Hospital management of acute exacerbations of chronic obstructive pulmonary disease

Reducing Chronic Obstructive Pulmonary Disease Hospital Readmissions. An Official American Thoracic Society Workshop Report

Chronic obstructive pulmonary disease (COPD) is the third leading cause of hospital readmissions in the United States. The quality of care delivered to patients with COPD is known to be lacking across the care continuum, and may contribute to high rates of readmission. As part of the response to these issues, the Centers for Medicare and Medicaid instituted a penalty for 30-day readmissions as part of their Hospital Readmission Reduction Program in October 2014. At the time the penalty was instated, there was little published evidence on effective hospital-based programs to reduce readmissions after acute exacerbations of COPD. Even now, several years later, few published programs exist, and we continue to lack consistent approaches that lead to improved readmission rates. In addition, there was concern that the penalty would widen health disparities. Despite the dearth of published evidence to reduce readmissions beyond available COPD guidelines, many hospitals across the United States began to develop and implement programs, based on little evidence, due to the financial penalty. We, therefore, assembled a diverse group of clinicians, researchers, payers, and program leaders from across the country to present and discuss approaches that had the greatest potential for success. We drew on expertise from ongoing readmission reduction programs, implementation methodologies, and stakeholder perspectives to develop this Workshop Report on current best practices and models for addressing COPD hospital readmissions.

Healthcare utilization after a first hospitalization for COPD: a new approach of State Sequence Analysis based on the '6W' multidimensional model of care trajectories

Background

Published methods to describe and visualize Care Trajectories (CTs) as patterns of healthcare use are very sparse, often incomplete, and not intuitive for non-experts.

Our objectives are to propose a typology of CTs one year after a first hospitalization for Chronic Obstructive Pulmonary Disease (COPD), and describe CT types and compare patients’ characteristics for each CT type.

Methods

This is an observational cohort study extracted from Quebec’s medico-administrative data of patients aged 40 to 84 years hospitalized for COPD in 2013 (index date). The cohort included patients hospitalized for the first time over a 3-year period before the index date and who survived over the follow-up period. The CTs consisted of sequences of healthcare use (e.g. ED-hospital-home-GP-respiratory therapists, etc.) over a one-year period. The main variable was a CT typology, which was generated by a ‘tailored’ multidimensional State Sequence Analysis, based on the “6W” model of Care Trajectories. Three dimensions were considered: the care setting (“where”), the reason for consultation (“why”), and the speciality of care providers (“which”). Patients were grouped into specific CT types, which were compared in terms of care use attributes and patients’ characteristics using the usual descriptive statistics.

Results

The 2581 patients were grouped into five distinct and homogeneous CT types: Type 1 (n = 1351, 52.3%) and Type 2 (n = 748, 29.0%) with low healthcare and moderate healthcare use respectively; Type 3 (n = 216, 8.4%) with high healthcare use, mainly for respiratory reasons, with the highest number of urgent in-hospital days, seen by pulmonologists and respiratory therapists at primary care settings; Type 4 (n = 100, 3.9%) with high healthcare use, mainly cardiovascular, high ED visits, and mostly seen by nurses in community-based primary care; Type 5 (n = 166, 6.4%) with high healthcare use, high ED visits and non-urgent hospitalisations, and with consultations at outpatient clinics and primary care settings, mainly for other reasons than respiratory or cardiovascular. Patients in the 3 highest utilization CT types were older, and had more comorbidities and more severe condition at index hospitalization.

Conclusions

The proposed method allows for a better representation of the sequences of healthcare use in the real world, supporting data-driven decision making.

Clinical Outcomes Of Using Nebulized Budesonide As The Initial Treatment For Acute Exacerbations Of Chronic Obstructive Pulmonary Disease: A Post-Hoc Analysis

Purpose

The current guidelines recommend the use of systemic corticosteroids (SCS) as the optimal treatment for acute exacerbations of chronic obstructive pulmonary disease (AECOPD). The aim of this real-world study was to evaluate whether nebulized budesonide (NBS) could also be used as an initial treatment for AECOPD.

Patients and methods

AECOPD patients initially treated with NBS or SCS (oral/intravenous) were enrolled. A large-scale, long-term multicenter cohort study of AECOPD patients was performed to analyze outcomes for each treatment (NCT02051166).

Results

Initial NBS and SCS treatment resulted in similar outcomes in terms of improvements in FEV₁, PaO₂, SaO₂, and PaCO₂. Disease severity affected outcome similarly in both groups. When the groups were stratified according to whether the initial treatment was subsequently intensified or reduced, more intubation was seen in the groups in which initial treatment was intensified. NBS escalation and SCS reduction groups spent more days in the hospital. The NBS escalation group was associated with the highest medical expenditure and a relatively higher rate of new-onset pneumonia. The NBS maintenance/reduction group showed the lowest mortality rate between groups. Stratification according to initial PaCO₂ level showed more intubation in the groups with high initial PaCO₂ concentrations.

Conclusion

These results indicate that NBS may be used as an initial treatment in certain AECOPD patients, and further studies are needed to better define those most likely to benefit.

Eosinophilic biomarkers for detection of acute exacerbation of chronic obstructive pulmonary disease with or without pulmonary embolism

Eosinophilia has been implicated in the pathophysiology of acute exacerbation of chronic obstructive pulmonary disease (AECOPD). However, the role of eosinophil activation in the development of AECOPD remains unclear. In the present study, the reliability of plasma levels of eosinophil activation markers, including eosinophil cationic protein (ECP), major basic protein (MBP), eosinophil-derived neurotoxin (EDN) and eosinophil peroxidase (EPX), were measured and used as diagnostic biomarkers of AECOPD with or without pulmonary embolism (PE). A total of 47 patients with AECOPD, 30 patients with AECOPD/PE and 35 healthy adults were enrolled in the present study. Plasma levels of ECP, EDN, EPX and MBP were measured using commercial ELISA kits. The mean concentrations of plasma ECP, EDN, EPX and MBP in the patients with AECOPD was significantly 2.87-, 3.06-, 1.60- and 1.92-fold higher, respectively, compared with the control group (P<0.05). Similar results were obtained in patients with AECOPD/PE, for whom plasma levels of ECP, EDN, EPX and MBP were significantly 2.06-, 2.21-, 1.42- and 2.42-fold higher, respectively, compared with the controls (P<0.05). No significant differences were observed in the levels of these proteins between patients with AECOPD or AECOPD/PE. Among the four potential markers, ECP was determined to be the optimal marker for distinguishing patients with AECOPD or AECOPD/PE from the controls. No significant correlation was observed between marker concentrations and gender, age or disease severity. The results of the present study may have clinical applications in the diagnosis of AECOPD using these novel biomarkers.

Health resource utilization for inpatients with COPD treated with nebulized arformoterol or nebulized formoterol

OBJECTIVE

Arformoterol is the (R,R)-enantiomer of formoterol. Preclinical studies suggest that it is a stronger bronchodilator than the racemic (R,R/S,S)-formoterol; however, its potential clinical advantages have not been demonstrated. This study compared the length of stay (LOS), 30-day readmission rates, and doses of rescue medication administered in hospitalized patients with COPD who were treated with nebulized arformoterol or nebulized formoterol.

METHODS

This retrospective analysis utilized data from Premier, Inc. (Charlotte, NC, USA), the largest nationwide hospital-based administrative database. COPD patients ≥40 years of age were included if they were hospitalized between January 2011 and July 2014, had no asthma diagnoses, and were treated with nebulized arformoterol or nebulized formoterol. LOS was measured from the day the patients initiated the study medication (index day). Rescue medications were defined as short-acting bronchodilators used from the index day onward. Multivariate statistical models included a random effect for hospital and controlled for patient demographics, hospital characteristics, admission characteristics, prior hospitalizations, comorbidities, pre-index service use, and pre-index medication use.

RESULTS

A total of 7,876 patients received arformoterol, and 3,612 patients received nebulized formoterol. There was no significant difference in 30-day all-cause (arformoterol =11.9%, formoterol =12.1%, odds ratio [OR] =0.981, P=0.82) or COPD-related hospital readmission rates (arformoterol =8.0%, formoterol =8.0%, OR =1.002, P=0.98) after adjusting for covariates. The adjusted mean LOS was significantly shorter for arformoterol-treated vs formoterol-treated patients (4.6 vs 4.9 days, P=0.039), and arformoterol-treated patients used significantly fewer doses of rescue medications vs formoterol-treated patients (5.9 vs 6.6 doses, P=0.006).

CONCLUSION

During inpatient stays, treating with arformoterol instead of nebulized formoterol may lead to shorter LOS and lower rescue medication use.

To Investigate the Effects of Air Pollution (PM10 and SO2) on the Respiratory Diseases Asthma and Chronic Obstructive Pulmonary Disease

OBJECTIVES

Effects of air pollution parameters of sulfur dioxide (SO2) and particulate matter (PM10) values on the respiratory system were investigated.

MATERIAL AND METHODS

Data of SO₂ and PM10 were obtained daily for air pollution and classified into two groups: Group I (2006-2007), coal burning years and Group II (2008-2009), natural gas+ coal burning. Groups I and II were divided into two subgroups according to the months of combustion as combustible (November-April) and noncombustible (May-October). The number of patients with asthma and chronic obstructive pulmonary disorder (COPD) was recorded between 2006 and 2009.

RESULTS

There was no statistically significant difference between Groups I and II for PM10 and SO₂ (p>0.05). Within the years, the values of SO₂ and PM10 were statistically different between the groups defined by month (p<0.01). The number of patients in the combustible and noncombustible subgroups were found to be different for every 4 years, and the numbers of patients with COPD or asthma were not changed through the years. There was a strong correlation between PM10 and COPD (r=0.59, p<0.01) and a weak correlation between PM10 and asthma (r=0.25, p>0.05). A correlation was found between SO₂ and COPD (p<0.01) but not between SO₂ and asthma (p>0.05). The number of visits for COPD and asthma was statistically different between combustible and noncombustible subgroups (X2:58.61, p=0.000; X2:34.55, p=0.000, respectively). The r2 values for SO₂ and PM10 for COPD patients were 17% and 24%, respectively, in contrast to 8% and 5%, respectivley for asthma patients.

CONCLUSION

Air pollution is known to increase respiratory disease occurrences. With decrease in the usage of solid fuel, air pollution could be reduced and may be effective in preventing respiratory diseases.