Key Points
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.
This cohort study investigates per capita rates of invasive mechanical ventilation in adults across 3 countries with widely variable intensive care unit bed availability.
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.
Introduction
The ability to provide invasive mechanical ventilation (IMV) is a mainstay of modern intensive care. However, initiation and use of IMV may vary among countries due to patient-specific characteristics, such as comorbidity burdens or goals of care at the end of life,1 or clinician-related factors, particularly in the absence of physiologic thresholds to inform and direct who needs intubation.2,3 More importantly, variability in the initiation of IMV may be driven by systems-level inequities, such as intensive care unit (ICU) bed availability, lack of reimbursement for advanced care planning, or availability of insurance coverage.4 To date, most comparisons of the use of IMV have been restricted to cohorts of patients in ICUs.5,6 However, this approach is confounded by international variability in ICU bed availability and limits the ability to describe (and compare) resource use at the population level. It remains unclear whether rates of IMV are similar across countries.
We therefore sought to assess per capita rates of IMV in adults across a sample of high-income countries with different ICU bed availability: England, Canada, and the US.6,7,8,9 We explored specific factors, such as age, diagnosis, and comorbidity, that might be associated with differences in the population-level use of IMV. Given the greater availability of ICU beds in the US, we hypothesized that the overall per capita rates of IMV would be higher both overall and among the more homogenous patient diagnoses and comorbidities and would be more similar among younger patients and diverge among older adult patients.
Methods
This population-based cohort study included patients who received IMV in 2018 (unless otherwise noted) in England, Canada, and the US. The year 2018 was selected to ensure recent pre–COVID-19 pandemic estimates and availability of data across countries. We used only 1 year of data to limit the potential effect of temporal trends in ICU care. Details regarding the data sources used for each country are provided in the eMethods in Supplement 1.
The study was approved by the institutional review board of Sunnybrook Health Sciences Centre in Canada, which waived patient consent requirements as the study involved deidentified patient information. In the US, the Baystate Medical Center institutional review board approved the study and waived informed consent due to the study being nonhuman participant research. Approval in England was by the Case Mix Programme, with a waiver of informed consent obtained under section 251 of the National Health Service Act 2006. The study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.10
Inclusion Criteria
We included all hospital admissions for patients aged 20 years or older who received IMV in acute care hospitals. This age cutoff was chosen to align with age bands of publicly available population estimates. We defined receipt of IMV as 1 or more episodes of positive pressure ventilation either through an endotracheal tube or tracheostomy outside of an operating room at any time during a hospitalization. Details of codes used to identify IMV in each country and relevant validation information are provided in eTable 1 in Supplement 1.
Admission Characteristics
Characteristics available for comparison across cohorts included age at the date of admission to the hospital, sex, and whether the admission was surgical. While race and ethnicity data would be helpful given the varying access to critical care services among patients, these data were not reliably available in the data sets used for our study. See eMethods in Supplement 1 for definitions of surgical admissions.
We also selected a few diagnoses and comorbidities that we believed might be comparably measured across these countries, have varying thresholds for initiation of IMV, and may represent more homogenous populations with respect to severity of illness and clinical phenotype. The primary discharge diagnoses included were acute myocardial infarction (AMI), pulmonary embolism, and upper gastrointestinal bleed. The 2 comorbidities were dementia and end-stage kidney disease requiring dialysis. These diagnoses and comorbidities were identified using comparable International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) codes in all countries (eTable 2 in Supplement 1).
In England, ICD-10 codes were available only after linking the Case Mix Programme Database to the Hospital Episode Statistics data set; therefore, the analyses stratified by primary discharge diagnosis and comorbidities used a prelinked cohort of patients from 2016 in England (eMethods in Supplement 1). Data from Canada and the US were from 2018. This approach introduced a limitation based on differing years but allowed us to avoid large differences in coding approaches to identify individuals across countries for these subgroups.
Hospital and ICU Admissions
We defined total hospital admissions for each country as an admission to an acute care hospital exclusive of day cases. For England, these data were provided by Hospital Episode Statistics from 2018. Intensive care unit admissions were identified using previously used methods in each country (eTable 3 in Supplement 1). Of note, all data from Canada excluded patients and populations in Quebec, and data from the US were from a subset of hospital admissions that were then weighted to generate national estimates.
Statistical Analysis
Data from each country were analyzed separately between January 1, 2021, and December 1, 2022, as data use agreements prevented the pooling of patient-level data. For each country, we assessed admission characteristics of patients who received IMV; these data are presented as percentages, means with SDs, and medians with IQRs, where appropriate.
Crude rates were calculated as the number of (1) hospital admissions, (2) ICU admissions, or (3) admitted patients who received IMV (numerator) divided by the estimated population count for 2018 for the individual country (denominator) and represented as a rate per 100 000 population.
Consistent with previous international comparisons,11 we used age-standardized rates as the primary measure for comparison of overall population-level rates among countries. Age standardization accounts for the differences in the age distribution of England, Canada, and the US in 2018 by adjusting the populations to have the same age distribution as a fourth population, known as a standardized population.12 Age-standardized rates were calculated using 5-year age bands of the 2010 US census as the standard population. We also assessed rates of IMV among patients with an ICU admission and stratified by whether admissions were surgical. Furthermore, we assessed rates of IMV per 1000 hospitalizations and per 1000 ICU admissions.
To assess whether IMV in each country varied by age, we derived age-specific rates of IMV using 10-year age groups by dividing the number of patients who received IMV in each age band by each country’s corresponding population estimate for that age band. Next, to compare rates of IMV in more homogenous populations, defined by primary diagnoses and comorbidities, we calculated age-specific rates of IMV per 1000 hospitalizations by dividing the number of patients who received IMV in each age band by the overall number of hospitalizations in that age band for each diagnosis and comorbidity in each country. Because of differences in data, we performed multiple sensitivity analyses for the main estimate of the rate of IMV per capita (eMethods in Supplement 1). Analyses were performed using SAS Enterprise Guide, version 8.3 and SAS, version 9.4 (SAS Institute Inc) and Stata, version 16.1 (StataCorp LLC) statistical software. Given the size of the samples and the inability to pool data sets, no statistical tests were performed.
Results
Patient Characteristics
In 2018, there were 59 873 hospital admissions with IMV in England, 70 250 in Canada (excluding Quebec), and an estimated 1 614 768 admissions in the US. Patients who received IMV in England were younger (median [IQR] age, 61 [47-72] years) than in Canada (median [IQR] age, 65 [54-74] years) and the US (median [IQR] age, 65 [54-74] years). More men than women received IMV in all 3 countries (England, 59% men [n = 35 578] and 41% women [n = 24 295]; Canada: 64% men [n = 45 175] and 36% women [n = 25 075]; US: 57% men [n = 923 474] and 43% women [n = 691 294]). A smaller percentage of patients who received IMV in England were surgical (30% [n = 18 003]) than in Canada (51% [n = 35 834]) and the US (48% [n = 778 282]). Among patients who received IMV, a larger percentage of admissions in the US had a diagnosis of AMI (7% [n = 105 136] vs 3% [n = 2211] in Canada and 3% [n = 1621] in England). A larger percentage of patients who received IMV in the US had a diagnosis of dementia (6% [n = 102 421] vs 1% [n = 938] in Canada and 1% [n = 797] in England) or were dependent on dialysis prior to receiving IMV (6% [n = 90 344] vs <1% [n = 235] in Canada and 1% [n = 729] in England) (Table 1).
Table 1. Characteristics of Patients Admitted to the Hospital Who Received Invasive Mechanical Ventilation in the US, Canada, and England in 2018.
| Characteristic | No. (%) | ||
|---|---|---|---|
| USa | Canadab | England | |
| No. of patients | 1 614 768 | 70 250 | 59 873 |
| Age, y | |||
| Mean (SD) | 63 (31) | 63 (16) | 59 (17) |
| Median (IQR) | 65 (54-74) | 65 (54-74) | 61 (47-72) |
| Sex | |||
| Female | 691 294 (43) | 25 075 (36) | 24 295 (41) |
| Male | 923 474 (57) | 45 175 (64) | 35 578 (59) |
| Surgical admission | 778 282 (48) | 35 834 (51) | 18 003 (30) |
| Primary reason for hospital admission | |||
| Acute myocardial infarction | 105 136 (7) | 2211 (3) | 1621 (3)c |
| Pulmonary embolism | 8012 (1) | 256 (<1) | 238 (<1)c |
| Gastrointestinal bleed | 14 491 (1) | 558 (1) | 885 (2)c |
| Comorbidity | |||
| Dementia | 102 421 (6) | 938 (1) | 797 (1)c |
| Dialysis | 90 344 (6) | 235 (<1) | 729 (1)c |
Weighted data.
Excludes Quebec.
Denominator = 55 332. To identify the primary reason for admission to hospital and comorbidities, we used Hospital Episode Statistics data previously linked to all ICU admissions in England for the year 2016.
Rates of IMV
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). Differences in age-standardized rates per 100 000 population persisted when the analysis was restricted to patients who both received IMV and were admitted to the ICU (England: 131 [95% CI, 130-132]; Canada: 278 [95% CI, 276-280]; US: 520 [95% CI, 520-521]) and after multiple sensitivity analyses (Table 2; eTable 4 in Supplement 1). Estimates remained unchanged after patients with a history of chronic IMV were excluded.
Table 2. Crude and Age-Standardized Rates of Hospitalizations, Intensive Care Unit (ICU) Admissions, and Invasive Mechanical Ventilation (IMV).
| Characteristic | Rate per 100 000 population (95% CI) | |||||
|---|---|---|---|---|---|---|
| US | Canada | England | ||||
| Crude | Age standardizeda | Crude | Age standardizeda | Crude | Age standardizeda | |
| Hospital admissions | 11 842 (11 838-11 847) | 11 244 (11 240-11 249) | 9439 (9426-9452) | 8918 (8906-8930) | 18 201 (18 188-18 214) | 16 923 (16 911-16 935) |
| ICU admissions | 1829 (1827-1831) | 1712 (1710-1713) | 1065 (1060-1069) | 982 (978-986) | 390 (388-392) | 355 (353-357) |
| IMV | 660 (659-661) | 614 (614-615) | 314 (312-317) | 290 (288-292) | 140 (139-141)b | 131 (130-132)b |
| Nonsurgical IMV | 342 (341-342) | 321 (320-321) | 154 (152-156) | 144 (143-146) | 98 (97-99)b | 93 (92-94)b |
| Surgical IMV | 318 (317-319) | 294 (293-295) | 160 (159-162) | 146 (144-147) | 42 (42-43)b | 38 (38-39)b |
| IMV in ICU | 559 (558-560) | 520 (520-521) | 302 (299-304) | 278 (276-280) | 140 (139-141) | 131 (130-132) |
| Nonsurgical IMV in ICU | 277 (276-277) | 260 (259-261) | 145 (144-147) | 136 (135-138) | 98 (97-99) | 93 (92-94) |
| Surgical IMV in ICU | 282 (282-283) | 261 (260-261) | 157 (155-158) | 142 (141-144) | 42 (42-43) | 38 (38-39) |
Age standardized to the US 2010 census population.
Same as data on IMV in the ICU as it was assumed that a limited amount of IMV is delivered outside an ICU in England.
The crude rate of IMV per 1000 hospitalizations was lowest in England (8.5; 95% CI, 8.5-8.6) compared with Canada (34.9; 95% CI, 34.6-35.1) and the US (55.7; 95% CI, 55.6-55.8) (eTable 5 in Supplement 1). However, the crude rate of IMV per 1000 ICU admissions was similar in each country (England: 359 [95% CI, 357-362]; Canada: 295 [95% CI, 293-298]; US: 360 [95% CI, 360-361]) (eFigure in Supplement 1).
Stratified by age, crude rates of IMV were similar among countries for younger patients and diverged for older patients (Figure 1). Among patients 80 years or older, the crude rate of IMV per 100 000 population was higher in the US (1788; 95% CI, 1781-1796) compared with Canada (694; 95% CI, 679-709) and England (209; 95% CI, 203-214). Additionally, the crude rate of IMV increased with each decade of age in all countries until patients reached 80 years of age, when overall rates decreased in Canada and England but not the US. However, rates continued to increase in both Canada and the US among nonsurgical patients older than 80 (Figure 1).
Figure 1. Age-Specific Rates of Invasive Mechanical Ventilation in Hospitals in the US, Canada, and England in 2018.
Whiskers indicate 95% CIs.
Specific Diagnoses and Comorbidities and IMV
Overall rates of IMV among patients admitted with an AMI were lower in England and Canada (each ≤40 per 1000 hospitalizations) than the US (150 per 1000 hospitalizations) (eTable 6 in Supplement 1). However, in the US and Canada, rates of IMV were similar among those hospitalized with a pulmonary embolism (40 and approximately 30 per 1000 hospitalizations, respectively) or gastrointestinal bleed (39 and approximately 25, respectively). England had the lowest overall rates of IMV among patients hospitalized with a pulmonary embolism (approximately 8 per 1000 hospitalizations) and gastrointestinal bleed (approximately 16 per 1000 hospitalizations). The overall pattern of use of IMV remained consistent in each age band, with the lowest rates in England and the highest in the US (Figure 2; eTable 6 in Supplement 1).
Figure 2. Rates of Invasive Mechanical Ventilation by Hospital Discharge Diagnosis.
Whiskers indicate 95% CIs.
Among patients hospitalized with diagnoses of dementia or dialysis dependence, rates of IMV were the highest in the US compared with England and Canada (Figure 3; eTable 6 in Supplement 1). Among hospitalized patients with a diagnosis of dementia, the rate of IMV decreased with age in all countries.
Figure 3. Rates of Invasive Mechanical Ventilation in Patients With a Known Comorbidity.
Whiskers indicate 95% CIs.
Discussion
In this cohort study of 3 high-income countries with distinct and different health care systems, we observed that the per capita rate of IMV in the US was 4 times higher than in England and twice that in Canada, a difference that mirrors the variation in rates of ICU admission. Per capita rates of IMV were more similar at younger ages and varied by almost 10-fold among patients older than 80 years. Such differences in overall use of IMV highlight the need to better understand patient-, clinician-, and systems-level choices that may result in such divergent use of a limited and expensive resource not usually considered discretionary.
Our findings are consistent with the recognized variability in availability of ICU beds and delivery of critical care services that exists among countries,13,14 provinces,15 and hospitals.16 The variation in rates of IMV among countries has multiple potential explanations, including patient and family preferences, supply-induced demand, health system structure, clinician behavior, and financial incentives. First, the role of patient preferences in dictating the intensity of care is complex. Patient cultural differences and norms at the end of life, including immigrant status, are associated with intensity of care.1 However, patient or family preferences do not always account for the high-intensity care provided in the US to Medicare beneficiaries, patients with limits on life-sustaining therapy, or patients with dementia.17,18,19 Second, supply-induced demand has been shown to occur with availability of ICU beds in the US.20 Teno et al21 found that the expansion of ICU beds in hospitals in the US was associated with increasing rates of IMV for hospitalized patients with dementia. Similarly, in our study, ICU admission rates mirrored IMV rates in each country. Third, there may be different norms among clinicians in different countries. For example, in a choice experiment in England, senior intensive care physicians were asked to prioritize patient profiles for ICU admission, and patient age had the largest association with ICU admission decisions.22 In our study, age and its associated burden of disease appeared to be an important factor associated with variation in rates of IMV among countries, particularly among older adults. Fourth, market forces in both Canada and the US, which have fee-for-service physician reimbursement models, may encourage the delivery of additional high-intensity care and IMV use in those countries.4,23
Our study does not delineate whether high rates of IMV are associated with worse outcome, the degree of variability in practice that is avoidable, or which older adults may benefit most from IMV. Controversy surrounding the role of IMV in older patients will persist as long as there are limited data on who benefits most and in whom it will cause harm.24 Moreover, health care providers continue to have a limited ability to prognosticate which patients will survive or their resulting quality of life.25 Additional aggressive care is not always beneficial. In a randomized controlled trial in France of systematically promoting ICU admission among critically ill elderly patients, the results were increased resource use without mortality benefit.26 Therefore, ensuring that patients’ individual goals and values are elicited by health care practitioners before delivering or denying intensive therapies such as IMV remains critical.
Strengths and Limitations
Strengths of this study include the ability to compare the use of IMV at a population level for 3 countries with similar age distributions and life expectancies but very different health care systems and cultural norms.7 Furthermore, in the era of COVID-19, when demands on health systems worldwide have created an acute need to assess potential rationing of medical equipment and interventions, this study provides an examination of patient care patterns and facilitates a more accurate understanding of available resources and capacity to deliver respiratory support.27
This study also has a number of limitations. These data are from 3 different data sets. While we aimed to ensure that our definitions of IMV, ICU, and associated diagnoses represented those with both the highest reliability and comparability, differences exist in data collection and definitions. In particular, identification of patients as surgical likely varied in England compared with the US and Canada. In England, we relied on more detailed data on location prior to ICU admission, whereas the definition of a surgical patient in the US and Canada depended more on general hospital procedure codes. Similarly, coding of chronic diseases or primary diagnoses has the potential for significant bias, as reimbursement relies much more on coding of disease in the US and Canada than in England. However, given the magnitude of the difference among countries, our findings may not be solely attributable to misclassification bias. Additionally, the relative differences in rates of IMV persisted despite multiple sensitivity analyses. We did not measure rates of noninvasive ventilation, which have increased over time in many countries.28,29 The use of this modality may vary and represents a substitute respiratory support in some patients. Furthermore, patients who received short-term IMV, such as in the emergency department without admission, were not captured in any country. While data in Canada and England relied on national publicly funded data sets that are likely more representative of the country’s population, data in the US were obtained from a nonrandom sample of hospitals. However, we used patient-level weighting to extrapolate to the US as a whole. This study was unable to distinguish the outcomes of decisions made by clinicians based on patient preferences for care, which may differ among countries and drive IMV use disparities. This study also only presents descriptive findings without formal statistical testing to confirm the differences identified.
Conclusion
In this population-based cohort study, we observed differences in the rate of IMV across 3 high-income countries. After accounting for differences in population age, patients in the US received IMV at a per capita rate 4 times higher than England and twice that of Canada. Additionally, the difference in rates of IMV was nearly 10-fold among older adults. These findings highlight the variation in practice that may result from differences in resource availability, physician practice, and patient preferences.
eMethods.
eTable 1. Identification of Invasive Mechanical Ventilation, by Country
eTable 2. Diagnostic Codes for Diagnoses and Comorbidities
eTable 3. Identification of Intensive Care Unit (ICU), by Country
eTable 4. Crude and Age-Standardized Rates of IMV and ICU Admissions per 100,000 Population, Varying Definition of IMV and ICU
eTable 5. Crude and Age-Standardized Rates of IMV per 1000 Hospitalizations
eTable 6. Overall Crude and Age-Standardized Rates of IMV for Each Diagnosis and Comorbidity
eFigure. Overall Crude Rate of IMV per 1000 ICU Admissions in 2018 in England, Canada, and the US
Data Sharing Statement
References
- 1.Yarnell CJ, Fu L, Manuel D, et al. Association between immigrant status and end-of-life care in Ontario, Canada. JAMA. 2017;318(15):1479-1488. doi: 10.1001/jama.2017.14418 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Yarnell CJ, Johnson A, Dam T, et al. Do thresholds for invasive ventilation in hypoxemic respiratory failure exist? a cohort study. Am J Respir Crit Care Med. 2023;207(3):271-282. doi: 10.1164/rccm.202206-1092OC [DOI] [PubMed] [Google Scholar]
- 3.de Montmollin E, Aboab J, Ferrer R, Azoulay E, Annane D. Criteria for initiation of invasive ventilation in septic shock: an international survey. J Crit Care. 2016;31(1):54-57. doi: 10.1016/j.jcrc.2015.09.032 [DOI] [PubMed] [Google Scholar]
- 4.Anesi GL, Admon AJ, Halpern SD, Kerlin MP. Understanding irresponsible use of intensive care unit resources in the USA. Lancet Respir Med. 2019;7(7):605-612. doi: 10.1016/S2213-2600(19)30088-8 [DOI] [PubMed] [Google Scholar]
- 5.Wunsch H, Linde-Zwirble WT, Harrison DA, Barnato AE, Rowan KM, Angus DC. Use of intensive care services during terminal hospitalizations in England and the United States. Am J Respir Crit Care Med. 2009;180(9):875-880. doi: 10.1164/rccm.200902-0201OC [DOI] [PubMed] [Google Scholar]
- 6.Wunsch H, Angus DC, Harrison DA, Linde-Zwirble WT, Rowan KM. Comparison of medical admissions to intensive care units in the United States and United Kingdom. Am J Respir Crit Care Med. 2011;183(12):1666-1673. doi: 10.1164/rccm.201012-1961OC [DOI] [PubMed] [Google Scholar]
- 7.Health at a glance 2021. Organisation for Economic Co-operation and Development ; 2021. Accessed March 15, 2023. https://www.oecd.org/health/health-at-a-glance
- 8.Phua J, Faruq MO, Kulkarni AP, et al. ; Asian Analysis of Bed Capacity in Critical Care (ABC) Study Investigators; Asian Critical Care Clinical Trials Group . Critical care bed capacity in Asian countries and regions. Crit Care Med. 2020;48(5):654-662. doi: 10.1097/CCM.0000000000004222 [DOI] [PubMed] [Google Scholar]
- 9.White DB, Lo B. A framework for rationing ventilators and critical care beds during the COVID-19 pandemic. JAMA. 2020;323(18):1773-1774. doi: 10.1001/jama.2020.5046 [DOI] [PubMed] [Google Scholar]
- 10.von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP; STROBE Initiative . Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. BMJ. 2007;335(7624):806-808. doi: 10.1136/bmj.39335.541782.AD [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Ahmad OB, Boschi-Pinto C, Lopez AD, Murray CJ, Lozano R, Inoue M. Age standardization of rates: a new WHO standard. World Health Organization ; 2001. Accessed March 15, 2023. https://cdn.who.int/media/docs/default-source/gho-documents/global-health-estimates/gpe_discussion_paper_series_paper31_2001_age_standardization_rates.pdf
- 12.Age-standardized rates. Statistics Canada ; 2017. Accessed September 21, 2021. https://www.statcan.gc.ca/en/dai/btd/asr
- 13.Bakhru RN, McWilliams DJ, Wiebe DJ, Spuhler VJ, Schweickert WD. Intensive care unit structure variation and implications for early mobilization practices. an international survey. Ann Am Thorac Soc. 2016;13(9):1527-1537. doi: 10.1513/AnnalsATS.201601-078OC [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Vargas M, Sutherasan Y, Antonelli M, et al. Tracheostomy procedures in the intensive care unit: an international survey. Crit Care. 2015;19(1):291. doi: 10.1186/s13054-015-1013-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Cook DJ, Guyatt GH, Jaeschke R, et al. ; Canadian Critical Care Trials Group . Determinants in Canadian health care workers of the decision to withdraw life support from the critically ill. JAMA. 1995;273(9):703-708. doi: 10.1001/jama.1995.03520330033033 [DOI] [PubMed] [Google Scholar]
- 16.Seymour CW, Iwashyna TJ, Ehlenbach WJ, Wunsch H, Cooke CR. Hospital-level variation in the use of intensive care. Health Serv Res. 2012;47(5):2060-2080. doi: 10.1111/j.1475-6773.2012.01402.x [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Barnato AE, Herndon MB, Anthony DL, et al. Are regional variations in end-of-life care intensity explained by patient preferences?: a study of the US Medicare population. Med Care. 2007;45(5):386-393. doi: 10.1097/01.mlr.0000255248.79308.41 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Hart JL, Harhay MO, Gabler NB, Ratcliffe SJ, Quill CM, Halpern SD. Variability among US intensive care units in managing the care of patients admitted with preexisting limits on life-sustaining therapies. JAMA Intern Med. 2015;175(6):1019-1026. doi: 10.1001/jamainternmed.2015.0372 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Mitchell SL, Teno JM, Kiely DK, et al. The clinical course of advanced dementia. N Engl J Med. 2009;361(16):1529-1538. doi: 10.1056/NEJMoa0902234 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Gooch RA, Kahn JM. ICU bed supply, utilization, and health care spending: an example of demand elasticity. JAMA. 2014;311(6):567-568. doi: 10.1001/jama.2013.283800 [DOI] [PubMed] [Google Scholar]
- 21.Teno JM, Gozalo P, Khandelwal N, et al. Association of increasing use of mechanical ventilation among nursing home residents with advanced dementia and intensive care unit beds. JAMA Intern Med. 2016;176(12):1809-1816. doi: 10.1001/jamainternmed.2016.5964 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Bassford CR, Krucien N, Ryan M, et al. U.K. intensivists’ preferences for patient admission to ICU: evidence from a choice experiment. Crit Care Med. 2019;47(11):1522-1530. doi: 10.1097/CCM.0000000000003903 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Manning WG, Leibowitz A, Goldberg GA, Rogers WH, Newhouse JP. A controlled trial of the effect of a prepaid group practice on use of services. N Engl J Med. 1984;310(23):1505-1510. doi: 10.1056/NEJM198406073102305 [DOI] [PubMed] [Google Scholar]
- 24.Angus DC. Admitting elderly patients to the intensive care unit—is it the right decision? JAMA. 2017;318(15):1443-1444. doi: 10.1001/jama.2017.14535 [DOI] [PubMed] [Google Scholar]
- 25.Detsky ME, Harhay MO, Bayard DF, et al. Discriminative accuracy of physician and nurse predictions for survival and functional outcomes 6 months after an ICU admission. JAMA. 2017;317(21):2187-2195. doi: 10.1001/jama.2017.4078 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Guidet B, Leblanc G, Simon T, et al. ; ICE-CUB 2 Study Network . Effect of systematic intensive care unit triage on long-term mortality among critically ill elderly patients in France: a randomized clinical trial. JAMA. 2017;318(15):1450-1459. doi: 10.1001/jama.2017.13889 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Keohane LM. Expanding ventilator capacity—the need for state and regional planning. JAMA Health Forum. 2020;1(4):e200391. doi: 10.1001/jamahealthforum.2020.0391 [DOI] [PubMed] [Google Scholar]
- 28.Demoule A, Chevret S, Carlucci A, et al. ; oVNI Study Group; REVA Network (Research Network in Mechanical Ventilation) . Changing use of noninvasive ventilation in critically ill patients: trends over 15 years in francophone countries. Intensive Care Med. 2016;42(1):82-92. doi: 10.1007/s00134-015-4087-4 [DOI] [PubMed] [Google Scholar]
- 29.Sullivan DR, Kim H, Gozalo PL, Bunker J, Teno JM. Trends in noninvasive and invasive mechanical ventilation among Medicare beneficiaries at the end of life. JAMA Intern Med. 2021;181(1):93-102. doi: 10.1001/jamainternmed.2020.5640 [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
eMethods.
eTable 1. Identification of Invasive Mechanical Ventilation, by Country
eTable 2. Diagnostic Codes for Diagnoses and Comorbidities
eTable 3. Identification of Intensive Care Unit (ICU), by Country
eTable 4. Crude and Age-Standardized Rates of IMV and ICU Admissions per 100,000 Population, Varying Definition of IMV and ICU
eTable 5. Crude and Age-Standardized Rates of IMV per 1000 Hospitalizations
eTable 6. Overall Crude and Age-Standardized Rates of IMV for Each Diagnosis and Comorbidity
eFigure. Overall Crude Rate of IMV per 1000 ICU Admissions in 2018 in England, Canada, and the US
Data Sharing Statement