Institutional Factors Contribute to Variation in Intubation Rates in Status Epilepticus

To explore intubation rates among patients with status epilepticus (SE) and the degree of institutional variation.

Serial cross-sectional study of SE-related hospitalizations from 2004 to 2013 using data from the National Inpatient Sample. The primary outcome was intubation of patients with SE. Multivariable models identified predictors of intubation, institutional variation in intubation rates, and the proportion of variance attributable to individual hospitals. This analysis was repeated using data from 5 states in the State Inpatient Databases (SID).

There were 119 337 SE hospitalizations. The overall intubation rate was 32.7% (95% confidence interval [CI]: 32.2%-33.3%). There was marked variation in estimated intubation rates, ranging from 2% to 80% in the lowest and highest quintile after adjustment. There was somewhat less variability in the SID cohort where quintiles ranged from 10% to 54%. Those undergoing intubation were more often men and presenting with stroke, intracerebral hemorrhage, central nervous system infection, hyponatremia, and alcohol withdrawal. Urban location (odds ratio [OR]: 3.8, 95% CI: 2.7-5.5) and hospitalization at a teaching institution (OR: 3.9, 95% CI: 1.2-12.6) were even stronger predictors of intubation after adjustment for clinical factors. A regression including both patient- and hospital-level variables to predict intubation also performed better than a regression including patient factors alone (C statistic 0.81 vs 0.59, respectively).

There is considerable institutional variation in intubation rates for SE independent of patient characteristics suggesting that decisions around intubation rest heavily on where one is hospitalized. Further work is needed to clarify how this variation influences outcomes.