Center effect in intubation risk in critically ill immunocompromised patients with acute hypoxemic respiratory failure
Center effect in intubation risk in critically ill immunocompromised patients with acute hypoxemic respiratory failure
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DOI：
10.1186/s13054-019-2590-7
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发表时间：
2019-09-06
期刊：
影响因子：
15.1
通讯作者：
Azoulay, Elie
中科院分区：
文献类型：
--
作者：
Dumas, Guillaume;Demoule, Alexandre;Azoulay, Elie
背景急性呼吸衰竭是免疫功能低下患者进入重症监护病房(ICU)的主要原因，在随机对照试验(RCT)中，有创机械通气的必要性已成为主要的临床终点。然而，关于插管是否是跨中心无偏见使用的客观标准，缺乏数据。这项研究探索了这种结果在不同的ICU中是如何变化的。方法应用分层模型和排列程序对来自观察性队列(试验-OH研究：703名患者，17个ICU)和随机对照试验(HIGH试验：776名患者，31个ICU)的数据进行分层模型和置换过程，以表征ICU在跨中心插管风险方面的差异。结果不同ICU的粗气管插管率在观察队列中为29%至80%，在随机对照试验中为0%至86%。这一中心效应对平均ICU插管率的影响具有统计学意义，即使在调整了个别患者的特征后也是如此(观察队列：P值=0.013，中位OR1.48[1.3-1.72]；随机对照：P值0.004，中位OR1.51[1.36-1.68])。两个ICU水平的特征与插管风险相关(每个中心的年插管率和从呼吸道症状到ICU入院的时间)，并可以部分解释这种中心效应。在对照使用高流量氧疗的随机对照试验中，我们没有发现氧合策略对跨中心插管风险的影响有显著差异，尽管有创机械通气的需要有显著差异。结论不同ICU的插管率差异很大，即使在对个体特征进行调整后也是如此。
Background Acute respiratory failure is the leading reason for intensive care unit (ICU) admission in immunocompromised patients, and the need for invasive mechanical ventilation has become a major clinical endpoint in randomized controlled trials (RCTs). However, data are lacking on whether intubation is an objective criteria that is used unbiasedly across centers. This study explores how this outcome varies across ICUs. Methods Hierarchical models and permutation procedures for testing multiple random effects were applied on both data from an observational cohort (the TRIAL-OH study: 703 patients, 17 ICUs) and a randomized controlled trial (the HIGH trial: 776 patients, 31 ICUs) to characterize ICU variation in intubation risk across centers. Results The crude intubation rate varied across ICUs from 29 to 80% in the observational cohort and from 0 to 86% in the RCT. This center effect on the mean ICU intubation rate was statistically significant, even after adjustment on individual patient characteristics (observational cohort: p value = 0.013, median OR 1.48 [1.30-1.72]; RCT: p value 0.004, median OR 1.51 [1.36-1.68]). Two ICU-level characteristics were associated with intubation risk (the annual rate of intubation procedure per center and the time from respiratory symptoms to ICU admission) and could partly explain this center effect. In the RCT that controlled for the use of high-flow oxygen therapy, we did not find significant variation in the effect of oxygenation strategy on intubation risk across centers, despite a significant variation in the need for invasive mechanical ventilation. Conclusion Intubation rates varied considerably among ICUs, even after adjustment on individual characteristics.