Establishing real world quality standards for domiciliary non-invasive ventilation.

Abstract

Introduction Chronic Obstructive Pulmonary Disease (COPD) places a significant burden on healthcare. Non-invasive ventilation (NIV) is an established treatment for acute respiratory failure in COPD, with comprehensive guidelines.1 However, evidence for its use in the domiciliary setting is more recent, with no standardised criteria for initiating or monitoring treatment. Trials such as HOT-HMV2 demonstrated clinical benefit but excluded patients with BMI >35 or obstructive sleep apnoea (OSA), highlighting limited real-world applicability. We hypothesised that testing local standards in real-world COPD populations could offer insight into realistic expectations for national domiciliary NIV services. Objectives We developed local criteria for domiciliary NIV initiation and follow-up, assessing their feasibility in routine care to inform service design. We also characterised our COPD population to evaluate how well existing research2 applies to real-world patients. Methods This retrospective observational study used cross-sectional and longitudinal data from 181 COPD patients initiated on domiciliary NIV between 1st July 2021 and 1st July 2024 within an NHS trust. Seven local standards (table 1) were defined using clinical reasoning alongside available guidelines. Demographics were evaluated at initiation. Patients with ≥12 months of follow-up (n=107) were assessed for hospital readmission, comparing admissions in the year before and after NIV initiation. Results Demographics: 62% female, mean BMI 34 (n=138), 48% BMI >35. 35% had OSA, 67% ≥1 additional respiratory diagnoses. Performance against quality standards was variable (see table 1). However, there was a 33% reduction in hospital admissions among patients with ≥12 months follow-up, and 81% attended ≥3 respiratory clinics in the first year on treatment. Conclusions This study trialled proposed quality standards and examined the real-world COPD population. Our findings show that trial populations do not reflect real-world COPD cohorts, limiting research generalisability. Many standards proved overly ambitious, highlighting the need for evidence-based, achievable national guidelines. These findings support the need for a national audit to inform realistic, standardised domiciliary NIV pathways.