Racial differences in treatment of COPD exacerbation within the VA healthcare system

Cannon KT, Vaughan Sarrazin MS, Kaldjian LC, Rosenthal GE. Racial differences in treatment of COPD exacerbation within the VA healthcare system. Poster session presented at: VA HSR&D National Meeting; 2007 Feb 22; Washington, DC.

Objectives: Black patients are more likely than white patients to desire life-sustaining treatments, such as mechanical ventilation (MV). In recent years, noninvasive ventilation (NIV) has emerged as an effective life-sustaining treatment for patients with advanced pulmonary disease including COPD. The objective of this study was to describe racial differences in use of NIV and MV for treatment of COPD exacerbation within the VHA. Methods: The Patient Treatment File was used to identify all black (n = 6439) and white (n = 39,672) patients admitted to VHA facilities during FY2003-2005 with COPD exacerbation. NIV and MV use during index hospitalization were identified using ICD-9-CM codes. Generalized estimating equations were used to compare rates of NIV and MV use by race, controlling for patient characteristics and hospital-level variation. Results: Unadjusted rates of MV were higher in black patients than in white patients (3.9% vs. 2.9%, p < .001), and slightly higher for NIV (7.1% vs. 6.4%; p = .04). After adjusting for patient characteristics and facility-level variation, the odds of MV for black patients relative to white patients remained higher (OR = 1.29; p = .003). In stratified analyses, MV was also higher for black patients who died (OR = 1.91; p < .001), or survived (OR = 1.26; p = .009). The adjusted odds of NIV, however, were similar for black and white patients in analysis of all patients (OR = 1.04; p = .57) and in analyses of patients who died (OR = 1.03; p = .84) or survived (OR = 1.07, p = .41). The use of MV was higher in black patients in analysis of patients who received NIV (OR = 1.54; p = .006). Implications: Black patients with COPD exacerbation are more likely to receive MV, either alone or in conjunction with NIV, compared to white patients, while overall use of NIV is similar for both races. Impacts: Higher use of MV among black patients supports prior literature demonstrating increased use of life-sustaining treatments towards the end-of-life, depending on clinical need. By contrast, white patients in this population appear more likely to limit the use of ventilation to NIV only, without MV. Further exploration of how racial differences influence treatment of COPD exacerbation may improve the use of NIV and MV within the VHA to be consistent with current guidelines and respect individual patient preference.