Home Initiation of Chronic Noninvasive Ventilation in Patients With COPD as Safe but Cheaper Than In-Hospital Initiation

Home-initiation of chronic noninvasive ventilation (NIV) in patients with chronic obstructive pulmonary disease (COPD) with chronic hypercapnic respiratory failure (CHRF) was shown to be as safe as in-hospital initiation, and reduced costs by over 50%, according to a study published last week in the journal BMJ.

Chronic NIV has become the standard of care for patients with severe stable COPD and CHRF. As the number of patients needing this evidence-based treatment grows, researchers hypothesized that the healthcare burden associated with in-hospital initiation would benefit greatly from home-initiation of NIV with the use of telemedicine. “It is generally thought that NIV initiation should be hospital-based, but there is little consensus on how and where it should exactly be organized,” explained the authors.

The study analyzed 67 randomized stable hypercapnic patients with COPD who were administered chronic NIV through either in-hospital initiation or home initiation using telemedicine. Results were based off 2 outcomes, in which the primary outcome was daytime arterial carbon dioxide pressure (PaCO₂) reduction after 6 months of NIV with a noninferiority margin of 0.4 kPa, and secondary outcomes were health-related quality of life (HRQoL) and costs.

Data revealed comparably significant PaCO₂ reduction at 6 months in both in-hospital initiation and home-initiation of chronic NIV compared to the baseline:

• From baseline to home-initiation (7.3±0.9 to 6.4±0.8 kPa; P <.001)
• From baseline to in-hospital initiation (7.4±0.9 to 6.4±0.8 kPa; P <.001)

Home-initiation of chronic NIV was shown to be noninferior to in-hospital initiation through the adjusted mean difference in PaCO₂ change for home-initiation versus in-hospital (0.04 kPa; 95% CI, —0.31 to 0.38 kPa). HRQoL additionally improved without difference between the 2 groups of patients as shown by the clinical COPD questionnaire total score-adjusted mean difference (0.0; 95% CI, –0.4 to 0.5).

Both in-hospital initiation and home-initiation of chronic NIV were shown to fulfill the 2 outcomes set for the study. Cost highlighted the importance of home-initiation as it was significantly cheaper than in-hospital (home: median €3768 or $4174 [interquartile range (IQR) €3546-€4163 or $3928-$4611] vs in-hospital: median €8537 or $9457 [IQR €7540-€9175 or $8352-$10,163]; P <.001).

“We showed for the first time that home initiation of NIV with the use of telemedicine in COPD patients with CHRF is non-inferior to hospital-initiation, safe and associated with savings of over 50% of the costs,” wrote the authors.

Limitations of the study do present some complications that may arise from home initiation. In the study, treatment was administered by 3 experienced ventilatory nurse specialists and the telemedicine used to initiate patients at home included a strict monitoring protocol. Patients who need NIV directly after a COPD exacerbation may also not apply to the data as all included study patients were initiated at least 4 weeks after an exacerbation. Based on the findings, patients who are administered treatments under these same conditions are the optimal source of benefit.

The comparable efficacy and reduced cost of home-initiation when compared to in-hospital initiation showcases the substantial benefit for patients with COPD with CHRF. Patient preference of home-initiation further enhances this benefit for healthcare services.

Reference

Duiverman ML, Vonk JM, Bladder G, et al. Home initiation of chronic non-invasive ventilation in COPD patients with chronic hypercapnic respiratory failure. [published online September 4, 2019]. BMJ. doi: 10.1136/thoraxjnl-2019-213303.