Abstract
BackgroundThis study investigates differences in treatment and outcome of ventilated patients with acute respiratory distress syndrome (ARDS) between university and non-university hospitals in Germany.MethodsThis subanalysis of a prospective, observational cohort study was performed to identify independent risk factors for mortality by examining: baseline factors, ventilator settings (e.g., driving pressure), complications, and care settings—for example, case volume of ventilated patients, size/type of intensive care unit (ICU), and type of hospital (university/non-university hospital). To control for potentially confounding factors at ARDS onset and to verify differences in mortality, ARDS patients in university vs non-university hospitals were compared using additional multivariable analysis.ResultsOf the 7540 patients admitted to 95 ICUs from 18 university and 62 non-university hospitals in May 2004, 1028 received mechanical ventilation and 198 developed ARDS. Although the characteristics of ARDS patients were very similar, hospital mortality was considerably lower in university compared with non-university hospitals (39.3% vs 57.5%; p = 0.012). Treatment in non-university hospitals was independently associated with increased mortality (OR (95% CI): 2.89 (1.31–6.38); p = 0.008). This was confirmed by additional independent comparisons between the two patient groups when controlling for confounding factors at ARDS onset. Higher driving pressures (OR 1.10; 1 cmH2O increments) were also independently associated with higher mortality. Compared with non-university hospitals, higher positive end-expiratory pressure (PEEP) (mean ± SD: 11.7 ± 4.7 vs 9.7 ± 3.7 cmH2O; p = 0.005) and lower driving pressures (15.1 ± 4.4 vs 17.0 ± 5.0 cmH2O; p = 0.02) were applied during therapeutic ventilation in university hospitals, and ventilation lasted twice as long (median (IQR): 16 (9–29) vs 8 (3–16) days; p < 0.001).ConclusionsMortality risk of ARDS patients was considerably higher in non-university compared with university hospitals. Differences in ventilatory care between hospitals might explain this finding and may at least partially imply regionalization of care and the export of ventilatory strategies to non-university hospitals.
Highlights
This study investigates differences in treatment and outcome of ventilated patients with acute respiratory distress syndrome (ARDS) between university and non-university hospitals in Germany
The hospital mortality rate of these 1028 ventilated patients was 30.1% (Additional file 1: Table S1)
The study design was observational and, the two groups were not compiled by randomization, the remarkable difference in mortality was not due to differences between the groups; that is, in both groups patients were very similar with respect to important demographic and clinical criteria
Summary
This study investigates differences in treatment and outcome of ventilated patients with acute respiratory distress syndrome (ARDS) between university and non-university hospitals in Germany. With the exception of one study performed in 1991 in Berlin [2] and studies including selected acute respiratory distress syndrome (ARDS) patients treated in referral centers [3,4,5], the characteristics and outcome of unselected, ventilated patients in Germany remain unknown. The Second International Study of Mechanical Ventilation (Second VENTILA study) was carried out in 23 countries, and one in five of the included patients originated from Germany. Randomized trials [5, 14,15,16,17,18,19,20] are mainly conducted in university hospitals, as are most observational studies [9,10,11,12,13]; these university centers represent only a very small proportion of all hospitals in which ARDS patients are treated
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