Outcomes following acute exacerbation of severe chronic obstructive lung disease. The SUPPORT investigators (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments)

Guidelines for the referral and management of patients eligible for solid organ transplantation

Members of the Clinical Practice Committee, American Society of Transplantation, have attempted to define referral criteria for solid organ transplantation. Work done by the Clinical Practice Committee does not represent the official position of the American Society of Transplantation. Recipients for solid organ transplantation are growing in numbers, progressively outstripping the availability of organ donors. As there may be discrepancies in referral practice and, therefore, inequity may exist in terms of access to transplantation, there needs to be uniformity about who should be referred to transplant centers so the system is fair for all patients. A review of the literature that is both generic and organ specific has been conducted so referring physicians can understand the criteria that make the patient a suitable potential transplant candidate. The psychosocial milieu that needs to be addressed is part of the transplant evaluation. Early intervention and evaluation appear to play a positive role in maximizing quality of life for the transplant recipient. There is evidence, especially in nephrology, that the majority of patients with progressive failure are referred to transplant centers at a late stage of disease. Evidence-based medicine forms the basis for medical decision-making about accepting the patient as a transplant candidate. The exact criteria for each organ are detailed. These guidelines reflect consensus opinions, synthesized by the authors after extensive literature review and reflecting the experience at their major transplant centers. These guidelines can be distributed by transplant centers to referring physicians, to aid them in understanding who is potentially an acceptable candidate for transplantation. The more familiar physicians are with the exact criteria for specific organ transplantation, the more likely they are to refer patients at an appropriate stage. Individual transplant centers will make final decisions on acceptability for transplantation based on specific patient factors. It is hoped that this overview will assist insurers/payors in reimbursing transplant centers for solid organ transplantation, based on criteria for acceptability by the transplant community. The selection and management of patients with end-stage organ failure are constantly changing, and future advances may make obsolete some of the criteria mentioned in the guidelines. Most importantly, these are intended to be guidelines, not rules.

Respiratory intensive care units in Italy: a national census and prospective cohort study

BACKGROUND

In Italy, respiratory intensive care units (RICUs) provide an intermediate level of care between the intensive care unit (ICU) and the general ward for patients with single organ respiratory failure. Because of the lack of official epidemiological data in these units, a two phase study was performed with the aim of describing the work profile in Italian RICUs.

METHODS

A national survey of RICUs was conducted from January to March 1997 using a questionnaire which comprised over 30 items regarding location, models of service provision, staff, and equipment. The following criteria were necessary for inclusion of a unit in the survey: (1) a nurse to patient ratio ranging from 1:2.5 to 1:4 per shift; (2) availability of adequate continuous non-invasive monitoring; (3) expertise for non-invasive ventilation (NIV) and for intubation in case of NIV failure; (4) physician availability 24 hours a day. Between November 1997 and January 1998 a 3 month prospective cohort study was performed to survey the patient population admitted to the RICUs.

RESULTS

Twenty six RICUs were included in the study: four were located in rehabilitation centres and 22 in general hospitals. In most, the reported nurse to patient ratio ranged from 1:2 to 1:3, with 36% of units reporting a ratio of 1:4 per shift. During the study period 756 consecutive patients of mean (SD) age 68 (12) years were admitted to the 26 RICUs. The highest proportion (47%) were admitted from emergency departments, 19% from other medical wards, 18% were transferred from the ICU, 13% from specialist respiratory wards, and 2% were transferred following surgery. All but 32 had respiratory failure on admission. The reasons for admission to the RICU were: monitoring for expected clinical instability (n=221), mechanical ventilation (n=473), and weaning (n=59); 586 patients needed mechanical ventilation during their stay in the RICU, 425 were treated with non-invasive techniques as a first line of treatment (374 by non-invasive positive pressure, 51 by iron lung), and 161 underwent invasive mechanical ventilation (63 intubated, 98 tracheostomies). All but 48 patients had chronic respiratory disease, mainly chronic obstructive pulmonary disease (COPD; n=451). More than 70% of patients (n=228) had comorbidity, mainly consisting of heart disorders. The median APACHE II score was 18 (range 1--43). The predicted inpatient mortality risk rate according to the APACHE II equation was 22.1% while the actual inpatient mortality rate was 16%. The mean length of stay in the RICU was 12 (11) days. The outcome in most patients (79.2%) admitted to RICUs was favourable.

CONCLUSIONS

Italian RICUs are specialised units mainly devoted to the monitoring and treatment of acute on chronic respiratory failure by non-invasive ventilation, but also to weaning from invasive mechanical ventilation. The results of this study provide a useful insight into an increasingly important field of respiratory medicine.

Epidemiology of chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a leading cause of world-wide mortality and disability. On average approximately 5-15% of adults in industrialized countries have COPD defined by spirometry. In 1990, COPD was considered to be at the twelfth position world-wide as a cause of combined mortality and disability but is expected to become the fifth cause by the year 2020. COPD has a chronic long-lasting course characterized by irreversible decline of forced expiratory volume in one second (FEV1), increasing presence of dyspnoea and other respiratory symptoms, and progressive deterioration of health status. After diagnosis the 10-yr survival rate is approximately 50% with more than one-third of patients dying due to respiratory insufficiency. Several environmental exposures such as air pollution increase the risk of death in COPD patients. The aetiology of COPD is overwhelmingly dominated by smoking although many other factors could play a role. Particular genetic variants are likely to increase the susceptibility to environmental factors although little is known about which are the relevant genes. There is clear evidence about the role of the alpha-1-antitrypsin but the fraction of COPD attributable to the relevant variants is only 1%. Phenotypic traits that are considered to play a role in the development of COPD include sex, with females being at a higher risk, bronchial responsiveness and atopy. There is strong causal evidence regarding the relationship between smoking and COPD with decline in FEVI levelling off after smoking cessation. Passive smoking has been found to be associated with a small though statistically significant decline in FEV1. Other risk factors that are likely to be relevant in the development of COPD are occupation, low socioeconomic status, diet and possibly some environmental exposures in early life. Although there is accumulating evidence that oxygen therapy, pharmacological treatment and rehabilitation may improve the course of chronic obstructive pulmonary disease, preventing smoking continues to be the most relevant measure, not only to prevent chronic obstructive pulmonary disease, but also to arrest its development.

Management of acute exacerbations of COPD: a summary and appraisal of published evidence

STUDY OBJECTIVES

To critically review the available data on the diagnostic evaluation, risk stratification, and therapeutic management of patients with acute exacerbations of COPD.

DESIGN, SETTING, AND PARTICIPANTS

English-language articles were identified from the following databases: MEDLINE (from 1966 to week 5, 2000), EMBASE (from 1974 to week 18, 2000), HealthStar (from 1975 to June 2000), and the Cochrane Controlled Trials Register (2000, issue 1). The best available evidence on each subtopic then was selected for analysis. Randomized trials, sometimes buttressed by cohort studies, were used to evaluate therapeutic interventions. Cohort studies were used to evaluate diagnostic tests and risk stratification. Study design and results were summarized in evidence tables. Individual studies were rated as to their internal validity, external validity, and quality of study design. Statistical analyses of combined data were not performed.

MEASUREMENT AND RESULTS

Limited data exist regarding the utility of most diagnostic tests. However, chest radiography and arterial blood gas sampling appear to be useful, while short-term spirometry measurements do not. In terms of the risk of relapse and the risk of death after hospitalization for an acute exacerbation, there are identifiable clinical variables that are associated with these outcomes. Therapies for which there is evidence of efficacy include bronchodilators, corticosteroids, and noninvasive positive-pressure ventilation. There is also support for the use of antibiotics in patients with more severe exacerbations. Based on limited data, mucolytics and chest physiotherapy do not appear to be of benefit, and oxygen supplementation appears to increase the risk of respiratory failure in an identifiable subgroup of patients.

CONCLUSIONS

Although suggestions for appropriate management can be made based on available evidence, the supporting literature is spotty. Further high-quality research is needed and will require an improved, generally acceptable, and transportable definition of the syndrome "acute exacerbation of COPD" and improved methods for observing and measuring outcomes.

Weaning from prolonged mechanical ventilation

The development of weaning failure and need for PMV is multifactorial in origin, involving disorders of pulmonary mechanics and complications associated with critical illness. The underlying disease process is clearly important when discussing mechanisms of ventilator dependence; interventions therefore must be tailored to individual patients. Unfortunately, the main conclusion that can be drawn from the sum of the studies investigating patients on PMV to date is that an evidence-based approach to weaning is not possible and more research needs to be done. New studies need to incorporate severity-of-illness scores and an assessment of principal and comorbid conditions to allow for comparison of the findings from different centers. The best approach to a patient requiring PMV after exclusion of easily treatable conditions is not known. The literature regarding both acute and chronic cases suggests that a systematic approach to weaning involving the participation of multiple caregivers, including nurses, physicians, and respiratory, physical, and speech therapists facilitates liberation from MV. Although a gradual decrement in ventilator support would seem prudent, Scheinhorn et al have begun to identify a subpopulation of patients who can tolerate an acceleration of the weaning process. Given the known complications associated with MV, it is crucial that further research be performed to identify patients as soon as they are capable of breathing spontaneously. The literature demonstrates through multiple studies that satisfactory patient outcomes are attainable and can be achieved at LTAC facilities in a more cost-effective manner than in an ICU setting. The trend toward the concentration of patients into specialized regional weaning centers should facilitate the research process and continue to improve outcomes in this population.

Dose dependent increased mortality risk in COPD patients treated with oral glucocorticoids

Systemic corticosteroids are often administered in COPD patients. The relationship between systemic glucocorticoids and mortality in patients with moderate to severe chronic obstructive pulmonary disease (COPD) was retrospectively analysed. Baseline characteristics of the patients, in stable clinical condition, were collected on admission to a pulmonary rehabilitation centre. Overall mortality was asessed at the end of follow-up. The Cox proportional hazards model was used to quantify the relationship between glucocorticoid use, distinguishing administration route (oral/inhalation) and oral dose, and overall mortality, adjusted for the influence of age, sex, smoking, lung function, resting arterial blood gases and body mass index. On multivariate analysis, oral glucocorticoid use at a (prednisone equivalent) dose of 10 mg x day(-1) without inhaled glucocorticoids, was associated with an increased risk (RR=2.34, 95% confidence interval (CI) 1.24-4.44) while 15 mg x day(-1) carried a relative risk of 4.03, CI = 1.99-8.15). A significant interaction was observed between inhaled and oral glucocorticoid use. Combined with inhaled glucocorticoids, the relative risk of oral glucocorticoid use appeared to be significantly smaller. It is concluded that in severe chronic obstructive pulmonary disease, maintenance treatment with oral glucocorticoids is associated with increased mortality in a dose-dependent manner. Since the present study design cannot exclude the possibility of bias by indication, further prospective studies are indicated using a broader patient characterization.

Noninvasive mechanical ventilation for post acute care

The increasing use of NPPV in both acute and chronic settings has added to ventilator options in the post acute setting. Some patients start NPPV during their acute presentation and continue use during their post acute stay. Others are difficult to wean from invasive mechanical ventilation, and, if selected carefully, can be extubated and weaned using NPPV. Still others may initiate NPPV in the post acute setting with the anticipation of long-term use. In any care settings, principles of patient selection and management in monitoring practices overlap considerably. Noninvasive ventilation has been shown to reduce morbidity, mortality, and hospital stay in the acute setting for selected patients, and almost certainly prolongs survival for patients with restrictive thoracic disorders in the chronic setting. Although efficacy studies have not been performed in the post acute setting, it is reasonable to anticipate that appropriate use of NPPV will yield similar benefits. Accordingly, clinicians working in the post acute setting must acquire skill and experience in the proper application of NPPV to optimally manage the increasing number of patients treated with NPPV in this expanding arena.

An economic overview of chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a major cause of mortality and morbidity. Relatively few pharmacoeconomic studies have been conducted on this disease. This article reviews available information about the utilisation of healthcare resources and cost of care, and the cost or cost effectiveness of therapeutic interventions reported for this disease. Burden-of-illness data indicate that hospital care, medications and oxygen therapy were the major cost drivers in these studies. Mean annual Medicare expenditures in the US were $US11,841 (2000 values) for patients with COPD compared with $US4,901 for all covered patients. Utilisation was skewed; the most expensive 10% of the Medicare beneficiaries accounted for nearly 50% of total expenditures for this disease. Costs are associated with health status, age, physician specialty, geographic location and type of insurance coverage. Six types of interventions were assessed in the literature--pharmacotherapy, oxygen therapy, home care, surgery, exercise and rehabilitation and health education. The studies used different analytic strategies (e.g. cost-minimisation and cost-effectiveness analyses) and even within the realm of cost-effectiveness analyses, no uniformity existed as to how outcome was measured. Patient severity was not always delineated, and the length of the follow-up period, while quite short, varied. Only 11 of the 34 evaluations were based on randomised controlled trials. Cost-minimisation studies generally found no significant difference in the cost of antimicrobial treatment for first-line, second-line and third-line agents. Studies of bronchodilators indicated that ipratropium bromide alone or in combination with salbutamol (albuterol) was the preferred medication. The major area for achieving cost savings is by reducing hospital utilisation. As the annual rate of hospitalisation is relatively low, large patient samples will be required to demonstrate an economic advantage for a new therapy. The major challenges will be financing such a study, and selecting an outcome measure that satisfies both clinical and economic conventions.

Lung transplantation for chronic obstructive pulmonary disease

Lung transplantation is able to provide dramatic gains in pulmonary function to patients with advanced pulmonary emphysema. At the present time, however, transplantation is available to a strictly defined pool of candidates, and outcomes are limited by numerous respiratory and nonrespiratory postoperative complications. Further progress is needed in expanding the supply of donor lungs, minimizing perioperative complications, and optimizing postoperative immunologic management.

The chronic obstructive pulmonary disease exacerbation

Chronic obstructive pulmonary disease is the only leading cause of death with a rising prevalence. The medical and economic costs arising from acute exacerbations of COPD are therefore expected to increase over the coming years. Although exacerbations may be initiated by multiple factors, the most common identifiable associations are with bacterial and viral infections. These are associated with approximately 50% to 70% and 20% to 30% of COPD exacerbations, respectively. In addition to smoking cessation, annual influenza vaccination is the most important method for preventing exacerbations. Controlled O2 is the most important intervention for patients with acute hypoxic respiratory failure. Evidence from randomized, controlled trials justifies the use of corticosteroids, bronchodilators (but not theophylline), noninvasive positive-pressure ventilation (in selected patients), and antibiotics, particularly for severe exacerbations. Antibiotics should be chosen according to the patient's risk for treatment failure and the potential for antibiotic resistance. In the acute setting, combined treatment with beta-agonist and anticholinergic bronchodilators is reasonable but not supported by randomized controlled studies. Physicians should identify and, when possible, correct malnutrition. Chest physiotherapy has no proven role in the management of acute exacerbations.

Corticosteroids in chronic obstructive pulmonary disease. Clinical benefits and risks

The use of systemic and inhaled corticosteroids for COPD has increased appreciably over the past 20 years. Clearer indications for corticosteroid therapy in COPD are beginning to emerge as the results from large clinical trials become available. Systemic corticosteroids are only modestly effective for acute COPD exacerbations, increase the risk for hyperglycemia, and should be given for no more than 2 weeks. The efficacy of long-term systemic corticosteroid therapy has not been adequately evaluated in this patient population. If longer term use of systemic steroids in COPD should be found to be useful, this conclusion would have to be weighed against the risk for serious adverse effects. High doses of inhaled corticosteroids cause a small sustained increase of the FEV1 in patients with mild and moderately severe COPD, but they do not slow the rate of FEV1 decline. Based on analyses of secondary outcome, inhaled corticosteroids may improve the respiratory symptoms and decrease the number and severity of COPD exacerbations in patients with more advanced disease. Low doses of inhaled corticosteroids appear to be safe, but there is growing awareness that higher doses may not be so benign.

Mechanical ventilation in chronic obstructive lung disease

Exacerbations of COPD are a leading indication for MV in the intensive care unit. A thorough understanding of the pathophysiology of AVF in COPD is critical for physicians caring for these patients. In particular, physicians should understand DHI and use the ventilator and ancillary techniques to minimize its impact. Noninvasive positive-pressure ventilation should be considered strongly in relatively stable patients with an adequate mental status and manageable secretions. Once AVF resolves, patients should be removed from the ventilator as soon as is safe to do so to minimize the adverse effects of prolonged MV. An organized approach to weaning and identifying patients capable of independent breathing is crucial. Most patients with COPD and AVF benefit from MV and generally return to or approach their premorbid functional status. A significant subset, however, will not benefit from, or choose not to undergo, MV. Deciding upon appropriate therapeutic options for these patients relies heavily on effective communication between physician and patient. Comprehensive discussions before the development of AVF can assist decision-making after respiratory failure develops.

"Hospital at home" versus hospital care in patients with exacerbations of chronic obstructive pulmonary disease: prospective randomised controlled trial

OBJECTIVES

To compare "hospital at home" and hospital care as an inpatient in acute exacerbations of chronic obstructive pulmonary disease.

DESIGN

Prospective randomised controlled trial with three months' follow up.

SETTING

University teaching hospital offering secondary care service to 350 000 patients.

PATIENTS

Selected patients with an exacerbation of chronic obstructive pulmonary disease where hospital admission had been recommended after medical assessment.

INTERVENTIONS

Nurse administered home care was provided as an alternative to inpatient admission.

MAIN OUTCOME MEASURES

Readmission rates at two weeks and three months, changes in forced expiratory volume in one second (FEV(1)) from baseline at these times and mortality.

RESULTS

583 patients with chronic obstructive pulmonary disease referred for admission were assessed. 192 met the criteria for home care, and 42 refused to enter the trial. 100 were randomised to home care and 50 to hospital care. On admission, FEV(1) after use of a bronchodilator was 36.1% (95% confidence interval 2.4% to 69.8%) predicted in home care and 35.1% (6.3% to 63. 9%) predicted in hospital care. No significant difference was found in FEV(1 )after use of a bronchodilator at two weeks (42.6%, 3.4% to 81.8% versus 42.1%, 5.1% to 79.1%) or three months (41.5%, 8.2% to 74.8% versus 41.9%, 6.2% to 77.6%) between the groups. 37% of patients receiving home care and 34% receiving hospital care were readmitted at three months. No significant difference was found in mortality between the groups at three months (9% versus 8%).

CONCLUSIONS

Hospital at home care is a practical alternative to emergency admission in selected patients with exacerbations of chronic obstructive pulmonary disease.

Is it possible to predict the success of non-invasive positive pressure ventilation in acute respiratory failure due to COPD?

There is now sufficient evidence that non-invasive positive pressure ventilation (NIPPV) in selected patients with severe hypercapnic acute respiratory failure due to chronic obstructive pulmonary disease (COPD) is more effective than pharmacological therapy alone. The aim of this study was to identify prognostic factors to predict the success of this technique. Fifty-nine consecutive patients with COPD admitted to a respiratory ward for 75 episodes of acute respiratory failure treated with NIPPV were analysed: success (77%) or failure (23%) were evaluated by survival and the need for endotracheal intubation. There were no significant differences in age, sex, cause of relapse and lung function tests between the two groups. Patients in whom NIPPV was unsuccessful were significantly underweight, had an higher Acute Physiology and Chronic Health Evaluation (APACHE) II score, and a lower serum level of albumin in comparison with those in whom NIPPV was successful. They demonstrated significantly greater abnormalities in pH and PaCO2 at baseline and after 2h of NIPPV. The logistic regression analysis demonstrated that, when all the variables were tested together, a high APACHE II score and a low albumin level continued to have a significant predictive effect. This analysis could predict the outcome in 82% of patients. In conclusion, our study suggests that low albumin serum levels and a high APACHE II score may be important indices in predicting the success of NIPPV.

Incidence and causes of non-invasive mechanical ventilation failure after initial success

BACKGROUND

The rate of failure of non-invasive mechanical ventilation (NIMV) in patients with chronic obstructive pulmonary disease (COPD) with acute respiratory insufficiency ranges from 5% to 40%. Most of the studies report an incidence of "late failure" (after >48 hours of NIMV) of about 10-20%. The recognition of this subset of patients is critical because prolonged application of NIMV may unduly delay the time of intubation.

METHODS

In this multicentre study the primary aims were to assess the rate of "late NIMV failure" and possible associated predictive factors; secondary aims of the study were evaluation of the best ventilatory strategy in this subset of patients and their outcomes in and out of hospital. The study was performed in two respiratory intensive care units (ICUs) on patients with COPD admitted with an episode of hypercapnic respiratory failure (mean (SD) pH 7.23 (0.07), PaCO(2) 85.3 (15.8) mm Hg).

RESULTS

One hundred and thirty seven patients initially responded to NIMV in terms of objective (arterial blood gas tensions) and subjective improvement. After 8.4 (2.8) days of NIMV 31 patients (23%; 95% confidence interval (CI) 18 to 33) experienced a new episode of acute respiratory failure while still ventilated. The occurrence of "late NIMV failure" was significantly associated with functional limitations (ADL scale) before admission to the respiratory ICU, the presence of medical complications (particularly hyperglycaemia), and a lower pH on admission. Depending on their willingness or not to be intubated, the patients received invasive ventilation (n=19) or "more aggressive" (more hours/day) NIMV (n=12). Eleven (92%) of those in this latter subgroup died while in the respiratory ICU compared with 10 (53%) of the patients receiving invasive ventilation. The overall 90 day mortality was 21% and, after discharge from hospital, was similar in the "late NIMV failure" group and in patients who did not experience a second episode of acute respiratory failure.

CONCLUSIONS

The chance of COPD patients with acute respiratory failure having a second episode of acute respiratory failure after an initial (first 48 hours) successful response to NIMV is about 20%. This event is more likely to occur in patients with more severe functional and clinical disease who have more complications at the time of admission to the ICU. These patients have a very poor in-hospital prognosis, especially if NIMV is continued rather than prompt initiation of invasive ventilation.

Disturbances in leptin metabolism are related to energy imbalance during acute exacerbations of chronic obstructive pulmonary disease

Previously we reported an impaired energy balance in patients with chronic obstructive pulmonary disease (COPD) during an acute disease exacerbation, but limited data are available on the underlying mechanisms. Experimental and clinical research supports the hypothesis of involvement of the hormone leptin in body weight and energy balance homeostasis. The aim of this study was to investigate the course of the energy balance in relation to leptin and the soluble tumor necrosis factor (TNF) receptors (sTNF-R) 55 and 75, plasma glucose, and serum insulin in patients with severe COPD during the first 7 d of hospitalization for an acute exacerbation (n = 17, 11 men, age mean [SD] 66 [10] yr, FEV(1) 36 [12] %pred). For reference values of the laboratory parameters, blood was collected from 23 (16 men) healthy, elderly subjects. On admission, the dietary intake/resting energy expenditure (REE) ratio was severely depressed (1.28 [0.57]), but gradually restored until Day 7 (1.65 [0. 45], p = 0.005 versus Day 1). Glucose and insulin concentrations were elevated on admission, but on Day 7 only plasma glucose was decreased. The sTNF-Rs were not different from healthy subjects and did not change. Plasma leptin, adjusted for fat mass expressed as percentage of body weight (%FM), was elevated on Day 1 compared with healthy subjects (1.82 [3.85] versus 0.32 [0.72] ng%/ml, p = 0.008), but decreased significantly until Day 7 (1.46 [3.77] ng%/ml, p = 0. 015 versus Day 1). On Day 7, sTNF-R55 was, independently of %FM, correlated with the natural logarithm (LN) of leptin (r = 0.65, p = 0.041) and with plasma glucose (r = 0.81, p = 0.015). In addition, the dietary intake/REE ratio was not only inversely related with LN leptin (-0.74, p = 0.037), but also with sTNF-R55 (r = -0.93, p = 0. 001) on day seven. In conclusion, temporary disturbances in the energy balance were seen during an acute exacerbation of COPD, related to increased leptin concentrations as well as to the systemic inflammatory response. Evidence was found that the elevated leptin concentrations were in turn under control of the systemic inflammatory response, and, presumably, the high-dose systemic glucocorticosteroid treatment.

Functional status and survival following pulmonary rehabilitation

BACKGROUND

Functional exercise capacity has been shown to be a strong predictor of survival following pulmonary rehabilitation. This study evaluated whether questionnaire-rated functional status is also predictive of survival.

PATIENTS AND METHODS

Following pulmonary rehabilitation, patients with advanced chronic lung disease were evaluated for survival, 6-min walk distance, and questionnaire-rated functional status. The latter was measured using the pulmonary functional status scale, which has subscores of functional activities, psychological status, and dyspnea. Information on survival was available on 149 patients.

RESULTS

The mean age was 69 years, and 45% of patients were male. Eighty-nine percent had a diagnosis of COPD, and their FEV(1) was 37+/-18% of predicted. Ninety-one (61%) were married. The 3-year survival for the group was 85%. Age, gender, body mass index, and primary diagnosis were not related to survival. Variables strongly associated with increased survival following pulmonary rehabilitation included a higher postrehabilitation Functional Activities score, a longer postrehabilitation 6-min walk distance, and being married (vs widowed, single, or divorced). Disease severity variables associated with survival included an initial referral to outpatient pulmonary rehabilitation, no supplemental oxygen requirement, and a higher percent-predicted FEV(1).

CONCLUSION

Indicators of functional status are strong predictors of survival in patients with advanced lung disease.

Age-related differences in care preferences, treatment decisions, and clinical outcomes of seriously ill hospitalized adults: lessons from SUPPORT

OBJECTIVES

To review previously published findings about how patient age influenced patterns of care for seriously ill patients enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT).

DESIGN

An observational prospective study.

SETTING

Five acute care hospitals.

PARTICIPANTS

A total of 9105 seriously ill patients enrolled in SUPPORT.

MEASUREMENTS

The outcomes examined included patients' preferences for aggressive care, decision making regarding cardiopulmonary resuscitation and use of other life-sustaining treatments, hospital costs, intensity of resource use, and survival.

RESULTS

Although older patients preferred less aggressive care than younger patients, many older patients wanted cardiopulmonary resuscitation and care focused on life extension. Patients' families and healthcare providers underestimated older patients' desire for aggressive care. After adjustment for illness severity, comorbidity, baseline function, and patients' preferences for aggressive care, older age was associated with lower hospital costs and resource intensity and higher rates of decisions to withhold life-sustaining treatments. In adjusted analyses, older age was associated with a slight survival disadvantage. This survival disadvantage persisted, even after adjustment for aggressiveness of care, suggesting that the relation between age and survival is not accounted for by less aggressive treatment of older patients.

CONCLUSIONS

Even after adjustment for patients' prognoses and care preferences, seriously ill hospitalized older patients were treated less aggressively than younger patients. SUPPORT cannot fully identify whether the relationship between older age and less aggressive treatment is better explained by the withholding of potentially beneficial treatments from older patients, or by the excessive provision of ineffective treatment to younger patients. However, the latter explanation is favored by the SUPPORT finding that less aggressive treatment for older patients does not contribute to the modest survival disadvantage associated with older age.

COPD: early detection and intervention

The compelling evidence for the increasing economic and social burden of COPD, resulting from its rising prevalence and significant morbidity, has been reviewed in other sections of this supplement. The impact of this disease within the United States and globally is projected to increase irrespective of short-term medical action, but developing successful strategies to identify the illness and reduce its impact is essential if this growing problem is to be managed successfully. In this article, some of the important concepts relevant to this process are considered, and some of the present techniques used to intervene in established COPD are reviewed.

Utilization in COPD: patient characteristics and diagnostic evaluation

STUDY OBJECTIVES

Information on current practices of COPD diagnosis and treatment is needed to identify opportunities for improving care. This study describes the clinical characteristics and diagnostic evaluations of COPD patients in a health maintenance organization (HMO) and a university-affiliated county medical center (UMC).

DESIGN

Cross-sectional survey performed in a 174,484-member regional HMO and in The University of New Mexico Hospitals and Clinics (UNMH).

PATIENTS

Two hundred COPD patients from each system randomly selected from administrative databases based on discharge diagnoses.

RESULTS

COPD patients in the UMC, compared to those in the HMO, were younger (mean age, 59.3 vs 66.9 years, respectively), were more likely to be using home oxygen (33% vs 20%, respectively), and had fewer chronic medical conditions (mean number of conditions, 3.1 vs 3.7, respectively) (p < 0.01 for all differences). Approximately half of the COPD patients in both groups continued to smoke cigarettes during the study year. Only 38% of patients in the HMO and 42% in the UNMH system had spirometry results documented in their medical records.

CONCLUSIONS

The demographic and clinical characteristics of the COPD patients in these two health-care systems were very different, but smoking status and utilization of diagnostic tests were similar. The diagnosis of COPD in most patients was based only on a history of chronic respiratory symptoms and smoking; spirometry often was not used to confirm the diagnosis. An increased emphasis on smoking cessation and more effective utilization of spirometry are needed to improve the management of COPD in these health-care systems.

Living and dying with chronic obstructive pulmonary disease

OBJECTIVE

To characterize chronic obstructive pulmonary disease (COPD) over patients' last 6 months of life.

STUDY DESIGN

A retrospective analysis of a prospective cohort from the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT).

SETTING

Hospitalization for exacerbation of COPD at five US teaching hospitals.

PARTICIPANTS

COPD patients who died within 1 year (n = 416) among 1016 enrolled.

METHODS

Interview and medical record data were organized into time windows beginning with death and ending 6 months earlier.

OUTCOME MEASURES

Days in hospital, prognosis, illness severity, function, symptoms, patients' preferences, and impacts on families.

RESULTS

One-year survival was 59%, 39% had > or = 3 comorbidities, and 15 to 25% of the patients' last 6 months were in hospitals. Exacerbation etiologies included respiratory infection (47%) and cardiac problems (30%). Better quality of life predicted longer survival (ARR: 0.36; 95% CI, 0.19-0.87) as did heart failure etiology of exacerbation (ARR: 0.57; CI, 0.40, 0.82). Estimates of survival by physicians and by prognostic model were well calibrated, although patients with the worst prognoses survived longer than predicted. Patients' estimates of prognosis were poorly calibrated. One-quarter of patients had serious pain throughout, and two-thirds had serious dyspnea. Patients' illnesses had a major impact on more than 25% of families. Patients' preferences for Do-Not-Resuscitate orders increased from 40% at 3 to 6 months before death to 77% within 1 month of death; their decisions not to use mechanical ventilation increased from 12 to 31%, and their preferences for resuscitation decreased from 52 to 23%.

CONCLUSIONS

Patients with advanced COPD often die within 1 year and have substantial comorbidities and symptoms. Adequate description anchors improved care.

Dying with lung cancer or chronic obstructive pulmonary disease: insights from SUPPORT. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments

CONTEXT

Many are calling for patients with advanced chronic obstructive pulmonary disease (COPD) to receive hospice care, but the traditional hospice model may be insufficient.

OBJECTIVE

To compare the course of illness and patterns of care for patients with non-small cell lung cancer and severe COPD.

DESIGN

Prospective cohort study of seriously ill, hospitalized adults.

SETTING

Five teaching hospitals in the United States.

PATIENTS

Patients with Stage III or IV non-small cell lung cancer (n = 939) or acute exacerbation of severe COPD (n = 1008).

MAIN OUTCOME MEASURES

Patients' preferences for pattern of care and for ventilator use; symptoms; life-sustaining interventions; and survival prognoses.

RESULTS

Sixty percent in each group wanted comfort-focused care; 81% with lung cancer and 78% with COPD were extremely unwilling to have mechanical ventilation indefinitely. Severe dyspnea occurred in 32% of patients with lung cancer and 56% of patients with COPD and severe pain in 28 % of patients with lung cancer and 21% of patients with COPD. Patients with COPD who died during index hospitalization were more likely than patients with lung cancer to receive mechanical ventilation (70.4% vs 19.8%), tube feeding (38.7% vs 18.5%), and cardiopulmonary resuscitation (25.2% vs 7.8%). Mechanical ventilation had greater short term effectiveness in patients with COPD, based on survival to hospital discharge (76% vs 38%). Patients with COPD maintained higher median 2-month and 6-month survival prognoses, even days before death.

CONCLUSIONS

Hospitalized patients with lung cancer or COPD preferred comfort-focused care, yet dyspnea and pain were problematic in both groups. Patients with COPD were more often treated with life-sustaining interventions, and short-term effectiveness was comparatively better than in patients with lung cancer. In caring for patients with severe COPD, consideration should be given to implementing palliative treatments more aggressively, even while remaining open to provision of life-sustaining interventions.

How is mechanical ventilation employed in the intensive care unit? An international utilization review

A 1-d point-prevalence study was performed with the aim of describing the characteristics of conventional mechanical ventilation in intensive care units ICUs from North America, South America, Spain, and Portugal. The study involved 412 medical-surgical ICUs and 1,638 patients receiving mechanical ventilation at the moment of the study. The main outcome measures were characterization of the indications for initiation of mechanical ventilation, the artificial airways used to deliver mechanical ventilation, the ventilator modes and settings, and the methods of weaning. The median age of the study patients was 61 yr, and the median duration of mechanical ventilation at the time of the study was 7 d. Common indications for the initiation of mechanical ventilation included acute respiratory failure (66%), acute exacerbation of chronic obstructive pulmonary disease (13%), coma (10%), and neuromuscular disorders (10%). Mechanical ventilation was delivered via an endotracheal tube in 75% of patients, a tracheostomy in 24%, and a facial mask in 1%. Ventilator modes consisted of assist/control ventilation in 47% of patients and 46% were ventilated with synchronized intermittent mandatory ventilation, pressure support, or the combination of both. The median tidal volume setting was 9 ml/kg in patients receiving assist/control and the median setting of pressure support was 18 cm H(2)O. Positive end-expiratory pressure was not employed in 31% of patients. Method of weaning varied considerably from country to country, and even within a country several methods were in use. We conclude that the primary indications for mechanical ventilation and the ventilator settings were remarkably similar across countries, but the selection of modes of mechanical ventilation and methods of weaning varied considerably from country to country.

Toward a consensus definition for COPD exacerbations

In patients with COPD, an acute worsening of respiratory symptoms is often described as an exacerbation. Exacerbations are associated with a significant increase in mortality, hospitalization, and health-care utilization, but there is currently no widely accepted definition of what constitutes an exacerbation of COPD. This paper summarizes the discussions of the workshop, "COPD: Working Towards a Greater Understanding," in which the participants proposed the following working definition of an exacerbation of COPD: a sustained worsening of the patient's condition, from the stable state and beyond normal day-to-day variations, that is acute in onset and necessitates a change in regular medication in a patient with underlying COPD.

Relation of FEV(1) to clinical outcomes during exacerbations of chronic obstructive pulmonary disease. Department of Veterans Affairs Cooperative Study Group

FEV(1) is an objective measure of airflow obstruction used in clinical practice and in therapeutic trials. The precise relationship of FEV(1) to clinical outcomes is generally uncertain. As part of a randomized trial to assess systemic corticosteroid efficacy, we obtained serial FEV(1) measurements in patients hospitalized for exacerbations of chronic obstructive pulmonary disease (COPD). Over the first 14 Study Days at least one FEV(1) value was obtained in 261 subjects. Sixty-four of these subjects experienced treatment failure, defined as death, intubation, readmission for COPD, or intensification of drug therapy, by Study Day 30. After adjustment, both FEV(1) at entry into the study (odds ratio [OR] for a 100-ml increase, 0.87; 95% confidence interval [CI], 0.79 to 0.96) and change in FEV(1) over the first two Study Days (OR for a 100 ml increase, 0.80; 95% CI, 0.69 to 0.92) predicted treatment failure. We identified no baseline characteristic that was significantly related to FEV(1) at entry into the study. Assignment to the systemic corticosteroid treatment arm was associated with a significantly larger FEV(1) at Study Day two (p = 0.01). We conclude that FEV(1) measurements at admission and over the first several days of hospitalization are highly predictive of clinical outcomes during exacerbations of COPD.

Early non-elective readmission for chronic obstructive pulmonary disease is associated with weight loss

AIM

To identify risk factors for early nonelective readmission in patients with chronic obstructive pulmonary disease, previously admitted for an exacerbation of their disease. Clinical characteristics were analysed with special emphasis on body weight on admission and weight changes during hospitalization.

METHODS

The computerized hospital database was used to select all hospital admissions in 1994 and 1995 with exacerbation of chronic obstructive pulmonary disease as main discharge diagnosis. Cases were retained if they were nonselectively readmitted within 14 days after prior discharge, and if they had no oedema. Controls were randomly selected from the discharge listing and were not readmitted within 3 months. Cases and controls were matched on several parameters including FEV(1)% predicted obtained during a stable phase of the disease. Hospital charts were reviewed for clinical parameters on admission, discharge and readmission.

RESULTS

Fourteen cases were retained in the study. On admission, lung function, blood gases and parameters describing morbidity and social factors, were not different in cases and controls. The discharge procedure was adequate. During hospitalization the cases lost weight (mean+/-SD) (-1.6+/-1.9 kg, P= 0.01), while controls remained weight stable. Using a matched pairs logistic regression analysis, weight loss during hospitalization (P= 0.011) and low BMI on admission (P= 0. 046) were related to the increased risk of unplanned readmission.

CONCLUSION

These findings provide further support for the concept that nutritional status is related to morbidity in COPD.

Cor Pulmonale

The goals of treatment of cor pulmonale are 1) to reduce pulmonary arterial hypertension; 2) to optimize gas-exchange efficiency; and 3) to improve survival. These goals are achieved through long-term oxygen therapy, bronchodilator and vasodilator therapy, aggressive treatment of pulmonary infection, and anticoagulation. Selected patients may benefit from available surgical options.

Management of acute exacerbations in chronic obstructive pulmonary disease

An acute exacerbation of chronic obstructive pulmonary disease (COPD) is characterized by an acute worsening of symptoms accompanied by lung infection. In severe cases, an acute exacerbation may cause respiratory failure and death. Successful management of acute exacerbation of COPD in either the inpatient or outpatient setting requires attention to a number of key issues. In this review, issues regarding the management of acute exacerbations of COPD are discussed. An inhaled beta-2 agonist along with the inhaled anticholinergic bronchodilator are recommended. Antibiotic therapy has been demonstrated to improve clinical recovery and physical outcomes. It should be directed against the most commonly occurring pathogens and, in more severe cases, coverage against Gram-negative bacteria is considered. Short course of systemic steroids does provide benefit in hospitalized patients. Supplemental oxygen is appropriate for all patients with hypoxemia. Ventilatory support treatment may be necessary, noninvasive ventilatory assistance being preferable early in the course of the acute episode. In a high number of cases, endotracheal intubation may be avoided. Promoting smoking cessation and the use of influenzae and pneumococcal vaccination may help decrease frequency of episodes of these exacerbations.

The distribution of costs of care in mechanically ventilated patients with chronic obstructive pulmonary disease

OBJECTIVES

To delineate the costs of care of patients with Chronic Obstructive Pulmonary Disease (COPD) and respiratory failure and to compare them with those of other mechanically ventilated patients.

DESIGN

A post hoc analysis of a prospective investigation.

SETTING

Medical and coronary intensive care units (ICUs) of an 804-bed, university-based hospital.

PATIENTS

A total of 300 mechanically ventilated patients, 44 with COPD and 256 others, were included.

MEASUREMENTS AND MAIN RESULTS

Despite similar lengths of ICU stay (9 days) and mechanical ventilation (5.5 days COPD vs. 5 days other, p = .11), ICU respiratory care costs for patients with COPD were $2,422 ($1,157-$6,110) [median U.S. dollars (interquartile range)] vs. $1,580 ($738-$3,322) for the others (p = .01). Ventilator costs for COPD patients were $1,795 ($943-$5,782) vs. $1,574 ($613-$3,112) (p = .12). Total hospitalization respiratory care costs for COPD patients were higher, $4,064 ($2,422-$9,572) vs. $2,342 ($1,186-$4,591), (p = .0001), and 74.4% of the median difference in cost between COPD patients and others was accounted for by spontaneous nebulizers (p = .001), metered dose inhalers (p = .01), and pulse oximetry (p = .02). By using multiple linear regression analyses, we found that COPD remained associated with higher respiratory costs (p<.05). Respiratory Care was the third largest category of hospital costs after beds (27%) and pharmacy expenses (25%), and it comprised approximately 14% of total cost. Total hospital costs were large for both groups, but did not differ between COPD and the others [$24,217 ($16,211-$58,834) vs. $27,672 ($15,692-$53,766), respectively (p = .96)]. Linear regression analyses showed that only Acute Lung Injury score was significantly related to total ICU and hospital costs of care (p<.05).

CONCLUSIONS

Costs of ICU and non-ICU respiratory care for patients with COPD are higher than costs of care for other mechanically ventilated patients. Although the increased cost of bronchodilators and oximetry in these patients may serve as target areas for reductions in respiratory care costs, it may also be true that these modalities of therapy and management are necessary and need to be used with even greater intensity to achieve better outcomes. The predominant contributions of bed and pharmacy costs in all of our patients with respiratory failure support research efforts addressing these aspects of care.

Using admission characteristics to predict return to the community from a post-acute geriatric evaluation and management unit

OBJECTIVE

To compare the Cumulative Illness Rating Scale (CIRS) and the Nursing Severity Index (NSI) as independent predictors of discharge outcome from a post-acute GEM unit and to define a multivariate model for predicting the same outcome.

DESIGN

Retrospective chart review for the entire sample. The sample was split into two cohorts, a derivation cohort (n = 298) and a validation cohort (n = 154).

SETTING

A 20-bed, post-acute GEM unit in a nonproprietary skilled nursing facility.

PARTICIPANTS

All 452 patients admitted to the GEM from the unit's inception in December 1994 until January 1998.

MEASUREMENT

Demographics, CIRS, NSI, functional status, and social support variables were measured using data available on admission to the GEM unit. The discharge outcome was dichotomized as return to the community or not.

RESULTS

A total of 99.7% of the individuals in the derivation cohort were living in the community before the index hospitalization; 75.8% of patients in the derivation cohort returned to the community. The NSI, individual "severe" items from the CIRS, age, and social support were in the final logistic regression model fitted to the derivation cohort. A total of 87.7% of the observed discharge outcomes were predicted when the model was applied to the validation cohort and the calculated probability of return to the community.

CONCLUSIONS

Variables for severity of illness, function, social support, and age combined into a logistic regression equation that predicted more than 80% of the dichotomized discharge outcome in the derivation cohort. The proportion of discharge outcomes that were predicted with the validation cohort remained high at 87.7%. The NSI and CIRS were each important to a model that is anticipated to refine the selection of geriatric patients for post-acute services.

Course and prognosis of chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) continues to increase in incidence as the population of developed countries ages. Much time has been devoted to studying the natural course of this disorder and to searching for risk factors for a decline in respiratory function. The major risk factor for a decline in 1-second forced expiratory volume (FEV1) is cigarette smoking, and smoking cessation is a major part of its prevention. Other risk factors for development of COPD include passive exposure to cigarette smoke, age, and genetic factors including airway hyperreactivity, eosinophilia, and a history of atopy. This discussion presents a review of the current literature regarding the natural course and prognosis of COPD. The approach to patients with end-stage disease and the use of advance directives is considered.

Acute purulent exacerbation of chronic obstructive pulmonary disease and Chlamydia pneumoniae infection

In order to investigate the role of bacteria, including Mycoplasma pneumoniae and especially Chlamydia pneumoniae in acute purulent exacerbations of chronic obstructive pulmonary disease (COPD), we examined sputum specimens and acute and convalescent sera taken 26 d apart from 49 outpatients experiencing an acute purulent exacerbation of COPD. The sera were tested for antibodies to C. pneumoniae with the microimmunofluorescence test, and for antibodies to M. pneumoniae with the indirect fluorescence antibody test. Routine microbiologic culture of sputum yielded potentially pathogenic microorganisms in 12 of the 49 patients (24%). Three patients (6%) showed serologic evidence of recent M. pneumoniae infection. Seven patients showed high IgG titers of >/= 1:1,024 to C. pneumoniae, and an additional four had a fourfold increase in IgG titer, suggesting reinfection with C. pneumoniae. Sputum from two of these 11 patients also grew Streptococcus pneumoniae, and one grew Moraxella catarrhalis. Patients with and without serologic evidence of current C. pneumoniae infection showed no significant differences in clinical features or pulmonary function. The high incidence of infection with C. pneumoniae (the sole causal agent in 16% of cases, and the causal agent with other agents in 6%) provides insight into the importance of this organism among agents leading to exacerbations of COPD in Turkey.

Effect of systemic glucocorticoids on exacerbations of chronic obstructive pulmonary disease. Department of Veterans Affairs Cooperative Study Group

BACKGROUND AND METHODS

Although their clinical efficacy is unclear and they may cause serious adverse effects, systemic glucocorticoids are a standard treatment for patients hospitalized with exacerbations of chronic obstructive pulmonary disease (COPD). We conducted a double-blind, randomized trial of systemic glucocorticoids (given for two or eight weeks) or placebo in addition to other therapies, for exacerbations of COPD. Most other care was standardized over the six-month period of follow-up. The primary end point was treatment failure, defined as death from any cause or the need for intubation and mechanical ventilation, readmission to the hospital for COPD, or intensification of drug therapy.

RESULTS

Of 1840 potential study participants at 25 Veterans Affairs medical centers, 271 were eligible for participation and were enrolled; 80 received an eight-week course of glucocorticoid therapy, 80 received a two-week course, and 111 received placebo. About half the potential participants were ineligible because they had received systemic glucocorticoids in the previous 30 days. Rates of treatment failure were significantly higher in the placebo group than in the two glucocorticoid groups combined at 30 days (33 percent vs. 23 percent, P=0.04) and at 90 days (48 percent vs. 37 percent, P=0.04). Systemic glucocorticoids (in both groups combined) were associated with a shorter initial hospital stay (8.5 days, vs. 9.7 days for placebo, P=0.03) and with a forced expiratory volume in one second that was about 0.10 liter higher than that in the placebo group by the first day after enrollment. Significant treatment benefits were no longer evident at six months. The eight-week regimen of therapy was not superior to the two-week regimen. The patients who received glucocorticoid therapy were more likely to have hyperglycemia requiring therapy than those who received placebo (15 percent vs. 4 percent, P=0.002).

CONCLUSIONS

Treatment with systemic glucocorticoids results in moderate improvement in clinical outcomes among patients hospitalized for exacerbations of COPD. The maximal benefit is obtained during the first two weeks of therapy. Hyperglycemia of sufficient severity to warrant treatment is the most frequent complication.

Electrocardiographic signs of chronic cor pulmonale: A negative prognostic finding in chronic obstructive pulmonary disease

BACKGROUND

Chronic cor pulmonale (CCP) is a strong predictor of death in chronic obstructive pulmonary disease (COPD). The aims of this study were to assess the prognostic role of individual ECG signs of CCP and of the interaction between these signs and abnormal arterial blood gases.

METHODS AND RESULTS

Two hundred sixty-three patients (217 men) with COPD, mean age 67+/-9 years, were grouped according to whether they had no ECG signs (group 1, n=100) or >/=1 ECG signs (group 2, n=163) of CCP and were followed up for 13 years after an exacerbation of respiratory failure. The median survival was significantly shorter in group 2 than in group 1 (2.58 versus 3. 45 years, respectively; Mantel-Cox test, 9.58; P=0.002). The Cox regression analysis identified S1S2S3 pattern, right atrial overload (RAO), and alveolar-arterial oxygen gradient (PAO2-PaO2) >48 mm Hg during oxygen therapy as the strongest predictors of death, with hazard rate (HR)=1.81 (95% CI, 1.22 to 2.69), HR=1.58 (95% CI, 1.15 to 2.18), and HR=1.96 (95% CI, 1.19 to 3.25), respectively. The median survivals of patients having both S1S2S3 pattern and RAO (n=14) and of patients having either S1S2S3 pattern or RAO (n=77) were 1.33 and 2.70 years, respectively (P=0.022). Group 2 patients had a 3-year survival of 18% or 53%, depending on whether their PAO2-PaO2 during oxygen therapy was or was not >48 mm Hg.

CONCLUSIONS

Some ECG signs of CCP and PAO2-PaO2 >48 mm Hg during oxygen therapy qualified as a simple and inexpensive tool for targeting subsets of COPD patients with severe or very severe short-term prognosis.

Economic consequences of chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is an important preventable cause of morbidity and mortality throughout the world. Little is known, however, about the economic burden of COPD imposed on society. This paper reviews the medical and economic literature pertaining to COPD in order to provide information and perspective for clinicians and those responsible for making payment and resource allocation decisions. There are only two published estimates of the burden of illness of COPD. In 1970, the estimated societal burden of emphysema was US$1.5 billion. Average individual expenditures for persons with COPD belonging to Medicare health maintenance organizations have been estimated to be more than twice as high as similar individuals without COPD. The burden of COPD on society is expected to increase substantially over the next three decades. COPD is a unique public health challenge to society now and for the foreseeable future.

Predictive factors of hospitalization for acute exacerbation in a series of 64 patients with chronic obstructive pulmonary disease

Hospitalizations for acute exacerbation in patients with chronic obstructive pulmonary disease (COPD) have a great impact on health care expenditure. The aim of this study was to look at predictive factors of hospitalization for acute exacerbation in a group of patients with moderate to severe COPD. During the year 1994, we included 64 patients with COPD in this study. At inclusion, the patients being in a stable state, we performed a complete evaluation of their clinical, spirometric, gasometric, and pulmonary hemodynamic characteristics. All patients were followed during a period of at least 2.5 yr. We recorded the intervals free of hospitalization for exacerbation and realized an analysis of the proportional hazards not to be hospitalized using the Kaplan-Meier method. Univariate analysis using the log-rank test showed that the risk of being hospitalized was significantly increased in patients with COPD with a low body mass index (BMI <= 20 kg/m2, p = 0.015) and in patients with a limited 6-min walk distance (<= 367 m, p = 0. 045). But above all, the risk of hospitalization for acute exacerbation was significantly increased by gas exchange impairment and pulmonary hemodynamic worsening: PaO2 <= 65 mm Hg versus PaO2 > 65 mm Hg, p = 0.005; PaCO2 > 44 mm Hg versus PaCO2 <= 44 mm Hg, p = 0.005; and mean pulmonary artery pressure ( Ppa) at rest > 18 mm Hg versus Ppa <= 18 mm Hg, p = 0.0008. Neither age, nor the association of one or more comorbidities with COPD, nor the smoking habits had a significant impact on the risk of hospitalization in our study. Multivariate analysis showed that only PaCO2 and Ppa were independently related to the risk of hospitalization for acute exacerbation of COPD. We conclude that chronic hypercapnic respiratory insufficiency and pulmonary hypertension are predictive factors of hospitalization for acute exacerbation in COPD patients.

A comparison of generalist and pulmonologist care for patients hospitalized with severe chronic obstructive pulmonary disease: resource intensity, hospital costs, and survival. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment

PURPOSE

Both generalist and pulmonologist physicians care for patients with severe chronic obstructive pulmonary disease (COPD). We studied patients hospitalized with severe COPD to explore whether supervision of care by pulmonologists is associated with greater costs or better survival.

SUBJECTS AND METHODS

We studied 866 adults with severe COPD enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT), a prospective study at five academic medical centers. Patients were admitted to the hospital or transferred to an intensive care setting for treatment of severe COPD, defined by hypoxia (PaO2 <60 mm Hg) and hypercapnia (PaCO2 >50 mm Hg) or hypercapnia alone if on supplemental oxygen. Resource intensity was measured using a modified version of the Therapeutic Intervention Scoring System and estimated hospital costs. To account for differences in the patient case mix, propensity scores were developed to represent each patient's probability of having a pulmonologist as attending physician and each patient's probability of being in an intensive care unit (ICU) at study admission.

RESULTS

Of the 866 patients studied, 512 had generalists and 354 pulmonologists as their attending physicians. The median patient age was 70 years; 52% were male; 14% died within 30 days. After adjusting for baseline differences in patient characteristics, there were no differences in resource intensity and hospital costs in those treated by pulmonologists or generalists. Adjusted average resource intensity scores for the entire hospitalization were 16.5 for pulmonologists and 17.0 for generalists (P = 0.34). Estimated hospital costs were the same ($6,400) for patients treated by pulmonologists and generalists (P = 0.99). Patients with pulmonologists as attending physicians did not experience better survival. Comparing patients of pulmonologists to patients of generalists, the adjusted hazard ratio for 30-day mortality was 1.6 (95% confidence interval: 0.98, 2.5); the hazard ratio for 180-day mortality was 1.2 (0.9, 1.7).

CONCLUSIONS

Our findings suggest that for patients hospitalized with exacerbation of severe COPD, those with pulmonologist attending physicians do not have higher hospital resource use or better survival than those with generalist attending physicians.