 mm H2O) was 31.4% and varied between centers (0%-65%), as did rates of adjunctive therapy use (27.1%-96.4%), methods used (neuromuscular blockade, prone positioning, systemic steroids, pulmonary vasodilators, and extracorporeal support), and mortality (16.7%-73.3%). Center standardized mortality ratios (SMRs), calculated using baseline patient-level characteristics to derive expected mortality rate, ranged from 0.33 to 1.98. Of the treatment-level factors explored, only center adherence to early LPV was correlated with SMR. Interpretation: Substantial center-to-center variability exists in ARDS management, suggesting that further opportunities for improving ARDS outcomes exist. Early adherence to LPV was associated with lower center mortality and may be a surrogate for overall quality of care processes. Future collaboration is needed to identify additional treatment-level factors influencing center-level outcomes. Trial Registry: ClinicalTrials.gov; No.: NCT03021824; URL: www.clinicaltrials.gov

AB - Background: Although specific interventions previously demonstrated benefit in patients with ARDS, use of these interventions is inconsistent, and patient mortality remains high. The impact of variability in center management practices on ARDS mortality rates remains unknown. Research Question: What is the impact of treatment variability on mortality in patients with moderate to severe ARDS in the United States? Study Design and Methods: We conducted a multicenter, observational cohort study of mechanically ventilated adults with ARDS and PaO2 to FIO2 ratio of ≤ 150 with positive end-expiratory pressure of ≥ 5 cm H2O, who were admitted to 29 US centers between October 1, 2016, and April 30, 2017. The primary outcome was 28-day in-hospital mortality. Center variation in ventilator management, adjunctive therapy use, and mortality also were assessed. Results: A total of 2,466 patients were enrolled. Median baseline PaO2 to FIO2 ratio was 105 (interquartile range, 78.0-129.0). In-hospital 28-day mortality was 40.7%. Initial adherence to lung protective ventilation (LPV; tidal volume, ≤ 6.5 mL/kg predicted body weight; plateau pressure, or when unavailable, peak inspiratory pressure, ≤ 30 mm H2O) was 31.4% and varied between centers (0%-65%), as did rates of adjunctive therapy use (27.1%-96.4%), methods used (neuromuscular blockade, prone positioning, systemic steroids, pulmonary vasodilators, and extracorporeal support), and mortality (16.7%-73.3%). Center standardized mortality ratios (SMRs), calculated using baseline patient-level characteristics to derive expected mortality rate, ranged from 0.33 to 1.98. Of the treatment-level factors explored, only center adherence to early LPV was correlated with SMR. Interpretation: Substantial center-to-center variability exists in ARDS management, suggesting that further opportunities for improving ARDS outcomes exist. Early adherence to LPV was associated with lower center mortality and may be a surrogate for overall quality of care processes. Future collaboration is needed to identify additional treatment-level factors influencing center-level outcomes. Trial Registry: ClinicalTrials.gov; No.: NCT03021824; URL: www.clinicaltrials.gov

KW - ARDS

KW - corticosteroids

KW - extracorporeal membrane oxygenation

KW - mechanical ventilation

KW - neuromuscular blockade

KW - prone positioning

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Variation in Early Management Practices in Moderate-to-Severe ARDS in the United States: The Severe ARDS: Generating Evidence Study

Abstract

Bibliographical note

Funding

Keywords

ASJC Scopus subject areas

Access to Document

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