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Original Research: CRITICAL CARE MEDICINE |

Prolonged Acute Mechanical Ventilation: Implications for Hospital Benchmarking

Marya D. Zilberberg, MD, MPH, FCCP; Andrew A. Kramer, PhD; Thomas L. Higgins, MD, MBA; Andrew F. Shorr, MD, MPH, FCCP
Author and Funding Information

*From the School of Public Health and Health Sciences (Dr. Zilberberg), University of Massachusetts, Amherst, MA; Cerner Corporation (Dr. Kramer), Kansas City, MO; the Division of Critical Care Medicine (Dr. Higgins), Baystate Medical Center, Springfield, MA; and the Division of Pulmonary and Critical Care (Dr. Shorr), Washington Hospital Center, Washington, DC.

Correspondence to: Marya D. Zilberberg, MD, MPH, FCCP, University of Massachusetts, School of Public Health and Health Sciences, PO Box 303, Goshen, MA 01032; e-mail: Marya@EviMedGroup.org


Dr. Kramer is an employee of Cerner Corporation, which holds the rights to the APACHE system. Drs. Zilberberg, Higgins, and Shorr have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).


© 2009 American College of Chest Physicians


Chest. 2009;135(5):1157-1162. doi:10.1378/chest.08-1928
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Background:  Hospital performance measures rely on aggregate outcomes. For patients receiving mechanical ventilation (MV), outcomes depend on severity of illness, hospital MV volume, and case mix. Patients requiring prolonged acute MV (PAMV) [MV for ≥ 96 h] comprise a resource-intensive group, but the impact of its volume on aggregate outcomes is unknown. We investigated whether observed outcomes differed from those predicted by APACHE (acute physiology and chronic health evaluation) IV risk adjustment and the relationship between hospital MV volume and outcomes among patients receiving PAMV.

Methods:  We conducted a retrospective cohort study using the APACHE IV database between the years 2001 and 2005.

Results:  Of the 94,553 patients receiving MV at 45 hospitals, 24,366 (25.8%) were receiving PAMV. Unadjusted mortality was 32.3% for patients receiving PAMV and 22.9% for patients receiving short-term MV (STMV) [< 96 h]. Although mortality predictions were accurate in both groups, the length-of-stay (LOS) predictions underestimated duration of MV, ICU LOS, and hospital LOS by 5.2, 4.6, and 5.4 days, respectively, in the PAMV group. After stratifying the PAMV group by hospital MV volume, except for quintile 1, the standardized mortality ratio (SMR) was found to be inversely related to the volume quintile. The difference between actual and predicted MV durations, however, exhibited a consistent direct relationship with the MV volume.

Conclusions:  In patients requiring PAMV, the SMR is inversely proportional to hospital MV volume. Conversely, the PAMV group had a disproportionate effect on durations of MV, ICU LOS, and hospital LOS, and these marginal excesses increased with the hospital MV volume quintile. Development of specific predictive equations for patients receiving PAMV is recommended. Benchmarking measures must consider the case mix of patients receiving STMV vs those receiving PAMV.


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