Emergency department management of acute exacerbations of chronic obstructive pulmonary disease in the elderly: the Multicenter Airway Research Collaboration

Management of acute exacerbations of COPD in the emergency department and its associations with clinical variables

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is a common cause for emergency department (ED) visits. Still, large scale studies that assess the management of AECOPD in the ED are limited. Our aim was to evaluate treatment characteristics of AE-COPD in the ED on a national scale. A prospective study as part of the COPD Israeli survey, conducted between 2017 and 2019, in 13 medical centers. Patients hospitalized with AECOPD were included and interviewed. Clinical data related to their ED and hospital stay were collected. 344 patients were included, 38% females, mean age of 70 ± 11 years. Median (IQR) time to first ED treatment was 59 (23-125) minutes and to admission 293 (173-490) minutes. Delayed ED treatment (> 1 h) was associated with older age (p = 0.01) and lack of a coded diagnosis of COPD in hospital records (p = 0.01). Long ED length-of-stay (> 5 h) was linked with longer hospitalizations (p = 0.01). Routine ED care included inhalations of short-acting bronchodilators (246 patients, 72%) and systemic steroids (188 patients, 55%). Receiving routine ED care was associated with its continuation during hospitalization (p < 0.001). In multivariate analysis, predictors for patients not receiving routine care were obesity (adjusted odds ratio 0.5, 95% CI 0.3-0.8, p = 0.01) and fever (AOR 0.3, 95% CI 0.1-0.6, p < 0.01), while oxygen saturation < 91% was an independent predictor for ED routine treatment (AOR 3.6, 95% CI 2.1-6.3, p < 0.01). Our findings highlight gaps in the treatment of AECOPD in the ED on a national scale, with specific predictors for their occurrence.

Clinical practice of non-invasive ventilation for acute exacerbations of chronic obstructive pulmonary disease

BACKGROUND

Non-invasive ventilation (NIV) is an evidence-based treatment for acute respiratory failure in chronic obstructive pulmonary disease (COPD). However, suboptimal application of NIV in clinical practice, possibly due to poor guideline adherence, can impact patient outcomes. This study aims to evaluate guideline adherence to NIV for acute COPD exacerbations and explore its impact on mortality.

METHODS

This retrospective study was performed in two Dutch medical centers from 2019 to 2021. All patients admitted to the pulmonary ward or intensive care unit with a COPD exacerbation were included. An indication for NIV was considered in the event of a respiratory acidosis.

RESULTS

A total of 1162 admissions (668 unique patients) were included. NIV was started in 154 of the 204 admissions (76%) where NIV was indicated upon admission. Among 78 admissions where patients deteriorated later on, NIV was started in 51 admissions (65%). Considering patients not receiving NIV due to contra-indications or patient refusal, the overall guideline adherence rate was 82%. Common reasons for not starting NIV when indicated included no perceived signs of respiratory distress, opting for comfort care only, and choosing a watchful waiting approach. Better survival was observed in patients who received NIV when indicated compared to those who did not.

CONCLUSIONS

The adherence to guidelines regarding NIV initiation is good. Nevertheless, further improving NIV treatment in clinical practice could be achieved through training healthcare professionals to increase awareness and reduce reluctance in utilizing NIV. By addressing these factors, patient outcomes may be further enhanced.

Terms and Definitions Used to Describe Recurrence, Treatment Failure and Recovery of Acute Exacerbations of COPD: A Systematic Review of Observational Studies

Introduction

Acute exacerbations of chronic obstructive pulmonary disease (AECOPDs) are important clinical events, with many patients experiencing multiple AECOPDs annually. The terms used in the literature to define recurring AECOPD events are inconsistent and may impact the ability to describe the true burden of these events. We undertook a systematic review to identify and summarize terms and definitions used in observational studies to describe AECOPD-related events occurring after an initial AECOPD (hereafter “subsequent AECOPD”).

Methods

PubMed was searched (2000–2019) for observational studies on subsequent AECOPD events using broad search strings for “COPD”, “exacerbation”, and “subsequent exacerbation events”. Only English-language studies were included. Small studies (n<50) and studies focusing on hospital re-admission only were excluded. Extracted data were analyzed descriptively to generate a narrative summary, using a thematic approach to group studies utilizing similar terms for subsequent AECOPD.

Results

Forty-seven studies were included. No single, distinct terms or definitions were used to define and identify multiple occurrences of AECOPDs, though most (46) studies used one or more of four clustered terms and definitions: reapse (n = 13), recurrence/re-exacerbation (n = 11), treatment failure (n = 12) and non-recovery/time to recovery (n = 16). Heterogeneity was observed within and between the four clusters with respect to study setting, starting point for observing subsequent AECOPDs, time frame to identify a subsequent AECOPD (except for studies using “time to recovery”), and basis for identifying a subsequent exacerbation.

Conclusion

Our review demonstrates that subsequent AECOPDs (including events such as relapse, recurrence/re-exacerbation, treatment failure, non-recovery/time to recovery) are ill-defined in the observational study literature, emphasizing the need to reach consensus on precise and objective definitions (for example, when one AECOPD ends and another begins). Use of standardized terminology and definitions may aid comparability between, and synthesis of, studies, thus improving the understanding of the natural history and burden of exacerbations in COPD patients.

Evaluation of the Management of Acute Exacerbations of Chronic Obstructive Pulmonary Disease in Hospitalized Patients

Background: Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are estimated to cost $1.5 billion annually in Canada. Previous studies have shown that barely half of all patients receive ideal care in hospitals. Deviations from guideline-defined optimal care lead to longer hospital stays, readmissions, and increased mortality. Objective: To determine the proportion of patients admitted to hospital for AECOPD who received treatment adherent to guidelines. Methods: A retrospective cohort study was conducted with ethics approval from the University of British Columbia Clinical Research Ethics Board. Patients hospitalized for ≥24 hours with an AECOPD at a tertiary care center and a community hospital were assessed. Guideline-adherent treatment was defined as appropriate use of supplemental oxygen, inhaled bronchodilators, systemic corticosteroids, antibiotics, venous thromboembolism prophylaxis, initiation/continuation of nicotine replacement therapy for current smokers, and vaccination optimization, reflecting international standards of care. Outcomes were assessed using descriptive statistics. Results: A random sample of 210 patients were selected of which 99 met inclusion criteria. Only 4% received therapy that met all recommendations. Differences in management were found between sites, specifically the appropriate use of bronchodilators, corticosteroids, antibiotics, and supplemental oxygen. Venous thromboembolism prophylaxis and smoking cessation rates were 97% and 94%, respectively, at the tertiary care center, compared with 73% and 100% at the community hospital. Additionally, less than half of all patients had their immunization history verified. Conclusion: Gaps in the inpatient management of AECOPD continue to exist. Initiatives must be targeted to optimize management and reduce the burden of the disease.

Acute Exacerbations of Chronic Obstructive Pulmonary Disease: A Primer for Emergency Physicians

BACKGROUND

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) impose a significant burden on patients and the emergency health care system. Patients with COPD who present to the emergency department (ED) often have comorbidities that can complicate their management.

OBJECTIVE

To discuss strategies for the management of acute exacerbations in the ED, from initial assessment through disposition, to enable effective patient care and minimize the risk of treatment failure and prevent hospital readmissions.

DISCUSSION

Establishing a correct diagnosis early on is critical; therefore, initial evaluations should be aimed at differentiating COPD exacerbations from other life-threatening conditions. Disposition decisions are based on the intensity of symptoms, presence of comorbidities, severity of the disease, and response to therapy. Patients who are appropriate for discharge from the ED should be prescribed evidence-based treatments and smoking cessation to prevent disease progression. A patient-centric discharge care plan should include medication reconciliation; bedside "teach-back," wherein patients demonstrate proper inhaler usage; and prompt follow-up.

CONCLUSIONS

An effective assessment, accurate diagnosis, and appropriate discharge plan for patients with AECOPD could improve treatment outcomes, reduce hospitalization, and decrease unplanned repeat visits to the ED.

Emergency department management of acute exacerbations of chronic obstructive pulmonary disease: factors predicting readmission

Rationale

Readmissions are common following acute exacerbations of chronic obstructive pulmonary disease (AECOPD) and are partially responsible for increased morbidity and mortality in COPD. Numerous factors have been shown to predict readmission of patients previously admitted to hospital for AECOPD; however, factors related to readmission in patients who are triaged in emergency departments (EDs) and sent directly home are poorly understood. We postulate that patients seen in the ED for AECOPD and directly sent home have a high readmission rate, and we suspect that inadequate management and follow-up contribute to this high readmission rate.

Methods

We conducted a 1-year retrospective study of all patients seen in the ED for AECOPD at an inner-city tertiary care hospital; 30- and 90-day readmission rates for COPD and all-cause admissions to the ED and hospital were determined. Patients discharged directly home from the ED were compared with those admitted to hospital for management. Patient, treatment, and system variables that could potentially impact readmission were documented. Multivariate Poisson regression models were used to determine which factors predicted readmissions.

Results

The readmission rates in the ED group (n=240) were significantly higher than that in the hospitalized group (n=271): 1) the 90-day ED readmissions (1.29 vs 0.51, p<0.0001) and 30-day ED readmissions (0.54 vs 0.20, p<0.0001) (ED vs hospitalized groups) were significantly higher in the ED group; 2) the time to first readmission was significantly shorter in the ED group than in the hospitalized group (24.1±22 vs 31.8±27.8 days; p<0.05). Cardiovascular comorbidities (p<0.00001), substance abuse disorder (p<0.001), and mental illness (p<0.001) were the strongest predictors of readmission in the ED group. Age (p<0.01), forced expiratory volume in 1 second (p<0.001), and cardiovascular comorbidities (p<0.05) were the best predictors for both 30- and 90-day COPD readmission rates in the ED group. Only 50% of the ED group patients received bronchodilators, oral steroids, and antibiotics inclusively, and only 68% were referred for community follow-up. The need for oral steroids to treat AECOPD predicted future 90-day COPD readmissions in the ED group (p<0.003).

Conclusion

Patients discharged directly home from EDs have a significantly higher risk of readmission to EDs than those who are hospitalized. One possible reason for this is that COPD management is variable in EDs with <50% receiving appropriate therapy.

COPD exacerbations in the emergency department: Epidemiology and related costs. A retrospective cohort multicentre study from the Italian Society of Emergency Medicine (SIMEU)

Acute exacerbations of chronic obstructive pulmonary disease (AECOPDs) frequently cause patients with COPD to access the emergency department and have a negative impact on the course of the disease. The objectives of our study were: 1) describing the socio-demographic and clinical characteristics, and the clinical management, of patients with AECOPD, when they present to the emergency department; and 2) estimating the costs related to the management of these patients. We conducted a retrospective cohort study in Italy, collecting data on 4396 patients, from 34 centres. Patients had a mean (SD) age of 76,6 (10.6) years, and 61.2% of them where males. >70% of the patients had a moderate to very high comorbidity burden, and heart failure was present in 26.4% of the cohort. The 64.6% of patients were admitted to hospital wards, with a mean (SD) length of stay of 10.8 (9.8) days. The estimated cost per patient was 2617 €.

CONCLUSIONS

Patients attending the ED for an AECOPD are old and present important comorbidities. The rate of admission is high, and costs are remarkable.

Epidemiology, treatment, disposition and outcome of patients with acute exacerbation of COPD presenting to emergency departments in Australia and South East Asia: An AANZDEM study

BACKGROUND AND OBJECTIVE

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is a common presentation to emergency departments (ED) but data regarding its epidemiology and outcomes are scarce. We describe the epidemiology, clinical features, treatment and outcome of patients treated for AECOPD in ED.

METHODS

This was a planned sub-study of patients with an ED diagnosis of AECOPD identified in the Asia, Australia and New Zealand Dyspnoea in Emergency Departments (AANZDEM) study. The AANZDEM was a prospective, interrupted time series cohort study conducted in 46 ED in Australia, New Zealand, Singapore, Hong Kong and Malaysia over three 72-h periods in May, August and October 2014. Primary outcomes were patient epidemiology, clinical features, treatment and outcomes (hospital length of stay (LOS) and mortality).

RESULTS

Forty-six ED participated. There were 415 patients with an ED primary diagnosis of AECOPD (13.6% of the overall cohort; 95% CI: 12.5-14.9%). Median age was 73 years, 60% males and 65% arrived by ambulance. Ninety-one percent had an existing COPD diagnosis. Eighty percent of patients received inhaled bronchodilators, 66% received systemic corticosteroids and 57% of those with pH < 7.30 were treated with non-invasive ventilation (NIV). Seventy-eight percent of patients were admitted to hospital, 7% to an intensive care unit. In-hospital mortality was 4% and median LOS was 4 days (95% CI: 2-7).

CONCLUSION

Patients treated in ED for AECOPD commonly arrive by ambulance, have a high admission rate and significant in-hospital mortality. Compliance with evidence-based treatments in ED is suboptimal affording an opportunity to improve care and potentially outcomes.

A Snapshot of Chronic Obstructive Airways Disease in Australian Emergency Departments

Objectives

To characterise emergency department (ED) attendances for chronic obstructive airways disease (COAD) by patient demographics and severity, to determine treatment and disposition of patients and to determine use of diagnostic tests and treatment provided to different severity groups. A secondary aim was to compare treatment given to established treatment guidelines.

Methods

Prospective, observational cohort study of patients who presented to nine Australian ED with a primary diagnosis of acute exacerbation of COAD in October 2002. Information collected included demographics, duration of symptoms, co-morbidities, assessment findings, severity, treatment, disposition, tests, in-hospital mortality and length of stay.

Results

A total of 137 patients were studied. Two-thirds (65%) of the group were male, and most (90%) were aged greater than 60 years. COAD severity was mild in 11%, moderate in 30% and severe in 59%, and 23% were receiving home oxygen therapy. As anticipated, patients with severe COAD were more likely to be admitted to hospital (mild: moderate: severe = 13%: 68%: 99%; p<0.0001) and to require ventilatory support (0%: 0%: 23%; p<0.002). There was under-utilisation of corticosteroids and antibiotics in the moderate and severe groups, and only 35% of the group had received influenza vaccination within the past year.

Conclusion

This study showed that adherence to best practice guidelines with respect to the use of corticosteroids and antibiotics for patients who presented to the ED with COAD was sub-optimal, as was the prevalence of prior influenza vaccination. Other aspects of treatment and investigation were consistent with available evidence. Efforts to address these deficiencies should be developed.

Adherence to GOLD Guidelines in the Inpatient COPD Population

PURPOSE

The Global Initiative for Chronic Obstructive Lung Disease guidelines provide recommendations to manage chronic obstructive lung disease (COPD) exacerbations. This study assessed the management of inpatient COPD exacerbations at an urban teaching hospital.

METHODS

A retrospective cohort analysis of adults admitted between December 2010 and August 2012 with a COPD exacerbation was conducted. Patient demographics, length of stay (LOS), Charlson comorbidity score, inpatient pulmonary medications, and 30-day readmission were collected. Descriptive statistics characterized guideline adherence and readmission.

RESULTS

94 patients were included with median LOS of 3 days (interquartile range [IQR]: 1-5 days) and median Charlson comorbidity score of 6 (IQR: 5-8). All patients received an inhaled short-acting beta agonist, and 52 (55.3%) also received an inhaled short-acting anticholinergic. Seventy-eight (83%) received systemic corticosteroids, of which 3 received guideline-recommended doses. Sixty-four (68.1%) received antibiotics for a pulmonary indication, of which 71.9% received appropriate antibiotics per indication. Of the 94 patients, 2 were managed in complete adherence with GOLD recommendations. A total of 24 (25.5%) patients were readmitted within 30 days of discharge, 9 of these for COPD.

CONCLUSION

COPD exacerbation treatment deviated from GOLD recommendations. This provides opportunities for further optimization of treatment of COPD exacerbations.

Compliance with a COPD bundle of care in an Australian emergency department: A cohort study

INTRODUCTION

Bundles of care are gaining popularity for treating acute severe illness.

OBJECTIVE

To describe compliance with bundle of care elements (individually and as a "bundle") for patients treated for chronic obstructive pulmonary disease (COPD) exacerbations in the emergency department (ED).

METHODS

Retrospective observational study of patients presenting in the 2014 calendar year with an ED diagnosis of COPD. The primary outcomes of interest were compliance with key bundle of care elements (individually and as a "bundle"). Analysis is descriptive.

RESULTS

381 patients were studied. Median age was 71 (IQR 64-80), 60% were male and 77% arrived by ambulance. Median duration of symptoms was 3 days (IQR 2-6 days). Compliance with the bundle elements was 90% for administration of controlled oxygen therapy (if oxygen given), 87% for administration of inhaled bronchodilators, 79% for administration of systemic corticosteroids, 75% of administration of antibiotics if evidence of infection, 77% for taking of a blood gas in non-mild disease, 98% for taking of a chest X-ray, and 74% for administration of NIV if pH <7.3. Compliance with all appropriate elements of the defined bundle of care was 49%. There was no difference in mean length of stay for admitted patients (P = .44), in-hospital mortality (P = 1.00) or re-admission within 30 days (P = .72) by bundle compliance.

CONCLUSION

Compliance with individual assessment and treatment recommendations was generally high; however, compliance with the overall recommended bundle was only 49%. This indicates that there is an opportunity to improve care in these patients.

Intensive care and invasive ventilation in the elderly patient, implications of chronic lung disease and comorbidities

Aims: Elderly patients have an increasing prevalence of illness that requires consideration of critical care and invasive ventilatory support. Although critical care of even the very elderly can provide value, with increasing age the potential risks of treatment and diminishing returns with respect to quality and quantity of life result in a need for careful evaluation. Variable combinations of impaired organ function, active disease and residual pathology from past disease and injury all affect critical care, with the consequence that the elderly are a very heterogeneous population. Recognizing that critical care is a limited resource, it is important to identify patients who may be at increased risk or least likely to benefit from treatment. Patients with functional impairments, nutritional deficiencies and multiple comorbidities may be at highest risk of poor outcomes. Those with very severe disease, extreme age and requirements for prolonged ventilatory support have high in-hospital mortality. Functional impairments, comorbidities and severity of illness are usually more important considerations than chronologic age. The objective of this review is to identify how common problems of the elderly affect critical care and decisions concerning use of invasive ventilatory support.

Appropriateness of diagnostic effort in hospital emergency room attention for episodes of COPD exacerbation

RATIONALE, AIMS AND OBJECTIVES

To assess the adequacy of diagnostic effort in the emergency departments of Spanish hospitals with respect to episodes of exacerbation of chronic obstructive pulmonary disease (COPD).

METHODS

A descriptive cross-sectional study, conducted between 2007 and 2010 in 15 hospitals in Andalusia, Catalonia, Madrid and the Basque Country. The study population included cases of COPD exacerbation attended at the emergency departments of the participating hospitals. Diagnostic efforts were considered sufficient and appropriate when the emergency room conducted a clinical evaluation including electrocardiogram, chest X-ray, arterial blood gas analysis and spirometry.

RESULTS

2852 episodes of COPD exacerbation attended in hospital emergency departments were assessed. 91.4% of the patients were male, with a mean age of 72.8 (SD 9.5) years, and 45.6% had had a previous emergency admission. The diagnostic effort was considered adequate in 60.1% of the episodes (95% CI: 58.3-61.9). The inter-hospital range of variation(25-75) was 1.67 and the coefficient of variation was 28.3%. In multivariate analysis, adjusting for hospital, date of admission and previous hospitalization, among the male patients, the OR for adequate diagnostic effort was 1.38 (95% CI: 1.04-1.84) CONCLUSION: With respect to diagnostic effort, inequities were observed in our assessment of episodes of COPD exacerbation attended in the emergency departments of Spanish public hospitals. In a high percentage of cases (40%), proper assessment was not conducted. Moreover, inter-individual and inter-hospital differences were observed.

Treatment patterns of chronic obstructive pulmonary disease in employed adults in the United States

BACKGROUND

This study evaluated patterns of pharmacotherapy in chronic obstructive pulmonary disease (COPD) as they relate to recommended guidelines in a prevalent COPD patient population with employer-sponsored health insurance in the US.

METHODS

Health care claims data from 2007 and 2008 were retrospectively analyzed for the study population defined as patients aged 40 years and older, continuously enrolled during the study period, and having at least one inpatient or one emergency department (ED) visit, or at least two outpatient claims coded with COPD (International Classification of Diseases, 9th Revision, Clinical Modification code 491.xx, 492.xx, 496.xx). Rates of any pharmacotherapy (both maintenance and reliever), long-acting maintenance pharmacotherapy in patients with an exacerbation history, and short-term treatment of acute exacerbations of COPD were evaluated in the overall population, newly diagnosed, and previously diagnosed patients (including maintenance-naïve and maintenance-experienced). Stratified analyses were also conducted by age group (40-64 years, ≥65 years) and physician specialty.

RESULTS

A total of 55,361 patients met study criteria of whom 39% were newly diagnosed. The mean age was 66 years, and 46% were male. Three-fourths (74%) of all COPD patients had some pharmacotherapy (maintenance or reliever) with less than half (45%) being treated with maintenance medications. The combination of an inhaled corticosteroid and a long-acting beta-agonist was the most prevalent drug class for maintenance treatment followed by tiotropium. Only 64% of patients with an exacerbation history had a prescription for a long-acting maintenance medication, and short-term treatment with oral corticosteroids or antibiotics was higher for hospitalization exacerbations compared to ED visit exacerbations (68% vs 44%). In general, the rates of pharmacotherapy were highest in patients who were maintenance-experienced followed by newly diagnosed and maintenance-naïve.

CONCLUSION

The majority of COPD patients received maintenance or reliever COPD medications, but less than half received guideline-recommended care, especially those with an exacerbation history or receiving short-term treatment for acute exacerbations.

Adherence to the Global Initiative for Chronic Obstructive Lung Disease guidelines for management of COPD: a hospital-base study

BACKGROUND AND AIMS

To determine the level of adherence to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines, we compared our inpatient management of exacerbations of chronic obstructive pulmonary disease (COPD) to these guidelines.

METHOD

This cross-sectional descriptive study was conducted from January 2011 to April 2012 in a 360-bed teaching hospital in Shiraz, Iran. We recorded the management data for 96 consecutive patients with COPD exacerbation. SPSS 11.5 software (SPSS Inc., Chicago, IL, USA) was used for all statistical analyses.

RESULTS

The mean (standard deviation) age of our patients was 67.3 (14) years, and more than 75% of them were men. Adherence for starting antibiotics was 84.4%. Most of our patients (82.3%) received oxygen therapy, for a level of adherence to GOLD recommendations of 74%. Nearly 95% received a short-acting bronchodilator, and 12.5% received a long-acting bronchodilator. Adherence to the guidelines was 19.8% for oral and 61.4% for inhaled steroids. Adherence to the guidelines was 49% for starting N-acetylcysteine, 77.1% for antitussives and 13.5% for xanthine derivatives (aminophylline and theophylline). The overall adherence to GOLD guidelines was 67.2% at our hospital.

CONCLUSION

The level of adherence to GOLD guidelines for the management of COPD exacerbation was suboptimal at our teaching hospital. Further improvements in adherence to these guidelines are needed.

Patient safety analysis of the ED care of patients with heart failure and COPD exacerbations: a multicenter prospective cohort study

OBJECTIVES

For emergency department (ED) patients with acute exacerbations of heart failure and chronic obstructive pulmonary disease (COPD), we aimed to assess the adherence to evidence-based care and determine the proportion that experienced adverse events.

METHODS

An expert panel identified critical actions for ED care of heart failure and COPD patients based on clinical practice guidelines. We collected outcome data for discharged ED patients >age 50 with acute heart failure or COPD in a multicenter prospective cohort study at five academic EDs. We measured 3 flagged outcomes: return ED visit, admission, or death within 14 days. Three trained physician reviewers reviewed case summaries for adverse event determination (flagged outcomes related to healthcare received). We evaluated health records for adherence to the critical actions for each condition.

RESULTS

We identified 122 (7.0%) flagged outcomes among 1,718 enrolled patients (61 heart failure, 59 COPD and 2 dual diagnoses). The mean age was 74.2 (SD 10.4) and 44.3% were female. Among 10 critical actions for heart failure and 13 for COPD, a mean proportion of 9.4/10 and 11.0/13 were adhered to respectively. We identified 12 adverse events (9.8%, 95%CI: 5.6-16.5%), all of which were deemed preventable, including 1 death. The most common contributors were unsafe disposition decisions (10/12, 83.3%) and diagnostic issues (5/12, 41.7%). Patients who died with heart failure were statistically significantly less likely to have guideline adherent care (P = .02).

CONCLUSIONS

A small proportion of return ED visits were related to index care. We believe there is need for improvement around disposition decision making for both conditions to reduce the highly preventable and clinically significant adverse events we found.

A post hoc pooled analysis of exacerbations among US participants in randomized controlled trials of tiotropium

BACKGROUND

Exacerbations are a defining outcome of chronic obstructive pulmonary disease (COPD). We evaluated the effect of tiotropium on COPD exacerbations and related hospitalizations among patients from the USA enrolled in clinical trials.

METHODS

Data were pooled from six randomized, double-blind, placebo-controlled trials (6 to ≥ 12 months' duration) of tiotropium in patients with COPD. Exacerbations were defined retrospectively as an increase in or new onset of >1 respiratory symptom lasting for ≥ 3 days and requiring treatment with systemic corticosteroids and/or antibiotics. Time to first exacerbation or hospitalization and exacerbation rates were analyzed at 6 months, and at 1 year for studies ≥ 1 year.

RESULTS

In total, 4355 patients (tiotropium, 2268, placebo, 2087; mean age 66.5 years; forced expiratory volume in 1 s [FEV1] 1.03 L [35.5% predicted]) were analyzed at 6 months and 2455 at 1 year (tiotropium 1317, placebo 1138; mean age 65.5 years; FEV1 1.03 L [37.0% predicted]). Tiotropium delayed time to first exacerbation or first hospitalized exacerbation at 6 months (hazard ratios [HRs], 0.80, 0.65, respectively; p < 0.001 vs placebo) and 1 year (HRs, 0.73 and 0.55; p < 0.001 vs placebo) and reduced exacerbation rates and hospitalization rates (6 months: HRs, 0.79, 0.64; 1 year: HRs, 0.78, 0.56, respectively; all p < 0.01 vs placebo). Tiotropium significantly reduced exacerbations, irrespective of inhaled corticosteroid use at baseline. Tiotropium was not associated with an increased risk of cardiac-related events.

CONCLUSIONS

Tiotropium significantly reduced the risk and rates of exacerbations and hospitalizations among US patients with COPD.

Guidelines for diagnosis and management of chronic obstructive pulmonary disease: Joint ICS/NCCP (I) recommendations

Chronic obstructive pulmonary disease (COPD) is a major public health problem in India. Although several International guidelines for diagnosis and management of COPD are available, yet there are lot of gaps in recognition and management of COPD in India due to vast differences in availability and affordability of healthcare facilities across the country. The Indian Chest Society (ICS) and the National College of Chest Physicians (NCCP) of India have joined hands to come out with these evidence-based guidelines to help the physicians at all levels of healthcare to diagnose and manage COPD in a scientific manner. Besides the International literature, the Indian studies were specifically analyzed to arrive at simple and practical recommendations. The evidence is presented under these five headings: (a) definitions, epidemiology, and disease burden; (b) disease assessment and diagnosis; (c) pharmacologic management of stable COPD; (d) management of acute exacerbations; and (e) nonpharmacologic and preventive measures. The modified grade system was used for classifying the quality of evidence as 1, 2, 3, or usual practice point (UPP). The strength of recommendation was graded as A or B depending upon the level of evidence.

[Evaluation of the management of COPD exacerbations: an audit in French emergency services]

INTRODUCTION

Acute exacerbations of chronic obstructive pulmonary disease (COPD) patients are major events in the history of this chronic respiratory disease. Their management in French emergency services is unknown, although national guidelines exist.

METHODS

This is a descriptive audit study, over a 10 weeks period (12/01-22/03/2009), of the management of COPD exacerbations in the RESUVal (Réseau des Urgences de la Vallée du Rhône, France) network emergency departments.

RESULTS

The enrollement of 16 emergency units allowed the analysis of 221 exacerbations of COPD. Measurement of respiratory rate and description of the sputum were mentioned in only 99 (45%) medical records. The rest of the initial assessment was generally satisfactory. Regarding the therapeutic management, 215 (97%) patients received oxygen, beta-2-agonist aerosols were administrated for 209 (95%) patients and anticholinergic aerosols were used for 176 (80%) patients. A systemic corticosteroid and antibiotics were respectively prescribed for 116 (52%) and 123 (56%) patients. Non-invasive ventilation (NIV) was used in only 59% of patients presenting a pH<7.35.

CONCLUSIONS

These findings demonstrate that management of exacerbations of COPD could be improved through systematic patients' respiratory rate and sputum characteristics recording or NIV utilization reinforcement.

Adherence to guidelines and protocols in the prehospital and emergency care setting: a systematic review

A gap between guidelines or protocols and clinical practice often exists, which may result in patients not receiving appropriate care. Therefore, the objectives of this systematic review were (1) to give an overview of professionals' adherence to (inter)national guidelines and protocols in the emergency medical dispatch, prehospital and emergency department (ED) settings, and (2) to explore which factors influencing adherence were described in studies reporting on adherence. PubMed (including MEDLINE), CINAHL, EMBASE and the Cochrane database for systematic reviews were systematically searched. Reference lists of included studies were also searched for eligible studies. Identified articles were screened on title, abstract and year of publication (≥1990) and were included when reporting on adherence in the eligible settings. Following the initial selection, articles were screened full text and included if they concerned adherence to a (inter)national guideline or protocol, and if the time interval between data collection and publication date was <10 years. Finally, articles were assessed on reporting quality. Each step was undertaken by two independent researchers. Thirty-five articles met the criteria, none of these addressed the emergency medical dispatch setting or protocols. Median adherence ranged from 7.8-95% in the prehospital setting, and from 0-98% in the ED setting. In the prehospital setting, recommendations on monitoring came with higher median adherence percentages than treatment recommendations. For both settings, cardiology treatment recommendations came with relatively low median adherence percentages. Eight studies identified patient and organisational factors influencing adherence. The results showed that professionals' adherence to (inter)national prehospital and emergency department guidelines shows a wide variation, while adherence in the emergency medical dispatch setting is not reported. As insight in influencing factors for adherence in the emergency care settings is minimal, future research should identify such factors to allow the development of strategies to improve adherence and thus improve quality of care.

Factors associated with hospital admission in patients reaching the emergency department with COPD exacerbation

BACKGROUND

The aim of this study was to determine the frequency of COPD exacerbations in our Emergency Department, as well as the hospitalization-related factors.

METHODS

Prospective observational study conducted in the Emergency Department of Salnés County Hospital among patients admitted for COPD exacerbation. Admission predictors were determined by multivariate analysis.

RESULTS

There were 409 exacerbations in 239 patients (79% male, mean age 75). 57% of exacerbations required hospitalization. Hospitalization-related factors were impaired oxygenation (p < 0.001), presence of neutrophilia (p < 0.01) and prescription of antibiotics in the Emergency Department (p < 0.05).

CONCLUSIONS

COPD exacerbation accounts for over 1% of all visits to our Emergency Department. 57% of them required hospitalization. Impaired oxygenation, greater neutrophilia and prescription of antibiotics in the Emergency Department were associated with greater probability of admission.

Acute exacerbations of chronic obstructive pulmonary disease in the emergency department

Chronic obstructive pulmonary disease (COPD) is a significant cause of morbidity and mortality worldwide. Acute exacerbations of COPD (AECOPDs) are a common presentation to emergency departments and are an important cause of respiratory failure. This article discusses the disease process and diagnosis of COPD and AECOPD. A further in-depth discussion is undertaken of evidence-based treatments, palliation, and disposition of patients who present to emergency departments with AECOPD.

Quality of care, health care costs, and utilization among Medicare Part D enrollees with and without low-income subsidy

The objective of this cross-sectional, retrospective, claims-based analysis was to evaluate disease-specific quality measures, use of acceptable therapies, and health care cost and utilization among Medicare Advantage Part D (MAPD) enrollees overall and by income/subsidy eligibility status. Individuals aged ≥65 years with evidence of ≥1 of 8 common conditions and continuously enrolled in a MAPD plan throughout 2007 were assigned to low-income/dually eligible (LI/DE) or non-LI/DE cohorts. Quality of care metrics were calculated for asthma, chronic obstructive pulmonary disease (COPD), diabetes, and new episode depression. Persistence (proportion with percentage of days covered ≥80%), compliance (proportion with medication possession ratio ≥80%), health care costs, and utilization metrics were assessed by condition. All measures were evaluated for calendar year 2007. Bivariate comparisons were made between all LI/DE and non-LI/DE subgroups. A total of 183,213 patients were included. Metrics showed deficiencies in quality of care overall but generally favored non-LI/DE patients. The proportion of patients filling acceptable medication was suboptimal for most conditions, ranging from 40% to 96% across conditions and cohorts, with COPD the lowest and heart failure (HF) the highest. LI/DE patients were significantly more likely than non-LI/DE patients to fill acceptable therapy in each disease group (P<0.001) except HF. Percentages persistent and compliant with acceptable therapies were lowest for asthma and COPD, and highest for HF; percentages were generally higher among LI/DE patients. Mean disease-specific health care costs ranged from $345 (hyperlipidemia) to $2086 (HF) and were significantly higher for LI/DE than for non-LI/DE enrollees (P<0.001) for all diseases except coronary artery disease and HF. Overall, quality indicators, use of acceptable medications, and persistence/compliance metrics were suboptimal. Quality metrics favored non-LI/DE patients but medication metrics favored LI/DE patients. With an aging population and increasing health care costs, the deficits identified highlight the need for comprehensive strategies to improve clinical and economic outcomes across diseases.

Assessment and management of chronic obstructive pulmonary disease in the emergency department and beyond

Acute exacerbations of chronic obstructive pulmonary disease (AECOPDs) are common, can result in emergency department presentation and often result in hospitalization. After confirming the diagnosis and treating comorbidities, management of severe AECOPD includes bronchodilators, systemic corticosteroids, antibiotics, noninvasive ventilation and, occasionally, endotracheal intubation. Once discharged, delayed follow-up and suboptimal management often occurs. Antibiotics, systemic corticosteroids and optimization of nonpharmacological interventions (e.g., smoking cessation, immunization and pulmonary rehabilitation) are important discharge considerations. Improving linkages to primary providers who adhere to management involving a pharmacological and nonpharmacological evidence-based treatment plan is critical to preventing future AECOPDs, reducing healthcare utilization and maintaining the quality of life of patients following an AECOPD.

Emergency department management of exacerbation of chronic obstructive pulmonary disease: audit of compliance with evidence-based guidelines

BACKGROUND

Emergency departments (ED) play a key role in management of exacerbation of chronic obstructive airways disease (COPD). Current guidelines for management of exacerbation of COPD showed highest levels of evidence (Level A and B) were related to use of medications and non-invasive positive pressure ventilation (NIPPV).

AIMS

The aim of this study was to examine compliance with high level evidence for management of exacerbation of COPD during the first 4 h of ED care.

METHODS

A retrospective medical record audit was conducted at four public and one private ED in Melbourne, Australia. Participants were adult patients with COPD presenting to the ED with a primary complaint of shortness of breath from July 2006 to July 2007. Outcome measures were compliance with evidence-based recommendations regarding use of bronchodilators, methylxanthines, steroids and NIPPV.

RESULTS

Of 273 patients in this study, 72.4% received short-acting beta-agonist bronchodilators, 37.8% received an inhaled short-acting anticholinergic medication and 56.6% received systemic steroid therapy. NIPPV was used in 21 patients, 15 of whom had documentation of acidosis and/or hypercapnia).

CONCLUSIONS

There was variation in the use of high level evidence for the ED management of exacerbation of COPD. The highest rate of compliance was non-use of methylxanthines and the greatest deficit was poor compliance with evidence related to NIPPV. There was also scope for improvement in the use of bronchodilators and systemic steroids.

Is pharmacologic care of chronic obstructive pulmonary disease consistent with the guidelines?

Chronic obstructive pulmonary disease (COPD) is a common chronic illness that affects an estimated 210 million people worldwide, including 12 million people in the United States. National and international guidelines for treatment of COPD recommend use of certain medications, especially bronchodilators and corticosteroids, but the extent to which these are used appropriately is largely unknown. The objective of this study was to determine the extent to which pharmacotherapy for COPD is consistent with guidelines. Individuals with COPD (N = 2272), enrolled for at least 2 years in a large midwestern managed care organization, were identified from medical claims data. Medications dispensed in 2003 were examined using National Drug Codes from dispensation records. Quality indictors, developed from guidelines, focused on (1) use of bronchodilators, (2) use of inhaled corticosteroids (ICS) for patients with frequent exacerbations, and (3) use of systemic corticosteroids for acute exacerbation of COPD (AE-COPD). A total of 2272 subjects aged 45 years or older with a diagnosis of COPD were identified. Seventy-two percent of subjects with COPD received at least 1 bronchodilator; 64% of subjects with frequent prior exacerbations (> or =3 in the past year) received ICS; and only 51% of subjects with AE-COPD during the study year received systemic corticosteroids. Although most patients received 1 or more respiratory medications recommended by the guidelines, there were gaps in care including limited use of systemic corticosteroids for AE-COPD and ICS for patients with frequent exacerbations. Greater use of appropriate medications could lead to improved health for patients with COPD.

Outcomes following chronic obstructive pulmonary disease presentations to emergency departments in Alberta: a population-based study

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is a complex, multisystem disorder that often results in exacerbations requiring emergency department (ED) management. Following an exacerbation and discharge from the ED, reassessment and management adjustment with a health care provider are recommended to re-establish control of the disease.

OBJECTIVES

To describe outcomes of all COPD presentations to EDs made by adults in Alberta including the time spent in the ED and the physician visits following the ED visit.

METHODS

Provincial administrative databases were used to obtain all ED encounters for COPD during six fiscal years (1999 to 2005). The information extracted included demographics, ED visit timing, and acute and subacute outcomes (physician visits up to 365 days after discharge for all 7302 discharged individuals during a one-year period). Data analysis included descriptive summaries and survival curves.

RESULTS

There were 85,330 ED visits for acute COPD, of which 67% were discharged from the ED. Median ED length of stay was longer in large urban areas (Calgary: 5 h 9 min; Edmonton: 4 h 58 min) than in other regions of Alberta (1 h 17 min). Admissions resulted from 32% of visits and varied among regions; however, few were admitted to the intensive care unit (1%) or died (0.1%). Following discharge, the median time to first follow-up with a physician was 13 days; however, only 40% of patients had follow-up visits in the first seven days. Repeat ED visits within seven days occurred in 5.7% of discharged patients, while 25.6% of discharged patients had repeat ED visits within 365 days of discharge.

CONCLUSIONS

More than 30% of COPD ED visits resulted in admission; regional variation was significant. Moreover, discharged patients experienced delayed follow-up and often required repeat ED visits. Interventions to improve reassessment and reduce COPD-related repeat ED visits should be explored.

ED visit volume and quality of care in acute exacerbations of chronic obstructive pulmonary disease

OBJECTIVE

The purpose of this study is to determine whether emergency department (ED) visit volume is associated with ED quality of care in patients with acute exacerbations of chronic obstructive pulmonary disease (COPD).

METHODS

We performed a prospective multicenter cohort study involving 29 EDs in the United States and Canada. Using a standard protocol, we interviewed consecutive ED patients with COPD exacerbation, reviewed their charts, and completed a 2-week telephone follow-up. The associations between ED visit volume and quality of care (process and outcome measures) were examined at both the ED and patient levels.

RESULTS

After adjustment for patient mix in the multivariable analyses, chest radiography was less frequent among patients with COPD exacerbations in the low-volume (odds ratio [OR], 0.2; 95% confidence interval [CI], 0.1-0.4) and high-volume EDs (OR, 0.1; 95% CI, 0.05-0.5), with medium-volume EDs as the reference. Arterial blood gas testing was less frequent in the low-volume EDs (OR, 0.1; 95% CI, 0.02-0.8). Medication use was similar across volume tertiles. With respect to outcome measures, patients in high-volume EDs were more likely to be discharged (OR, 4.2; 95% CI, 2.2-7.7) and to report ongoing exacerbation at a 2-week follow-up (OR, 1.9; 95% CI, 1.02-3.5).

CONCLUSIONS

Traditional positive volume-quality relationships did not apply to emergency care of COPD exacerbation. High-volume EDs used less guideline-recommended diagnostic procedures, had a higher admission threshold, and had a worse short-term patient-centered outcome.

Inhospital management of COPD exacerbations: a systematic review of the literature with regard to adherence to international guidelines

Rationale Chronic obstructive pulmonary disease (COPD) exacerbations are a leading cause of hospitalization. Suboptimal inhospital management is expected to lead to more frequent exacerbations and recurrent hospital admission, and is associated with increased mortality. Aims To explore inhospital management of COPD and to compare the results with recommendations from international guidelines. Methods A literature search was carried out for relevant articles published 2000-2009 in the databases Medline, Cochrane Library, Cumulative Index for Nursing and Allied Health Literature and Invert. In addition, the reference lists of the selected articles were examined. Main inclusion criteria were as follows: COPD, exacerbation, hospitalization, description of inpatient management, and clinical trials. Assessment and treatment strategies in different studies were analysed and compared with American Thoracic Society-European Respiratory Society and Global Initiative for Chronic Obstructive Lung Disease guidelines. Outcomes were analysed. Results Seven eligible studies were selected. Non-pharmacological treatment was infrequently explored. When compared with international guidelines, diagnostic assessment and therapy were suboptimal, especially non-pharmacological treatment. Respiratory physicians were more likely to perform recommended interventions than non-respiratory physicians. Conclusions Adherence to international guidelines is low for inhospital management of COPD exacerbations, especially in terms of non-pharmacological treatment. Further investigation is recommended to explore strategies like care pathways that improve performance of recommended interventions.

Acute exacerbations of COPD: delay in presentation and the risk of hospitalization

To determine if a delay in presentation to the emergency department (ED) after the onset of symptoms of an acute exacerbation of chronic obstructive pulmonary disease (AECOPD) increases the risk of hospital admission. A prospective cohort study utilizing data from 396 patient visits to 29 North American EDs. Inclusion criteria were age > or = 55 years; a diagnosis of COPD; and presentation for treatment of AECOPD, as defined by increasing shortness of breath, worsening cough, or change in sputum production at presentation. The median age was 69 years and 54% were female. Most patients (70%) presented to the ED > 24 hours after symptom onset, and most (61%) were hospitalized. On multivariate logistic regression analysis, after adjusting for 12 potential confounders (including demographics, clinical features, other diagnoses, and bronchodilator use before arrival), a delay in presentation > or = 24 hours was associated with a over two-fold increase in the odds of admission (odds ratio = 2.2, 95% confidence interval 1.1-4.8). This increase in risk persisted for delay in presentation > or = 12 hours in place of 24 hours, after restricting the analysis to patients admitted outside the intensive care unit, and to those reporting the ED as their usual site of care. A majority of patients delay presentation to the ED for > or = 24 hours after symptom onset, and are at higher risk of hospitalization. Early presentation should be emphasized to patients and caregivers to advance efforts to decrease the morbidity, mortality, and costs of AECOPD treatment.

Mortality after an Emergency Department Visit for Exacerbation of Chronic Obstructive Pulmonary Disease

OBJECTIVE

To describe the mortality after emergency department (ED) visits for chronic obstructive pulmonary disease (COPD) exacerbation.

DESIGN

Retrospective cohort study of ED patients with COPD exacerbation. Setting. Administrative data analysis.

PARTICIPANTS

Patients age 55 and over who visited the ED during a 2-year period with primary ICD-9 codes of 491, 492, or 496.

MEASUREMENTS

Demographic characteristics, comorbid conditions, hospital utilization for COPD, and vital status.

RESULTS

During the study period, there were 482 index visits with a median follow-up of 1,128 days (3.1 years). Demographic characteristics of the cohort were as follows: mean age 72 years, 56% female, 93% White, and 37% currently married. Mortality increased over time: 5% at 30 days, 9% at 60 days, 11% at 90 days, 16% at 180 days, 23% at 1 year, 32% at 2 years, and 39% at 3 years. At the end of follow-up, 220 (46%) patients had died. On multivariate analysis, independent predictors of mortality were increasing age (hazard ratio [HR] 1.3 per 5-year increase, 95% CI 1.2-1.4), having congestive heart failure (HR 1.6, 95% CI 1.2-2.1), having metastatic solid tumor (HR 3.3, 95% CI 2.0-5.5), and hospital utilization for COPD exacerbation during past year (HR 1.9, 95% CI 1.4-2.6).

CONCLUSION

The mortality rate after an ED visit for COPD exacerbation is quite high. Mortality is related to older age, specific comorbid conditions, and history of prior COPD exacerbations.

Improved care of acute exacerbation of chronic obstructive pulmonary disease in two academic emergency departments

Background

Although several chronic obstructive pulmonary disease (COPD) practice guidelines have been published, there is sparse data on the actual emergency department (ED) management of acute exacerbation of COPD (AECOPD).

Aims

Our objectives were to examine concordance of ED care of AECOPD in older patients with guideline recommendations and to evaluate whether concordance has improved over time in two academic EDs.

Methods

Data were obtained from two cohort studies on AECOPD performed in two academic EDs during two different time periods, 2000 and 2005–2006. Both studies included ED patients, aged 55 and older, who presented with AECOPD, and cases were confirmed by emergency physicians. Data on ED management and disposition were obtained from chart review for both cohorts.

Results

The analysis included 272 patients: 72 in the 2000 database and 200 in the 2005–2006 database. The mean age of the patients was 72 years; 50% were women and 80% white. In 2005–2006, overall concordance with guideline recommendations was high (for chest radiography, pulse oximetry, bronchodilators, all ≥ 90%), except for arterial blood gas testing (7% among the admitted) and discharge medication with systemic corticosteroids (42%). Compared to the 2000 data, the use of systemic corticosteroids in the ED improved from 53 to 77% [absolute improvement: 24%, 95% confidence interval (CI): 11–37%], and the use of antibiotics among the patients with respiratory infection symptoms improved from 56 to 78% (absolute improvement: 22%, 95% CI: 6–38%).

Conclusions

Overall concordance with guideline-recommended care for AECOPD was high in two academic EDs, and some emergency treatments have improved over time.

Racial and ethnic differences in emergency care for acute exacerbation of chronic obstructive pulmonary disease

OBJECTIVES

The objective was to investigate racial and ethnic differences in emergency care for patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD).

METHODS

The authors performed a prospective multicenter cohort study involving 24 emergency departments (EDs) in 15 U.S. states. Using a standard protocol, consecutive ED patients with AECOPD were interviewed, their charts reviewed, and 2-week telephone follow-ups were completed.

RESULTS

Among 330 patients, 218 (66%) were white, 84 (25%) were African American, and 28 (8%) were Hispanic. A quarter of the 24 EDs cared for 59% of all minority patients. Compared with white patients, African American and Hispanic patients were more likely to be uninsured or with Medicaid (19, 49, and 52%, respectively; p < 0.001), were less likely to have a primary care provider (93, 81, and 82%, respectively; p = 0.005), and had more frequent ED visits in the past year (medians = 1, 2, and 3, respectively; p = 0.002). In the unadjusted analyses, minority patients were less likely to receive diagnostic procedures, more likely to receive systemic corticosteroids in the ED, less likely to be admitted, and more likely to have a relapse. After adjustment for patient and ED characteristics, these many racial and ethnic differences in quality of care were nearly completely eliminated.

CONCLUSIONS

Despite pronounced racial and ethnic differences in stable COPD, all racial and ethnic groups received comparable quality of emergency care for AECOPD and had similar short-term outcomes.

Factors associated with short-term recovery of health status among emergency department patients with acute exacerbations of chronic obstructive pulmonary disease

OBJECTIVE

To determine the factors associated with short-term recovery of health status following chronic obstructive pulmonary disease (COPD) exacerbation.

METHODS

In a prospective multicenter cohort study, consecutive emergency department (ED) patients with COPD exacerbation were enrolled. Patients were interviewed and instructed to complete the validated Short Form Chronic Respiratory disease Questionnaire. Follow-up data were collected 2 weeks later, and included the global transition question. The primary outcome was recovery of health status, which was assigned to patients who stated that their COPD was "a little better" or "much better" than at the time of their ED presentation.

RESULTS

Of the 330 patients, 270 [82%; 95% confidence interval (CI), 77-86%] reported recovery of health status following acute exacerbations. Multivariable analysis showed that recovery of health status was associated with having a primary care provider (PCP) [odds ratio (OR), 3.1; 95% CI, 1.5-6.4] and a co-diagnosis of asthma (OR, 2.2; 95% CI, 1.2-3.8). By contrast, frequent exacerbations (two or more exacerbations in the past year) (OR, 0.4; 95% CI, 0.2-0.7) was inversely associated with recovery.

CONCLUSIONS

Reducing exacerbation frequency and provision of adequate PCP follow-up after ED visit may help improve the recovery of health status following acute exacerbations of COPD.

National study of emergency department visits for acute exacerbation of chronic obstructive pulmonary disease, 1993-2005

OBJECTIVES

Little is known about recent trends in U.S. emergency department (ED) visits for acute exacerbation of chronic obstructive pulmonary disease (AECOPD) or about ED management of AECOPD. This study aimed to describe the epidemiology of ED visits for AECOPD and to evaluate concordance with guideline-recommended care.

METHODS

Data were obtained from National Hospital Ambulatory Medical Care Survey (NHAMCS). ED visits for AECOPD, during 1993 to 2005, were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Concordance with guideline recommendations was evaluated using process measures.

RESULTS

Over the 13-year study period, there was an average annual 0.6 million ED visits for AECOPD, and the visit rates for AECOPD were consistently high (3.2 per 1,000 U.S. population; P(trend) = 0.13). The trends in the use of chest radiograph, pulse oximetry, or bronchodilator remained stable (all P(trend) > 0.5). By contrast, the use of systemic corticosteroids increased from 29% in 1993-1994 to 60% in 2005, antibiotics increased from 14% to 42%, and methylxanthines decreased from 15% to <1% (all P(trend) < 0.001). Multivariable analysis showed patients in the South (vs. the Northeast) were less likely to receive systemic corticosteroids (odds ratio [OR] = 0.6; 95% confidence interval [CI] = 0.4 to 0.9).

CONCLUSIONS

The high burden of ED visits for AECOPD persisted. Overall concordance with guideline-recommended care for AECOPD was moderate, and some emergency treatments had improved over time.

Comparison of Canadian versus United States emergency department visits for chronic obstructive pulmonary disease exacerbation

INTRODUCTION

Despite the frequency of emergency department (ED) visits for chronic obstructive pulmonary disease (COPD) exacerbation, little is known about practice variation in EDs.

OBJECTIVES

To examine the differences between Canadian and United States (US) COPD patients, and the ED management they receive.

METHODS

A prospective multicentre cohort study was conducted involving 29 EDs in the US and Canada. Using a standard protocol, consecutive ED patients with COPD exacerbations were interviewed, their charts reviewed and a two-week telephone follow-up completed. Comparisons between Canadian and US patients, as well as their treatment and outcomes, were made. Predictors of antibiotic use were determined by multivariate logistic regression.

RESULTS

Of 584 patients who had physician-diagnosed COPD, 397 (68%) were enrolled. Of these, 63 patients (16%) were from Canada. Canadians were older (73 years versus 69 years; P=0.002), more often white (97% versus 65%; P<0.001), less educated (P=0.003) and more commonly insured (P<0.001) than the US patients. US patients more commonly used the ED for their usual COPD medications (17% versus 3%; P=0.005). Although Canadian patients had fewer pack-years of smoking (45 pack-years versus 53 pack-years; P=0.001), current COPD medications and comorbidities were similar. At ED presentation, Canadian patients were more often hypoxic and symptomatic. ED treatment with inhaled beta-agonists (approximately 90%) and systemic corticosteroids (approximately 65%) were similar; Canadians received more antibiotics (46% versus 25%; P<0.001) and other treatments (29% versus 11%; P=0.002). Admission rates were similar in both countries (approximately 65%), although Canadian patients remained in the ED longer than the US patients (10 h versus 5 h, respectively; P<0.001).

CONCLUSIONS

Overall, patients with acute COPD in Canada and the US appear to have similar history, ED treatment and outcomes; however, Canadian patients are older and receive more aggressive treatment in the ED. In both countries, the prolonged length of stay and high admission rate contribute to the ED overcrowding crisis facing EDs.

Physician characteristics and the reported effect of evidence-based practice guidelines

OBJECTIVE

To explore characteristics that may contribute to the effect practice guidelines have on the practice of medicine.

DATA SOURCES

From the third round of the Community Tracking Study, Physician Survey, 2000-2001.

STUDY DESIGN

An ordinal logistic regression model was estimated to capture the full range of responses.

PRINCIPAL FINDINGS

Recent medical school graduates, women, minorities, ob-gyn specialists, physicians who use computers for information in their practices, and physicians in nonsolo practice types were significantly more likely to state practice guidelines had an effect on their practice.

CONCLUSIONS

Many barriers have prevented wide acceptance of practice guidelines among the medical community. Our findings suggest there will be positive results on guideline effects as recent graduates, women, and minorities enter the physician workforce.

Changing the process of care and practice in acute asthma in the emergency department: experience with an asthma care map in a regional hospital

INTRODUCTION

Despite the frequency of acute asthma in the emergency department (ED) and the availability of guidelines, significant practice variation exists. Asthma care maps (ACMs) may standardize treatment. This study examined the use of an ACM to determine its effects on patient management in a regional hospital.

METHODS

Patients aged 2 to 65 years who presented to the ED with a primary diagnosis of acute asthma were enrolled in a prospective study that took place 5 months before (pre) and 5 months after (post) ACM implementation. Research assistants using a standardized questionnaire abstracted data through direct patient interviews and then followed up at 2 weeks with a standardized telephone interview.

RESULTS

Overall, 71 pre patients and 70 post patients were enrolled. Characteristics in both groups were similar. The care map was used in 100% of the cases during the post period. The mean length of stay in the ED for the pre, compared with the post period, was similar (2 h 14 min v. 2 h 25 min; p = 0.60), as were admission rates (11% v. 9%; p = 0.59). Systemic corticosteroid use was similar (62% v. 57%; p = 0.56); however, the total number of beta-agonists (2 v. 4 treatments; p = 0.002) and anticholinergics (1 v. 2 treatments; p < 0.001) administered in the ED was higher during the post period. Prescriptions for oral (73% v. 60%; p = 0.15) and inhaled (78% v. 78%; p = 0.98) corticosteroids at discharge remained the same. Relapse rates at follow-up were unchanged (29% v. 34%; p = 0.52).

CONCLUSION

This study provides evidence that implementation of an ACM increased acute bronchodilator use; however, prescribing preventive medications did not increase. Further research is required to evaluate other strategies to improve asthma care by emergency physicians.

Circadian-rhythm differences among emergency department patients with chronic obstructive pulmonary disease exacerbation

The purpose of the study was determine whether patients with chronic obstructive pulmonary disease (COPD) exacerbation who present to the emergency department (ED) during the night (00:00 to 07:59 h) vs. other times of the day have more severe COPD exacerbation, require more intensive treatment, and have worse clinical outcomes. A multicenter cohort study was completed involving 29 EDs in the United States and Canada. Using a standard protocol, consecutive ED patients with COPD exacerbation were interviewed, and their charts were reviewed. Of 582 patients enrolled, 52% were women, and the median age was 71 yrs (interquartile range, 64-77 yrs). Nighttime patients (15% of cohort) did not differ from patients presenting at other times except that they were less likely to have private insurance, more likely to have a history of corticosteroid use, and have a shorter duration of symptoms exacerbation. Except for a few features indicative of more severe COPD exacerbation (such as higher respiratory rate at ED presentation, greater likelihood of receiving noninvasive positive pressure ventilation, and increased risk of endotracheal intubation), nighttime patients did not differ from other patients with respect to ED management. Nighttime patients were approximately three-fold more likely to be intubated in the ED (odds ratio, 3.46; 95% confidence interval, 1.10-10.9). There were no day-night differences regarding ED disposition and post-ED relapse. Except for some features indicating more severe exacerbation, nighttime ED patients had similar chronic COPD characteristics, received similar treatments in the ED, and had similar clinical outcomes compared with patients presenting to the ED at other times of the day.

Factors associated with frequency of emergency department visits for chronic obstructive pulmonary disease exacerbation

BACKGROUND

Little is known about the factors associated with frequency of emergency department visits (FEDV) in chronic obstructive pulmonary disease (COPD) patients with recurrent exacerbations.

OBJECTIVE

To characterize the use of emergency department (ED) services in patients with COPD exacerbation and identify factors associated with FEDV.

DESIGN

A prospective, multicenter cohort study.

PATIENTS

Three hundred eighty-eight patients were included. Fifty-two percent were women and the median age was 69 years (interquartile range 62-76).

MEASUREMENTS

Using a standard questionnaire, consecutive ED patients with COPD exacerbation were interviewed. The number of ED visits in the previous year was retrospectively collected.

RESULTS

Over the past year, this cohort reported a total of 1,090 ED visits because of COPD exacerbation. Thirteen percent of COPD patients had 6 or more ED visits, accounting for 57% of the total ED visits in the past year. Multivariate analysis showed that patients with an increased FEDV were more likely to be Hispanic (incidence rate ratio [IRR] 1.97, 95% confidence interval [CI] 1.16-3.33), to have more severe COPD as determined by previous hospitalizations (IRR 2.06, 95% CI 1.51-2.82), prior intubations (IRR 1.49, 95% CI 1.02-2.18), prior use of systemic corticosteroids (IRR 1.57, 95% CI 1.16-2.13) and methylxanthine (IRR 1.48, 95% CI 1.04-2.12), and less likely to have a primary care provider (IRR 0.51, 95% CI 0.31-0.82).

CONCLUSIONS

Our results suggest that both disease and health care-related factors were associated with FEDV in COPD exacerbation. Multidisciplinary efforts through primary care provider follow-up should be assessed to test the effects on reducing the high morbidity and cost of recurrent COPD exacerbations.

Factors associated with hospital admission among emergency department patients with chronic obstructive pulmonary disease exacerbation

OBJECTIVES To determine the patient factors associated with hospital admission among adults who present to the emergency department (ED) with acute exacerbations of chronic obstructive pulmonary disease (COPD) and to determine whether admissions were concordant with recommendations in the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines.

METHODS

The authors performed a prospective multicenter cohort study involving 29 EDs in the United States and Canada. By using a standard protocol, consecutive ED patients with COPD exacerbation were interviewed, and their charts were reviewed. Predictors of admission were determined by multivariate logistic regression.

RESULTS

Of 384 patients, 233 (61%; 95% confidence interval = 56% to 66%) were admitted. Multivariate analysis showed that a higher likelihood of admission was associated with older age, female gender, more pack-years of smoking, recent use of inhaled corticosteroid, self-reported activity limitation in the past 24 hours, higher respiratory rate at ED presentation, and a concomitant diagnosis of pneumonia. Patients who reported the ED as their usual site for problem COPD care, or who had mixed COPD and asthma, were less likely to be admitted. The authors confirmed five of the seven testable indications for hospital admission in the GOLD guidelines.

CONCLUSIONS

Several patient factors were independently associated with hospital admission among ED patients with COPD exacerbations. Overall, concordance with admission recommendations in the GOLD guidelines was high. The authors also identified a few novel predictors of admission (female gender, ED as the usual site for problem COPD care, mixed diagnosis of COPD and asthma, recent use of inhaled corticosteroid) that require replication in future studies.