Study: ICU ventilator use significantly higher in U.S than in England and Canada

A new study published today in JAMA Internal Medicine has found that patients in the United States were four times more likely to receive invasive mechanical ventilation (IMV) compared to patients in England. The study, which examined data of patients who received IMV in England, Canada and the United States in 2018, also found that patients in the U.S received IMV at a rate twice that in Canada.

“The ability to provide invasive mechanical ventilation is a mainstay of modern intensive care,” says Dr. Hannah Wunsch, senior author of the study and critical care physician and senior scientist at Sunnybrook Health Sciences Centre. “However, there is little research describing what variability exists when it comes to initiating and delivering that care around the world.”

The research team’s goal was to better understand how population-level rates of mechanical ventilation differ among countries and what might be driving these differences. To do this, the team examined 2018 data of patients aged 20 years or older who received mechanical ventilation across three high-income countries with a large variation in per-capita intensive care unit bed availability (England, Canada and the United States). Rates were analyzed by age, specific diagnoses and comorbidities.

“While we found that there is significant variability in use and likelihood of being placed on a mechanical ventilator between countries, it is unclear whether more ‘intensive care’ is better,” says Dr. Naheed Jivraj, co-author of the study and an anesthesiologist in the Department of Anesthesiology and Pain Medicine at the University of Toronto. Moreover, greater use of such interventions and care options does not necessarily translate into better population health. “Despite having more ICU beds and a high rate of mechanical ventilation, the U.S. has a lower life expectancy, ranks lower on international comparisons, and had a higher mortality rate from COVID-19. On the other hand, England had the lowest rates of mechanical ventilation, and almost always outranks Canada and the United States in international comparisons of health systems, such as in the Commonwealth Fund Report.”

The authors also noted that one of the largest drivers in differences between countries was age, with widening differences in rate of use among older people. “With an aging population, we need more research to better understand which older adults stand to benefit most from mechanical ventilation,” says Dr. Jivraj. “We also need to ensure they receive equitable access to the intensity of care that aligns with their goals and values.”

When it comes to determining explanations for the differences among countries, Dr. Wunsch adds that the variation likely has many causes, including, supply-induced demand, and different patient and family preferences, health system structures, clinician behaviours and financial incentives. “A next step in our research is to better understand factors that are driving these differences to ultimately identify best practices.”