The increase in the number of hospitalizations for severe sepsis coupled with declining in-hospital mortality and declining geometric mean cost per case may reflect improvements in care or increases in discharges to skilled nursing facilities; however, these findings more likely represent changes in documentation and hospital coding practices that could bias efforts to conduct national surveillance.

NEUMONIA IS A LEADING CAUSE of morbidity and mortality among US adults, resulting in more than 1 million annual hospital admissions and accounting for more than $10.5 billion in aggregate costs. 1,2 Given its public health significance, pneumonia has been the target of quality improvement activities for nearly 2 decades. This began with the publication of clinical practice guidelines in the early 1990s, 3 was followed by a series of statewide and national quality improvement initiatives, 4 and more recently has included public reporting and pay-for-performance programs led by the Joint Commission and the Centers for Medicare & Medicaid Services (CMS) and other payers. 5,6 These efforts have been associated with favorable trends in adherence to recommended processes of care, 7-10 including the choice and timely administration of antibiotics. At the same time, several epidemiologic analyses have reported that survival among pneumonia patients appears to be improving, suggesting that clinical advances, improvements in health care quality, or both are having beneficial effects. 11-14 Although the decline in pneumonia mortality may reflect real improvements in clinical outcomes, in the absence of any For editorial comment see p 1433.

IMPORTANCE Small clinical trials have shown that noninvasive ventilation (NIV) is efficacious in reducing the need for intubation and improving short-term survival among patients with severe exacerbations of chronic obstructive pulmonary disease (COPD). Little is known, however, about the effectiveness of NIV in routine clinical practice.OBJECTIVE To compare the outcomes of patients with COPD treated with NIV to those treated with invasive mechanical ventilation (IMV). DESIGN, SETTING, AND PARTICIPANTSThis was a retrospective cohort study of 25 628 patients hospitalized for exacerbation of COPD who received mechanical ventilation on the first or second hospital day at 420 US hospitals participating in the Premier Inpatient Database.EXPOSURES Initial ventilation strategy. MAIN OUTCOMES AND MEASURESIn-hospital mortality, hospital-acquired pneumonia, hospital length of stay and cost, and 30-day readmission. RESULTSIn the study population, a total of 17 978 (70%) were initially treated with NIV on hospital day 1 or 2. When compared with those initially treated with IMV, NIV-treated patients were older, had less comorbidity, and were less likely to have concomitant pneumonia present on admission. In a propensity-adjusted analysis, NIV was associated with lower risk of mortality than IMV (odds ratio [OR] 0.54; [95% CI, 0.48-0.61]). Treatment with NIV was associated with lower risk of hospital-acquired pneumonia (OR, 0.53 [95% CI, 0.44-0.64]), lower costs (ratio, 0.68 [95% CI, 0.67-0.69]), and a shorter length of stay (ratio, 0.81 [95% CI, 0.79-0.82]), but no difference in 30-day all-cause readmission (OR, 1.04 [95% CI, 0.94-1.15]) or COPD-specific readmission (OR, 1.05 [95% CI, 0.91-1.22]). Propensity matching attenuated these associations. The benefits of NIV were similar in a sample restricted to patients younger than 85 years and were attenuated among patients with higher levels of comorbidity and concomitant pneumonia. Using the hospital as an instrumental variable, the strength of association between NIV and mortality was modestly attenuated (OR, 0.66 [95% CI, 0.47-0.91]). In sensitivity analyses, the benefit of NIV was robust in the face of a strong hypothetical unmeasured confounder. CONCLUSIONS AND RELEVANCEIn a large retrospective cohort study, patients with COPD treated with NIV at the time of hospitalization had lower inpatient mortality, shorter length of stay, and lower costs compared with those treated with IMV.