Laveena Munshi, MD

Clinical Associate, Interdepartmental Division of CCMMount Sinai Hospital/University Health NetworkUniversity of TorontoInstitute of Health Policy, Management and Evaluation

Adjuvants to Mechanical Ventilation for

Acute Respiratory Distress Syndrome:

Changes in Use Over Time,

Adoption and De-adoption

No disclosures

1. Adoption of innovations/therapeutics in medicine

2. De-adoption of innovations/therapeutics in medicine

3. Changes in use, Adoption and De-adoption:

Adjuvants to Mechanical Ventilation for ARDS

Understanding

Adoption

in Medicine

~10 ml/kg

<1% received 6 ml/kg

Evidence is only one part of adoption

Rubenfeld GD. Understanding why we agree on the evidence but disagree on the medicine. Respir Care. 2001;46(12):1442-1449.

Evidence

UncertaintyPrior probability

Plausibility

Rationale Belief about effect of therapy

Patient

Factors

Applicability

Benefits

Risks

Alternatives

Costs

Availability

Decision

Mode

Delivery

Physician

Preferences

Physiologic Response

New Gadgets

Anecdotal experience/Hunches

Personal Values

Feasibility

Press

Understanding

De-Adoption

In Medicine

Tight Glycemic Control Hypoglycemia

Bedside

Echocardiography

Non invasive

hemodynamic

monitoring

DE-ADOPTION IS NOT ALWAYS SLOW

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Lung Protective Ventilation

PEEP

Corticosteroids

Fluid

ECMO

HFO

iNO

NMBA

HFO

NMBA

Evolution of the Evidence

HFO

Prone Positioning

Adjuvants to

ARDS: Changes

over time

STUDY OBJECTIVE

1. To evaluate temporal changes in use of

adjuvant strategies to mechanical

ventilation for acute respiratory failure

(2008-2013)

2. To evaluate adoption/ de-adoption

practices with regard to landmark

publications

MethodsCohort patients undergoing

mechanical ventilation for

respiratory failure

(2008-2013)

OUTCOME:

Use of adjuvant strategies to

mechanical ventilationExtracorporeal Membrane Oxygenation

Inhaled Pulmonary Vasodilators

Neuromuscular Blockading Agents

High Frequency Oscillation

ICD-9

Hospital Bill

EXCLUSION:

Pulmonary Hypertension

Cardiac Surgery

Transplant

Final Cohort for Analysisn = 514,913

(Acute Resp Failure

“ARF”)

Sensitivity Analysis

n = 70,435

(“ARDS”)

MV first two days

Sepsis &

Respiratory Failure &

Pneumonia

Reflects an ARDS Cohort, Outcomes, Broad Population

ARF “ARDS”DEMOGRAPHIC 514,809 70,435

AGE 62 (± 17) 64 (± 16)

SEX (FEMALE) 46% 44%

Race (WHITE) 65% 65%

CLINICAL BASELINE

Rothberg PPD 0.2 (0.1, 0.4) 0.4 (0.2-0.5)

ARDS CausePneumoniaSepsis (Non-Pneumonia)Non-Infectious SIRSTrauma

53%13%4%10%

(all)

MECHANICAL VENTILATION

MV within first 2 days of 73% (all)

Mean ± SD or Median (IQR)

OUTCOMES

Use of Any Adjuvant(ECMO, iPV, cNMBA, HFO)

4% 5%

DURATION OF MV (survivors -days)

4 (3,9) 7 (4, 12)

LENGTH ICU ADMISSION (survivors - days)

6 (3,12) 8 (5, 14)

28 DAY MORTALITY 31% 35%

HOSPITAL MORTALITY 33% 35%

HOSPITAL VARIABLES 543 hospitals 532 hospitals

URBAN 89% 88%

TEACHING 44% 42%

BEDSIZELarge ≥ 400 bedsMedium 200-399 bedsSmall < 200 beds

50%36%13%

48%38%14%

LOCATIONMidwestNortheastSouthWest

18%18%47%17%

19%18%45%19%

LOCATION PRE-ADMISSIONERELECTIVETRAUMAOTHER

76%8%2%14%

81%3%0.4%17%

Acute Respiratory Failure

(514,809)

ARDS (70,435)

ECMO

(195)

IPV

(1,837)

NMBA

(10,230)

HFO

(66)

ECMO Rates/1000 personssex and age adjusted

0.5

11

.5

2008 2009 2010 2011 2012 2013admissionyear

ecmorates Fitted values

0.5

11

.5

2008 2009 2010 2011 2012 2013admissionyear

ecmorates Fitted values

CESAR

October 2009

Intercept change p 0.32

Slope change p 0.28

Strength of

Evidence

Risk/Benefit Modality and

Medium

Of Delivery

Alternatives

Cost

Availability

Physician

Preferences

Physiologic

Rationale

Debated

High risks (non expert ctrs)

Perceived Benefit

Lots of

Associated

Press, H1N1

Yes (Alternatives)

Costs (High)

Not always

available

Instant

Physiologic

Gratification,

Rescue, Anecdotal

ARF “ARDS”

p < 0.001 p < 0.001

iPV Rates/1000 personssex and age adjusted

02

46

8

2008 2009 2010 2011 2012 2013admissionyear

IPVrates Fitted values

02

46

8

2008 2009 2010 2011 2012 2013admissionyear

IPVrates Fitted values

ARF “ARDS”

p < 0.001 p < 0.001

iNO Rates/1000 personssex and age adjusted

05

10

15

20

2008 2009 2010 2011 2012 2013admissionyear

iNOrates Fitted values

05

10

15

20

2008 2009 2010 2011 2012 2013admissionyear

iNOrates Fitted values

COCHRANE RevJune 2010Intercept change p 0.32Slope change p 0.28

Strength of

Evidence

Risk/Benefit Modality and

Medium

Of Delivery

Alternatives

Costs

Availability

Physician

Preferences

Good High (renal failure) Persistent Clear

Message

?? Center

Dependent

High Cost

Instant Gratification

Physiologic Benefit

Rescue

ARF “ARDS”

p = 0.51 p = 0.56

01

02

03

04

0

2008 2009 2010 2011 2012 2013admissionyear

acurasysrates Fitted values

01

02

03

04

0

2008 2009 2010 2011 2012 2013admissionyear

acurasysrates Fitted values

cNMBA Rates/1000 personssex and age adjusted

Strength of

Evidence

Risk/Benefit Modality and

Medium

Of Delivery

Alternatives

Costs

Availability

Physician

Preferences

Debated

(?why mortality

benefit)

Low risk? Not a lot of

associated

press

Yes

Low Costs

Available

Delayed

gratification

Absence of Adoption:

1. Early adoption pre-time period

2. Slow adoption

ARF “ARDS”ACURASYSSeptember 2010Intercept change p 0.74Slope change p 0.57

p 0.29 p <0.001

-.1

0.1

.2.3

2008 2009 2010 2011 2012 2013admissionyear

hfovrates Fitted values

-.2

0.2

.4.6

2008 2009 2010 2011 2012 2013admissionyear

hfovrates Fitted values

HFO Rates/1000 personssex and age adjusted

Strength of

Evidence

Risk/Benefit Modality and

Medium

Of Delivery

Alternatives Physician

Preferences

Strong High risk Strong (multiple

papers)

Yes Experience?

Esthetics?

ARF “ARDS”

OSCILLATEFebruary 2013No cases after October 2012

p < 0.001 p < 0.001

IMPLICATIONS

• Adoption and De-adoption Art vs. Science

• Variability between Critical Care and Other Specialities:• Characteristics of underlying condition (MI vs. ARDS)

• Characteristics of innovation or intervention (ASA vs LPV)

• Quality of evidence (1M vs. 1T person trials)/Delivery

• Consistency of evidence over time or over jurisdictions

• Ideally evaluate practices at a population-based level

• Particularly challenging in ARDS

• Even more challenging when evaluating therapies that

are used infrequently and challenging to identify

CONCLUSIONS

Changes in use do not necessarily follow what evidence may suggest

evidence =/= recommended best practice =/= bedside medicine

Evidence

Alternatives

Costs

AccessibilityModality

Risks

Benefit

Patient

Factors

The more inconsistent the evidence, the greater role the additional factors play in adoption/de-adoption – particularly

true for ARDS

Physician Preferences

Questions:

Are these patterns of adoption/de-adoption similar across countries?

Teaching vs. non-teaching centers

Rescue vs. non-rescue interventions

Evidence

Acknowledgements

Dr. Gordon Rubenfeld

Dr. Eddy Fan

Dr. Hannah Wunsch

Dr. Niall Ferguson

Dr. Hayley Gershengorn

Dr. Therese Stukel

Clinician Scientist Training Program Department of Medicine

Canadian Institute for Health Research Fellowship

25

Thank You.