Original Investigation
June 26, 2023
Use of Mechanical Ventilation Across 3 Countries
Naheed K. Jivraj, Andrea D. Hill, Meng-Shiou Shieh, et al
JAMA Intern Med. Published online June 26, 2023. doi:10.1001/jamainternmed.2023.2371
Question Do population-level rates of invasive mechanical ventilation differ among countries?
Findings In this cohort study of 59 873 hospital admissions in England, 70 250 in Canada, and 1 614 768 in the US, the age-standardized rates of invasive mechanical ventilation per 100 000 population were 131, 290, and 614, respectively.
Meaning These findings suggest that there may be large variability in the use of invasive mechanical ventilation in different countries, highlighting the need to better understand patient-, clinician-, and systems-level factors associated with such divergent use of a limited and expensive resource.
Abstract
Importance The ability to provide invasive mechanical ventilation (IMV) is a mainstay of modern intensive care; however, whether rates of IMV vary among countries is unclear.
Objective To estimate the per capita rates of IMV in adults across 3 high-income countries with large variation in per capita intensive care unit (ICU) bed availability.
Design, Setting, and Participants This cohort study examined 2018 data of patients aged 20 years or older who received IMV in England, Canada, and the US.
Exposure The country in which IMV was received.
Main Outcomes and Measures The main outcome was the age-standardized rate of IMV and ICU admissions in each country. Rates were stratified by age, specific diagnoses (acute myocardial infarction, pulmonary embolus, upper gastrointestinal bleed), and comorbidities (dementia, dialysis dependence). Data analyses were conducted between January 1, 2021, and December 1, 2022.
Results The study included 59 873 hospital admissions with IMV in England (median [IQR] patient age, 61 [47-72] years; 59% men, 41% women), 70 250 in Canada (median [IQR] patient age, 65 [54-74] years; 64% men, 36% women), and 1 614 768 in the US (median [IQR] patient age, 65 [54-74] years; 57% men, 43% women). The age-standardized rate per 100 000 population of IMV was the lowest in England (131; 95% CI, 130-132) compared with Canada (290; 95% CI, 288-292) and the US (614; 95% CI, 614-615). Stratified by age, per capita rates of IMV were more similar across countries among younger patients and diverged markedly in older patients. Among patients aged 80 years or older, the crude rate of IMV per 100 000 population was highest in the US (1788; 95% CI, 1781-1796) compared with Canada (694; 95% CI, 679-709) and England (209; 95% CI, 203-214). Concerning measured comorbidities, 6.3% of admitted patients who received IMV in the US had a diagnosis of dementia (vs 1.4% in England and 1.3% in Canada). Similarly, 5.6% of admitted patients in the US were dependent on dialysis prior to receiving IMV (vs 1.3% in England and 0.3% in Canada).
Conclusions and Relevance This cohort study found that patients in the US received IMV at a rate 4 times higher than in England and twice that in Canada in 2018. The greatest divergence was in the use of IMV among older adults, and patient characteristics among those who received IMV varied markedly. The differences in overall use of IMV among these countries highlight the need to better understand patient-, clinician-, and systems-level choices associated with the varied use of a limited and expensive resource.
