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Styrvold M, Heggset Sterten AJ, Shrestha S, Dhakal S, Harstad I. An audit of patients admitted to hospital in Nepal for COPD exacerbation. SAGE Open Med 2022; 10:20503121221085087. [PMID: 35321460 PMCID: PMC8935543 DOI: 10.1177/20503121221085087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 02/14/2022] [Indexed: 11/17/2022] Open
Abstract
Objectives: Chronic obstructive pulmonary disease is a large and increasing problem in low- and middle-income countries; Nepal is no exception. We aimed to obtain information on patient characteristics and the level of care provided to patients admitted for acute exacerbation of chronic obstructive pulmonary disease in two Nepalese hospitals and to compare the given care with the Global Initiative for Chronic Obstructive Lung Disease guidelines. Methods: This was a cross-sectional, observational, descriptive study. All patients admitted to two Nepalese hospitals due to acute exacerbation of chronic obstructive pulmonary disease between 18 February and 5 April 2019 were asked to participate. Results: In total, 108 patients with a median age of 70 years participated. Fifty-three (42.7%) were male, 80 (74.8%) were former smokers, and 46 (45.1%) were farmers. Using the Global Initiative for Chronic Obstructive Lung Disease A-D classification, 97 (90.6%) of the patients were classified in group D. All the patients received supplementary oxygen treatment and 103 (95.4%) were treated with short-acting beta2 agonists. A total of 105 (97.2%) patients received antibiotics, and 80 (74.5%) received systemic corticosteroids. The majority was discharged with triple therapy including long-acting muscarinic antagonist, long-acting beta2 agonist, and inhaled corticosteroids, and 72 (75.8%) were discharged with long-term oxygen treatment. Conclusion: All elements of the Global Initiative for Chronic Obstructive Lung Disease guidelines were applied. However, due to a lack of information, it cannot be concluded whether the treatment was provided on the correct indications. The average patient received almost all the treatment alternatives available. This might indicate a very sick population or over-treatment.
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Affiliation(s)
- Marte Styrvold
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Ane Jonette Heggset Sterten
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Sudeep Shrestha
- Department of Internal Medicine, Dhulikhel Hospital, Dhulikhel, Nepal
| | - Subodh Dhakal
- Department of Internal Medicine, Kathmandu Medical College, Kathmandu, Nepal
| | - Ingunn Harstad
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Pulmonary Medicine, St. Olav’s University Hospital, Trondheim, Norway
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2
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Li M, Cheng K, Ku K, Li J, Hu H, Ung COL. Factors Influencing the Length of Hospital Stay Among Patients with Chronic Obstructive Pulmonary Disease (COPD) in Macao Population: A Retrospective Study of Inpatient Health Record. Int J Chron Obstruct Pulmon Dis 2021; 16:1677-1685. [PMID: 34135579 PMCID: PMC8200153 DOI: 10.2147/copd.s307164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 05/04/2021] [Indexed: 12/03/2022] Open
Abstract
Purpose This study aims to identify the effects of patient and clinical therapy factors on the length of hospital stay (LOS) for admission due to chronic obstructive pulmonary disease (COPD) in Macao. Patients and Methods Health record of patients with COPD admitted to Kiang Wu Hospital from January 2017 to December 2019 was retrospectively analyzed. Demographic information, blood test results, clinical therapies, and LOS were described and analyzed by multivariable regression. Results A total of 1116 admissions were included with the average LOS being 12.28 (±9.23) days. Among them, 735 (66.6%) were male with mean age 79.42 (±10.35) years old, 697 were current or previous smokers (62.5%), and 360 (32.2%) had 3 or more comorbidities. During hospitalization, the most common treatments received were oxygen therapy (n=991,88.8%), antibiotics (n=828,74.2%), and systemic steroids (n=596,53.4%); only 120 (10.8%) had pulmonary rehabilitation (PR) and 128 (11.5%) received noninvasive ventilation (NIV). Inhaled medications were used during nearly 95% of hospitalization cases, while 2 and 3 types of inhaled medications were used during 230 (20.6%) and 582 (52.2%) hospitalization cases, respectively. Patient factors including age (B=0.178, 95% CI:0.535–1.072), being female (B=−1.147, 95% CI:-0.138–0.056), being current (B=−0.086, 95% CI:-0.124–0.018) or previous smoker (B=0.072, 95% CI:0.004–0.087), having 1, 2, 3 and over 3 comorbidities (B=0.126, 95% CI:0.034–0.147; B=0.125, 95% CI:0.031–0.144; B=0.116, 95% CI:0.028–0.146, B=0.090, 95% CI:0.021–0.166) and having low hemoglobin level (B=−0.118, 95% CI:-0.629- −0.214) exhibited significant associations with LOS. The use of NIV (B=0.080, 95% CI:0.022–0.138), pulmonary rehabilitation (B=0.269, 95% CI:0.212–0.327), two and three types of inhaled medications (B=0.109, 95% CI:0.003–0.166, B=0.255, 95% CI:0.083–0.237) were significantly associated with longer LOS (P<0.05). Conclusion NIV, PR and combined inhaled medications, which are often used for AECOPD, are the main clinical therapies associated with longer LOS in Macao. Smoking cessation, early treatments of comorbidities may be crucial to avoiding AECOPD and reducing LOS and disease burden.
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Affiliation(s)
- Meng Li
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macao SAR, China
| | - Kun Cheng
- Internal Medicine Department, Kiang Wu Hospital, Macao SAR, China
| | - Keisun Ku
- Internal Medicine Department, Kiang Wu Hospital, Macao SAR, China
| | - Junlei Li
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macao SAR, China
| | - Hao Hu
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macao SAR, China
| | - Carolina Oi Lam Ung
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macao SAR, China
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Vaughan L, Bardsley M, Bell D, Davies M, Goddard A, Imison C, Melnychuk M, Morris S, Rafferty AM. Models of generalist and specialist care in smaller hospitals in England: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2021. [DOI: 10.3310/hsdr09040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
The increasing number of older, complex patients who require emergency admission to hospital has prompted calls for better models of medical generalist care, especially for smaller hospitals, whose size constrains resources and staffing.
Objective
To investigate the strengths and weaknesses of the current models of medical generalism used in smaller hospitals from patient, professional and service perspectives.
Methods
The design was a mixed-methods study. Phase 1 was a scoping and mapping exercise to create a typology of models of care, which was then explored further through 11 case studies. Phase 2 created a classification using the Hospital Episode Statistics of acute medical ‘generalist’ and ‘specialist’ work and described differences in workload and explored the links between case mix, typology and length of stay and between case mix and skill mix. Phase 3 analysed the relationships between models of care and patient-level costs. Phase 4 examined the strengths and weaknesses of the models of care through focus groups, a discrete choice experiment and an exploration of the impact of typology on other outcomes.
Results
In total, 50 models of care were explored through 48 interviews. A typology was constructed around generalist versus specialist patterns of consultant working. Twenty-five models were deployed by 48 hospitals, and no more than four hospitals used any one model of care. From the patient perspective, analysis of Hospital Episode Statistics data of 1.9 million care episodes found that the differences in case mix between hospitals were relatively small, with 65–70% of episodes accounted for by 20 case types. The skill mix of hospital staff varied widely; there were no relationships with case mix. Patients exhibited a preference for specialist care in the discrete choice experiment but indicated in focus groups that overall hospital quality was more important. From a service perspective, qualitative work found that models of care were contingent on complex constellations of factors, including staffing, the local hospital environment and policy imperatives. Neither the model of care nor the case mix accounted for variability in the length of stay (no associations were significant at p < 0.05). No significant differences were found in the costs of the models. Professionally, the preferences of doctors for specialist versus generalist work depended on their experiences of providing care and were associated with a healthy organisational culture and a co-operative approach to managing emergency work. Concepts of medical generalism were found to be complex and difficult to define, with theoretical models differing markedly from models in action.
Limitations
Smaller hospitals in multisite trusts were excluded, potentially leading to sample bias. The rapidly changing nature of the models limited the analysis of typology against outcomes.
Conclusions
The case mix of smaller hospitals was dominated by patients with presentations amenable to generalist approaches to care; however, there was no evidence to support any particular pattern of consultant working. Matching hospital staff to better meet local need and the creation of more collaborative working environments appear more likely to improve care in smaller hospitals than changing models.
Future work
The exploration of the relationships between workforce, measures of hospital culture, models of care, costs and outcomes in both smaller and larger hospitals is urgently required to underpin service reforms.
Study registration
This study is registered as Integrated Research Application System project ID 191393.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 4. See the NIHR Journals Library website for further project information.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Anne Marie Rafferty
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King’s College London, London, UK
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Hurst JR, Quint JK, Stone RA, Silove Y, Youde J, Roberts CM. National clinical audit for hospitalised exacerbations of COPD. ERJ Open Res 2020; 6:00208-2020. [PMID: 32984418 PMCID: PMC7502696 DOI: 10.1183/23120541.00208-2020] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 06/10/2020] [Indexed: 01/26/2023] Open
Abstract
Introduction Exacerbations of COPD requiring hospital admission are burdensome to patients and health services. Audit enables benchmarking performance between units and against national standards, and supports quality improvement. We summarise 23 years of UK audit for hospitalised COPD exacerbations to better understand which features of audit design have had most impact. Method Pilot audits were performed in 1997 and 2001, with national cross-sectional audits in 2003, 2008 and 2014. Continuous audit commenced in 2017. Overall, 96% of eligible units took part in cross-sectional audit, 86% in the most recent round of continuous audit. We synthesised data from eight rounds of national COPD audit. Results Clinical outcomes were observed to change at the same time as changes in delivery of care: length of stay halved from 8 to 4 days between 1997 and 2014, alongside wider availability of integrated care. Process indicators did not generally improve with sequential cross-sectional audit. Under continuous audit with quality improvement support, process indicators linked to financial incentives (early specialist review (55–66%) and provision of a discharge bundle (53–74%)) improved more rapidly than those not linked (availability of spirometry (40–46%) and timely noninvasive ventilation (21–24%)). Conclusion Careful piloting and engagement can result in successful roll-out of cross-sectional national audit in a high-burden disease. Audit outcome measures and process indicators may be affected by changes in care pathways. Sequential cross-sectional national audit alone was not generally accompanied by improvements in care. However, improvements in process indicators were seen when continuous audit was combined with quality improvement support and, in particular, financial incentives. National audit in COPD is feasible and can improve process indicators, particularly when continuous audit is associated with quality improvement initiatives and financial incentiveshttps://bit.ly/3eiOvOY
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Affiliation(s)
- John R Hurst
- National Asthma and COPD Audit Programme, Royal College of Physicians, London, UK.,UCL Respiratory, University College London, London, UK.,Royal Free London NHS Foundation Trust, London, UK
| | - Jennifer K Quint
- National Asthma and COPD Audit Programme, Royal College of Physicians, London, UK.,National Heart and Lung Institute, Imperial College London, London, UK
| | - Robert A Stone
- Somerset Lung Centre, Musgrove Park Hospital, Taunton, UK
| | - Yvonne Silove
- National Clinical Audit and Patient Outcomes Programme, Healthcare Quality Improvement Partnership, London, UK
| | - Jane Youde
- Care Quality Improvement Dept, Royal College of Physicians, London, UK
| | - C Michael Roberts
- National Asthma and COPD Audit Programme, Royal College of Physicians, London, UK.,School of Medicine and Dentistry, Queen Mary University of London, London, UK
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5
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Jayadev A, Stone R, Steiner MC, McMillan V, Roberts CM. Time to NIV and mortality in AECOPD hospital admissions: an observational study into real world insights from National COPD Audits. BMJ Open Respir Res 2019; 6:e000444. [PMID: 31423314 PMCID: PMC6688668 DOI: 10.1136/bmjresp-2019-000444] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 07/02/2019] [Accepted: 07/02/2019] [Indexed: 12/14/2022] Open
Abstract
Background Randomised control trial (RCT)-derived survival figures for acute exacerbation of chronic obstructive pulmonary disease admissions managed with non-invasive ventilation (NIV) have not been replicated in UK clinical audits. Subsequent guidelines have emphasised the need for timely NIV application. Methods Data from the 2008 and 2014 national chronic obstructive pulmonary disease audits was used to analyse the association between time to NIV and mortality. Results 1032 patients received NIV in 2008, and 1612 in 2014. Overall mortality rates reduced between the audits from 24.9% in 2008 to 16.8% in 2014 but time to NIV lengthened. In 2014, 20.9% of patients received NIV within 60 min versus 24.9% in 2008 (p=0.001). The proportion of patients receiving NIV between 3 and 24 hours increased from 31.3% in 2008 to 39% in 2014 (p=0.001). Patients admitted with hypercapnic acidotic respiratory failure who received NIV within 3 hours had lower in-patient mortality than those who received NIV between 3 and 24 hours, 15.9% versus 18.4%, but this did not reach statistical significance (p=0.425), but acidotic patients receiving NIV >24 hours after admission had significantly higher mortality (28.9%, p=0.002). A second cohort admitted with hypercapnia but normal range pH, who developed later acidosis, had higher mortality (24.6%), compared with those acidotic on admission (18% p≤0.001) and an extremely high mortality when NIV was given >24 hours after admission (42.6%). Conclusion Survival rates for those treated with NIV has improved between the two audits but remains lower than reported in RCTs. Patients who developed acidosis after admission and received NIV later in the hospital stay have even higher mortality and deserve further study and clinical attention.
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Affiliation(s)
- Anita Jayadev
- Respiratory Medicine, Wexham Park Hospital, Slough, UK
| | | | - Michael C Steiner
- Leicester Respiratory Biomedical Unit, Institute for Lung Health, Leicester, UK
| | - Viktoria McMillan
- National COPD audit Programme, Royal College of Physicians, London, UK
| | - C Michael Roberts
- Department of Respiratory Medicine, Princess Alexandra Hospital NHS Trust, Harlow, UK
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6
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Gayle AV, Axson EL, Bloom CI, Navaratnam V, Quint JK. Changing causes of death for patients with chronic respiratory disease in England, 2005-2015. Thorax 2019; 74:483-491. [PMID: 30696745 DOI: 10.1136/thoraxjnl-2018-212514] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 12/19/2018] [Accepted: 12/24/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Chronic respiratory diseases (CRD) are common, are increasing in prevalence, and cause significant morbidity and mortality worldwide. However, we have limited knowledge on causes of death of patients with CRD in the general population. OBJECTIVE We evaluated mortality rates and causes of death over time in patients with CRD. METHODS We used linked primary care and mortality data to determine mortality rates and the most common causes of death in people with CRD (including asthma, bronchiectasis, COPD and interstitial lung diseases (ILD)) during 2005-2015 in England. RESULTS We identified 558 888 patients with CRD (451 830 asthma, 137 709 COPD, 19 374 bronchiectasis, 10 745 ILD). The age-standardised mortality rate of patients with CRD was 1607 per 100 000 persons (asthma=856, COPD=1503, ILD=2609, bronchiectasis=1463). CRD mortality was overall 54% higher than the general population. A third of patients with CRD died from respiratory-related causes. Respiratory-related mortality was constant, while cardiovascular-related mortality decreased significantly over time. COPD accounted for the majority of respiratory-related deaths (66% overall) in all patient groups except ILD. CONCLUSIONS Patients with CRD continue to experience substantial morbidity and mortality due to respiratory diseases. Disease-modifying intervention strategies are needed to improve outcomes for patients with CRD.
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Affiliation(s)
- Alicia V Gayle
- Respiratory Epidemiology, Occupational Medicine and Public Health, National Heart and Lung Institute, Imperial College London, London, UK.,Market Access, Boehringer Ingelheim Ltd, Bracknell, UK
| | - Eleanor L Axson
- Respiratory Epidemiology, Occupational Medicine and Public Health, National Heart and Lung Institute, Imperial College London, London, UK
| | - Chloe I Bloom
- Respiratory Epidemiology, Occupational Medicine and Public Health, National Heart and Lung Institute, Imperial College London, London, UK
| | - Vidya Navaratnam
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Jennifer K Quint
- Respiratory Epidemiology, Occupational Medicine and Public Health, National Heart and Lung Institute, Imperial College London, London, UK
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7
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Ozsancak Ugurlu A, Habesoglu MA. Epidemiology of NIV for Acute Respiratory Failure in COPD Patients: Results from the International Surveys vs. the "Real World". COPD 2017. [PMID: 28636452 DOI: 10.1080/15412555.2017.1336527] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Non-invasive ventilation (NIV) has been recommended as the first-line ventilation modality for acute respiratory failure (ARF) due to acute exacerbation of chronic obstructive pulmonary disease (AECOPD) based on strong evidence. However, everyday clinical practice may differ from findings of multiple randomized controlled trials. Physicians and respiratory therapists involved in NIV management have been queried about its utilization and effectiveness. In addition to these estimates, cohort studies and analysis of large inpatient dataset of patients with AECOPD and ARF managed with NIV have been extensively published over the last two decades. This review summarizes the perception of medical staff vs. the "real life" data about NIV use for ARF in AECOPD patients.
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8
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Harries TH, Thornton H, Crichton S, Schofield P, Gilkes A, White PT. Hospital readmissions for COPD: a retrospective longitudinal study. NPJ Prim Care Respir Med 2017; 27:31. [PMID: 28450741 PMCID: PMC5435097 DOI: 10.1038/s41533-017-0028-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 03/03/2017] [Accepted: 03/21/2017] [Indexed: 02/05/2023] Open
Abstract
Prevention of chronic obstructive pulmonary disease hospital readmissions is an international priority aimed to slow disease progression and limit costs. Evidence of the risk of readmission and of interventions that might prevent it is lacking. We aimed to determine readmission risk for chronic obstructive pulmonary disease, factors influencing that risk, and variation in readmission risk between hospitals across 7.5 million people in London. This retrospective longitudinal observational study included all chronic obstructive pulmonary disease admissions to any hospital in the United Kingdom among patients registered at London general practices who had emergency National Health Service chronic obstructive pulmonary disease hospital admissions between April 2006 and March 2010. Influence of patient characteristics, geographical deprivation score, length of stay, day of week of admission or of discharge, and admitting hospital, were assessed using multiple logistic regression. 38,894 chronic obstructive pulmonary disease admissions of 20,932 patients aged ≥ 45 years registered with London general practices were recorded. 6295 patients (32.2%) had at least one chronic obstructive pulmonary disease readmission within 1 year. 1993 patients (10.2%) were readmitted within 30 days and 3471 patients (17.8%) were readmitted within 90 days. Age and patient geographical deprivation score were very weak predictors of readmission. Rates of chronic obstructive pulmonary disease readmissions within 30 days and within 90 days did not vary among the majority of hospitals. The finding of lower chronic obstructive pulmonary disease readmission rates than was previously estimated and the limited variation in these rates between hospitals suggests that the opportunity to reduce chronic obstructive pulmonary disease readmission risk is small. A managed reduction of hospital readmissions for London-based chronic lung disease patients may not be needed. Preventing hospital readmissions for patients with chronic obstructive pulmonary disease (COPD) is a key priority to improve patient care and limit costs. However, few data are available to determine and ultimately reduce the risk of readmission. Timothy Harries at King’s College, London, and co-workers conducted a longitudinal study incorporating all COPD admissions into UK hospitals for 20,932 patients registered at London general practitioners between 2006 and 2010. They found that 32% of patients were readmitted within a year, 17.8% within 90 days and 10% within 30 days. Neither age nor geographical deprivation were useful predictors of readmission. These represent lower than estimated levels of readmission, suggesting there may be fewer opportunities to reduce the risk of readmission further.
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Affiliation(s)
- Timothy H Harries
- King's College London, King's Health Partners, Division of Health and Social Care Research, London, SE1 3QD, UK.
| | - Hannah Thornton
- Centre for Academic Primary Care, NIHR School for Primary Care Research, School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Siobhan Crichton
- King's College London, King's Health Partners, Division of Health and Social Care Research, London, SE1 3QD, UK
| | - Peter Schofield
- King's College London, King's Health Partners, Division of Health and Social Care Research, London, SE1 3QD, UK
| | - Alexander Gilkes
- King's College London, King's Health Partners, Division of Health and Social Care Research, London, SE1 3QD, UK
| | - Patrick T White
- King's College London, King's Health Partners, Division of Health and Social Care Research, London, SE1 3QD, UK
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9
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Gerber A, Moynihan C, Klim S, Ritchie P, Kelly AM. Compliance with a COPD bundle of care in an Australian emergency department: A cohort study. CLINICAL RESPIRATORY JOURNAL 2016; 12:706-711. [PMID: 27860342 DOI: 10.1111/crj.12583] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 10/17/2016] [Accepted: 11/06/2016] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Alexis Gerber
- Department of Emergency Medicine, Western Health, St Albans, Victoria, Australia
| | - Catriona Moynihan
- Department of Emergency Medicine, Western Health, St Albans, Victoria, Australia
| | - Sharon Klim
- Joseph Epstein Centre for Emergency Medicine Research, St Albans, Victoria, Australia
| | - Peter Ritchie
- Department of Emergency Medicine, Western Health, St Albans, Victoria, Australia
| | - Anne-Maree Kelly
- Joseph Epstein Centre for Emergency Medicine Research, St Albans, Victoria, Australia.,School of Medicine, Western Clinical School, The University of Melbourne, Parkville, Victoria, Australia
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10
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White PT, Harries TH. Have rates of readmission for COPD been overestimated? NPJ Prim Care Respir Med 2016; 26:16066. [PMID: 27734967 PMCID: PMC5062563 DOI: 10.1038/npjpcrm.2016.66] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Patrick T White
- Department of Primary Care and Public Health Sciences, Division of Health and Social Care Research, King's College London, London, UK
| | - Timothy H Harries
- Department of Primary Care and Public Health Sciences, Division of Health and Social Care Research, King's College London, London, UK
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11
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Chow JWY, Khullar K, Katechia K, Klim S, Kelly AM. Controlled oxygen therapy at emergency department presentation increases the likelihood of achieving target oxygen saturations in patients with exacerbations of chronic obstructive pulmonary disease. Emerg Med Australas 2016; 28:44-7. [DOI: 10.1111/1742-6723.12528] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 09/30/2015] [Accepted: 10/15/2015] [Indexed: 11/29/2022]
Affiliation(s)
| | - Keshav Khullar
- Department of Emergency Medicine; Western Health; Melbourne, Victoria Australia
| | - Kashyap Katechia
- Department of Emergency Medicine; Western Health; Melbourne, Victoria Australia
| | - Sharon Klim
- Joseph Epstein Centre for Emergency Medicine Research @ Western Health; Melbourne, Victoria Australia
| | - Anne-Maree Kelly
- Joseph Epstein Centre for Emergency Medicine Research @ Western Health; Melbourne, Victoria Australia
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12
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Ruparel M, López-Campos JL, Castro-Acosta A, Hartl S, Pozo-Rodriguez F, Roberts CM. Understanding variation in length of hospital stay for COPD exacerbation: European COPD audit. ERJ Open Res 2016; 2:00034-2015. [PMID: 27730166 PMCID: PMC5005149 DOI: 10.1183/23120541.00034-2015] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 01/18/2016] [Indexed: 11/05/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) care across Europe has high heterogeneity with respect to cost and the services available. Variations in length of stay (LOS) may be attributed to patient characteristics, resource and organisational characteristics, and/or the so-called hospital cluster effect. The European COPD Audit in 13 countries included data from 16 018 hospitalised patients. The recorded variables included information on patient and disease characteristics, and resources available. Variables associated with LOS were evaluated by a multivariate, multilevel analysis. Mean±sd LOS was 8.7±8.3 days (median 7 days, interquartile range 4-11 days). Crude variability between countries was reduced after accounting for clinical factors and the clustering effect. The main factors associated with LOS being longer than the median were related to disease or exacerbation severity, including GOLD class IV (OR 1.77) and use of mechanical ventilation (OR 2.15). Few individual resource variables were associated with LOS after accounting for the hospital cluster effect. This study emphasises the importance of the patients' clinical severity at presentation in predicting LOS. Identifying patients at risk of a long hospital stay at admission and providing targeted interventions offers the potential to reduce LOS for these individuals. The complex interactions between factors and systems were more important that any single resource or organisational factor in determining differences in LOS between hospitals or countries.
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Affiliation(s)
| | - Jose Luis López-Campos
- Unidad Medico-Quirúrgica de Enfermedades Respiratorias/Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Seville, Spain
- Centre for Biomedical Research on Respiratory Diseases (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Ady Castro-Acosta
- Centre for Biomedical Research on Respiratory Diseases (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Instituto de Investigación, Hospital 12 de Octubre, Madrid, Spain
| | - Sylvia Hartl
- Ludwig Boltzmann Institute of COPD and Respiratory Epidemiology, Otto Wagner Hospital, Vienna, Austria
| | - Francisco Pozo-Rodriguez
- Centre for Biomedical Research on Respiratory Diseases (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Instituto de Investigación, Hospital 12 de Octubre, Madrid, Spain
| | - C. Michael Roberts
- Barts and The London School of Medicine and Dentistry, Queen Mary, University of London, London, UK
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Rivas-Ruiz F, Redondo M, González N, Vidal S, García S, Lafuente I, Bare M, Cano Aguirre MDP, Quintana-López JM. Appropriateness of diagnostic effort in hospital emergency room attention for episodes of COPD exacerbation. J Eval Clin Pract 2015; 21:848-54. [PMID: 26139468 DOI: 10.1111/jep.12390] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/24/2015] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Francisco Rivas-Ruiz
- Agencia Sanitaria Costa del Sol, Unidad de Investigación, Marbella, Spain.,Red Nacional de Investigación de Servicios de Salud en Enfermedades Crónicas (REDISSEC), Madrid, Spain
| | - Maximino Redondo
- Agencia Sanitaria Costa del Sol, Unidad de Investigación, Marbella, Spain.,Red Nacional de Investigación de Servicios de Salud en Enfermedades Crónicas (REDISSEC), Madrid, Spain
| | - Nerea González
- Red Nacional de Investigación de Servicios de Salud en Enfermedades Crónicas (REDISSEC), Madrid, Spain.,Unidad de Investigación, Hospital Galdakao-Usansolo, Vizcaya, Spain
| | - Silvia Vidal
- Agencia Sanitaria Costa del Sol, Unidad de Investigación, Marbella, Spain
| | - Susana García
- Red Nacional de Investigación de Servicios de Salud en Enfermedades Crónicas (REDISSEC), Madrid, Spain.,Unidad de Investigación, Hospital Galdakao-Usansolo, Vizcaya, Spain
| | - Iratxe Lafuente
- Red Nacional de Investigación de Servicios de Salud en Enfermedades Crónicas (REDISSEC), Madrid, Spain.,Unidad de Investigación, Hospital Galdakao-Usansolo, Vizcaya, Spain
| | - Marisa Bare
- Red Nacional de Investigación de Servicios de Salud en Enfermedades Crónicas (REDISSEC), Madrid, Spain.,Unidad de Investigación, Hospital Galdakao-Usansolo, Vizcaya, Spain.,Corporaciò Parc Taulí, Unidad de Epidemiología Clínica, Barcelona, Spain
| | | | - José María Quintana-López
- Red Nacional de Investigación de Servicios de Salud en Enfermedades Crónicas (REDISSEC), Madrid, Spain.,Unidad de Investigación, Hospital Galdakao-Usansolo, Vizcaya, Spain
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Escarrabill J, Torrente E, Esquinas C, Hernández C, Monsó E, Freixas M, Almagro P, Tresserras R. Auditoría clínica de los pacientes que ingresan en el hospital por agudización de EPOC. Estudio MAG-1. Arch Bronconeumol 2015; 51:483-9. [DOI: 10.1016/j.arbres.2014.06.023] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Revised: 06/18/2014] [Accepted: 06/18/2014] [Indexed: 10/24/2022]
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15
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Factors influencing the length of hospital stay in patients with acute exacerbations of chronic obstructive pulmonary disease admitted to intensive care units. Qual Manag Health Care 2015; 23:86-93. [PMID: 24710184 DOI: 10.1097/qmh.0000000000000024] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The cost of hospital admissions for acute exacerbations of COPD (AECOPD) accounts for 70% of total costs for the treatment of COPD patients. We wanted to identify clinical parameters associated with a longer length of stay (LOS) in these patients. METHODS We reviewed electronic medical records of patients with AECOPD admitted between January 1, 2006, and December 31, 2010. The inclusion criteria were age 45 years or older, the diagnosis of AECOPD by GOLD (Global Initiative for Chronic Obstructive Lung Disease) guideline criteria, and admission to an intensive care unit. We compared the quartile with the longest LOS group with the other 3 quartiles using routine clinical data. RESULTS 217 patients met inclusion criteria. The mean age was 67.4 ± 10.9 years, 47% were male, the mean FEV1s (forced expiratory volume in 1 second) was 42.4% ± 17.4% of predicted, and the mean LOS was 9.0 ± 6.0 days. Univariate analysis demonstrated that nursing home status, low albumins, the presence of pleural effusions, intubation, and high APACHE II scores were associated with increased LOS (P < .05 for each factor). Multivariate logistic regression demonstrated that the need for intubation (P < .001) predicted an increased LOS. CONCLUSIONS Our study demonstrates that intubation for mechanical ventilation increased the LOS in patients with AECOPD. More intensive interventions in these patients might decrease the LOS and improve outcomes.
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16
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Quintana JM, Unzurrunzaga A, Garcia-Gutierrez S, Gonzalez N, Lafuente I, Bare M, de Larrea NF, Rivas F, Esteban C. Predictors of Hospital Length of Stay in Patients with Exacerbations of COPD: A Cohort Study. J Gen Intern Med 2015; 30:824-31. [PMID: 25472508 PMCID: PMC4441653 DOI: 10.1007/s11606-014-3129-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Revised: 10/09/2014] [Accepted: 11/18/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Various studies have tried to delimit the predictors of hospital length of stay (LOS) for patients with exacerbated chronic obstructive pulmonary disease (eCOPD), but have been disadvantaged by certain limiting factors. OBJECTIVE Our goal was to prospectively identify predictors of LOS in these patients and to validate our results. DESIGN This was a prospective cohort study. PARTICIPANTS Subjects were patients with eCOPD who visited 16 hospital emergency departments (EDs) and who were admitted to the hospital. MAIN MEASURES Data were recorded on possible predictor variables at the ED visit, on admission and 24 hours later, during hospitalization, and on discharge. LOS and prolonged LOS (≥ 9 days, considering the 75th percentile of LOS in our sample) were the outcomes of interest. Multivariate multilevel linear and logistic regression models were employed. RESULTS A total of 1,453 patients were equally divided between derivation and validation samples. The hospital variable was the best predictor of LOS. Multivariate predictors of LOS, as log-transformed variables, were the hospital, baseline dyspnea and physical activity levels and fatigue at 24 hours, intensive care or intensive respiratory care unit admission, the need for antibiotics, and complications during hospitalization. Predictors of prolonged LOS were also the hospital, baseline dyspnea and fatigue at 24 hours, ICU or IRCU admission, and complications during hospitalization (AUC: 0.77). Models were validated in the validation sample (AUC: 0.75). CONCLUSIONS We identified a number of modifiable factors, including baseline dyspnea, physical activity level, and hospital variability, that influenced the LOS of patients with eCOPD who were admitted to the hospital.
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Affiliation(s)
- José M Quintana
- Unidad de Investigación, Hospital Galdakao-Usansolo, Barrio Labeaga s/n, 48960, Galdakao, Vizcaya, Spain,
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17
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Srivastava K, Thakur D, Sharma S, Punekar YS. Systematic review of humanistic and economic burden of symptomatic chronic obstructive pulmonary disease. PHARMACOECONOMICS 2015; 33:467-488. [PMID: 25663178 DOI: 10.1007/s40273-015-0252-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND An understanding of the humanistic and economic burden of individuals with symptomatic chronic obstructive pulmonary disease (COPD) is required to inform payers and healthcare professionals about the disease burden. OBJECTIVES The aim of this systematic review was to identify and present humanistic [health-related quality of life (HRQoL)] and economic burdens of symptomatic COPD. METHODS A comprehensive search of online databases (reimbursement or claims databases/other databases), abstracts from conference proceedings, published literature, clinical trials, medical records, health ministries, financial reports, registries, and other sources was conducted. Adult patients of any race or gender with symptomatic COPD were included. Humanistic and economic burdens included studies evaluating HRQoL and cost and resource use, respectively, associated with symptomatic COPD. RESULTS Thirty-two studies reporting humanistic burden and 74 economic studies were identified. Symptomatic COPD led to impairment in the health state of patients, as assessed by HRQoL instruments. It was also associated with high economic burden across all countries. The overall, direct, and indirect costs per patient increased with an increase in symptoms, dyspnoea severity, and duration of disease. Across countries, the annual societal costs associated with symptomatic COPD were higher among patients with comorbidities. CONCLUSIONS Symptomatic COPD is associated with a substantial economic burden. The HRQoL of patients with symptomatic COPD is, in general, low and influenced by dyspnoea.
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Affiliation(s)
- Kunal Srivastava
- HERON Health PVT (Now Parexel), 3rd Floor, DLF Tower E, Rajiv Gandhi IT Park, Chandigarh, India
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18
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Harries TH, Thornton HV, Crichton S, Schofield P, Gilkes A, White PT. Length of stay of COPD hospital admissions between 2006 and 2010: a retrospective longitudinal study. Int J Chron Obstruct Pulmon Dis 2015; 10:603-11. [PMID: 25834419 PMCID: PMC4370686 DOI: 10.2147/copd.s77092] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Background Hospitalizations for COPD are associated with poor patient prognosis. Length of stay (LOS) of COPD admissions in a large urban area and patient and hospital factors associated with it are described. Methods Retrospective longitudinal study. All COPD patients registered with London general practitioners and admitted as an emergency with COPD (2006–2010), not having been admitted with COPD in the preceding 12 months were included. Association of patient and hospital characteristics with mean LOS of COPD admissions was assessed. Association between hospital and LOS was determined by negative binomial regression. Results The total number of admissions was 38,504, from 22,462 patients. The mean LOS for first admissions fell by 0.8 days (95% confidence interval [CI]: 0.7–1.5) from 8.2 to 7.0 days between 2006 and 2010. Seventy-nine percent of first admissions were ≤10 days, with a mean LOS of 3.7 days (2009–2010). The mean LOS of successive COPD admissions of the same patients was the same or less throughout the study period. The interval between successive admissions fell from a mean of 357 days between the first and second admission to a mean of 19 days after eight admissions. Age accounted for 2.3% of the variance in LOS. Socioeconomic deprivation did not predict LOS. Fewer discharges happened at the weekend (1,893/day) than on weekdays (5,218/day). The mean LOS varied between hospitals, from 4.9 days (95% CI: 3.8–5.9) to 9.5 days (95% CI: 8.6–10.3) when adjusting for clustering, age, sex, and socioeconomic deprivation. Conclusion The fall in LOS of the first COPD admission between 2006 and 2010 reflects international trends. The stability of LOS in successive admissions suggests that increasing severity of disease does not affect recovery time from an exacerbation. Variations between hospitals of nearly 5 days in LOS for COPD admissions suggests that significant improvements in patient outcomes and in savings in health care utilization could be made in hospitals with longer LOS.
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Affiliation(s)
- Timothy H Harries
- King's College London, King's Health Partners, Division of Health and Social Care Research, London, UK
| | - Hannah V Thornton
- University of Bristol, Centre for Academic Primary Care, NIHR School for Primary Care Research, School of Social and Community Medicine, Canynge Hall, Bristol, UK
| | - Siobhan Crichton
- King's College London, King's Health Partners, Division of Health and Social Care Research, London, UK
| | - Peter Schofield
- King's College London, King's Health Partners, Division of Health and Social Care Research, London, UK
| | - Alexander Gilkes
- King's College London, King's Health Partners, Division of Health and Social Care Research, London, UK
| | - Patrick T White
- King's College London, King's Health Partners, Division of Health and Social Care Research, London, UK
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Jones R, Roberts M. National cohort data from Sweden to the National COPD audit in England and Wales: grand designs for quality improvement. PRIMARY CARE RESPIRATORY JOURNAL : JOURNAL OF THE GENERAL PRACTICE AIRWAYS GROUP 2014; 23:7-8. [PMID: 24553824 PMCID: PMC6442281 DOI: 10.4104/pcrj.2014.00013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Rupert Jones
- Clinical Research Fellow, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK; General Practitioner, Armada Surgery, Plymouth, UK
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20
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Maddocks M, Kon SS, Singh SJ, Man WDC. Rehabilitation following hospitalization in patients with COPD: Can it reduce readmissions? Respirology 2014; 20:395-404. [DOI: 10.1111/resp.12454] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Revised: 10/16/2014] [Accepted: 11/09/2014] [Indexed: 12/14/2022]
Affiliation(s)
- Matthew Maddocks
- King's College London; Cicely Saunders Institute; London UK
- Harefield Pulmonary Rehabilitation Unit; Royal Brompton and Harefield NHS Foundation Trust; London UK
| | - Samantha S.C. Kon
- Harefield Pulmonary Rehabilitation Unit; Royal Brompton and Harefield NHS Foundation Trust; London UK
- NIHR Respiratory Biomedical Research Unit; Royal Brompton and Harefield NHS Foundation Trust and Imperial College; London UK
| | - Sally J. Singh
- Centre for Exercise and Rehabilitation Science and Institute for Lung Health; University Hospitals of Leicester NHS Trust; Leicester UK
| | - William D.-C. Man
- Harefield Pulmonary Rehabilitation Unit; Royal Brompton and Harefield NHS Foundation Trust; London UK
- NIHR Respiratory Biomedical Research Unit; Royal Brompton and Harefield NHS Foundation Trust and Imperial College; London UK
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21
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Roberts CM. Auditoría de la enfermedad pulmonar obstructiva crónica: convertir los datos en una mejor asistencia de los pacientes. Arch Bronconeumol 2014; 50:263-4. [DOI: 10.1016/j.arbres.2014.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Revised: 02/12/2014] [Accepted: 02/12/2014] [Indexed: 11/25/2022]
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Turner AM, Dalay SK, Talwar A, Snelson C, Mukherjee R. Reforming respiratory outpatient services: a before-and-after observational study assessing the impact of a quality improvement project applying British Thoracic Society criteria to the discharge of patients to primary care. PRIMARY CARE RESPIRATORY JOURNAL : JOURNAL OF THE GENERAL PRACTICE AIRWAYS GROUP 2013; 22:72-8. [PMID: 23443226 PMCID: PMC6442754 DOI: 10.4104/pcrj.2013.00013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Secondary care physicians caring for people with long-term conditions (LTCs) are under increasing pressure to discharge long-term follow-up patients to primary care. In respiratory medicine, the 2008 British Thoracic Society (BTS) statement on criteria for specialist referral, admission, discharge, and follow-up for adults with respiratory disease remains the only available basis for this dialogue. There is widespread concern about reforming outpatient clinics to meet these demands and the impact of discharging people with respiratory LTCs to primary care. AIMS To examine the impact of implementing BTS guidance on secondary care follow-up of patients with respiratory disease. METHODS We undertook a clinic reform project, which included one-stop medical reviews, providing more open access appointments, and implementing the BTS criteria. The impact on patients was assessed by patient survey, and the impact on GPs was assessed by an analysis of referral patterns pre- and post-reform. RESULTS There was a significant improvement in commissioner-mandated performance through reduction in follow-up (p=0.006) and the unscheduled hospital admission rate decreased significantly (p=0.021). However, many patients were dissatisfied with the process and re-referral rates rose. CONCLUSIONS Our findings suggest that the delivery of a responsive service capable of sustainable management of respiratory LTCs can be achieved using the BTS criteria. It seems to be efficacious within secondary care, increasing the quality and value of the clinic activity, although hidden impacts on primary care will require further prospective studies.
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Affiliation(s)
- Alice M Turner
- University of Birmingham, QEHB Research Laboratories, QEHB, Birmingham, UK.
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Almagro P, Castro A. Helping COPD patients change health behavior in order to improve their quality of life. Int J Chron Obstruct Pulmon Dis 2013; 8:335-45. [PMID: 23901267 PMCID: PMC3726303 DOI: 10.2147/copd.s34211] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is one of the most prevalent and debilitating diseases in adults worldwide and is associated with a deleterious effect on the quality of life of affected patients. Although it remains one of the leading causes of global mortality, the prognosis seems to have improved in recent years. Even so, the number of patients with COPD and multiple comorbidities has risen, hindering their management and highlighting the need for futures changes in the model of care. Together with standard medical treatment and therapy adherence--essential to optimizing disease control--several nonpharmacological therapies have proven useful in the management of these patients, improving their health-related quality of life (HRQoL) regardless of lung function parameters. Among these are improved diagnosis and treatment of comorbidities, prevention of COPD exacerbations, and greater attention to physical disability related to hospitalization. Pulmonary rehabilitation reduces symptoms, optimizes functional status, improves activity and daily function, and restores the highest level of independent physical function in these patients, thereby improving HRQoL even more than pharmacological treatment. Greater physical activity is significantly correlated with improvement of dyspnea, HRQoL, and mobility, along with a decrease in the loss of lung function. Nutritional support in malnourished COPD patients improves exercise capacity, while smoking cessation slows disease progression and increases HRQoL. Other treatments such as psychological and behavioral therapies have proven useful in the treatment of depression and anxiety, both of which are frequent in these patients. More recently, telehealthcare has been associated with improved quality of life and a reduction in exacerbations in some patients. A more multidisciplinary approach and individualization of interventions will be essential in the near future.
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Affiliation(s)
- Pere Almagro
- Acute Geriatric Care Unit, Internal Medicine Department, University Hospital Mútua de Terrassa, Barcelona, Spain.
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Jacques RM, Fotheringham J, Campbell MJ, Nicholl J. Did hospital mortality in England change from 2005 to 2010? A retrospective cohort analysis. BMC Health Serv Res 2013; 13:216. [PMID: 23763942 PMCID: PMC3700823 DOI: 10.1186/1472-6963-13-216] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Accepted: 06/10/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is some evidence that hospital performance in England measured by the Dr Foster Hospital Standardised Mortality Ratio (HSMR) has improved substantially over the last 10 years. This study explores mortality in-hospital and up to 30 days post-discharge over a five year period to determine whether there have been improvements in case-mix adjusted mortality, to examine if any changes are due to changes in case-mix adjustment variables such as age, sex, method of admission and comorbidity, and to compare changes between hospital trusts. METHODS Using Hospital Episode Statistics linked to mortality data from the Office for National Statistics the Summary Hospital-Level Mortality Index (SHMI) was calculated for all patients who were discharged or died in general acute hospital trusts in England for the period 01/04/2005 to 30/09/2010. RESULTS During this five year period the number of admissions rose by 8% but deaths fell by 5%. The SHMI fell by 24% from 112 to 85 over the period, partly due to fewer deaths but partly due to increasing numbers predicted by the SHMI model. Excluding comorbidities from the model the SHMI fell by 18% from 108 to 89 over this period. The reduction was similar in emergency and elective admissions and in all other sub-groups examined. The average quarterly change in SHMI varied considerably between trusts (range: -4.4 to -0.2). CONCLUSIONS As measured by the SHMI there has been a 24% improvement in mortality in acute general trusts in England over a period of five and a half years. Part of this improvement is an artificial effect caused by changes in the depth of coding of comorbidities and other effects due to change in case-mix or non-constant risk.
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de Miguel-Díez J, Jiménez-García R, Hernández-Barrera V, Puente-Maestu L, Rodríguez-Rodríguez P, López de Andrés A, Carrasco-Garrido P. Trends in hospital admissions for acute exacerbation of COPD in Spain from 2006 to 2010. Respir Med 2013; 107:717-23. [PMID: 23421969 DOI: 10.1016/j.rmed.2013.01.007] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2012] [Revised: 01/02/2013] [Accepted: 01/11/2013] [Indexed: 11/16/2022]
Abstract
OBJECTIVE We aim to analyze changes in incidence, comorbidity profile, length of hospital stay (LOHS), costs and in-hospital mortality (IHM) of patients hospitalized for acute exacerbations of chronic obstructive pulmonary disease (AE-COPD) over a 5-year study period in Spain. METHODS We selected all hospital admissions for AE-COPD between 2006 and 2010 from the National Hospital Discharge Database covering the entire population of Spain. RESULTS We identified a total of 215,835 patients. Overall crude incidence had decreased from 2.9 to 2.4 exacerbations of COPD per 10,000 inhabitants from 2006 to 2010 (p < 0.001). In 2006, 17.9% of patients had a Charlson Index >2 and in 2010, the prevalence had increased to 25.0% (p < 0.001). Regarding to treatment, we detected a significant increase in the use of non-invasive ventilation from 2.1% in 2006 to 5.3% in 2010 (p < 0.001). The median LOHS was 7 days in 2006 and it remained stable until 2010. During the period studied, the mean cost per patient increased from 3747 to 4129 Euros. Multivariate analysis showed that incidence of hospitalizations for AE-COPD and IHM had significantly decreased from 2006 to 2010. CONCLUSIONS The current study provides data indicating a decrease in incidence of hospital admissions for AE-COPD in Spain from 2006 to 2010 with concomitant reduction in IHM, despite increasing comorbidity during this period, with no variations in LOHS. The mean cost per patient has risen significantly.
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Affiliation(s)
- Javier de Miguel-Díez
- Pneumology Department, Hospital General Universitario Gregorio Marañon, C/ Doctor Esquerdo 46, 28007 Madrid, Spain.
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Agboado G, Peters J, Donkin L. Factors influencing the length of hospital stay among patients resident in Blackpool admitted with COPD: a cross-sectional study. BMJ Open 2012; 2:e000869. [PMID: 22942230 PMCID: PMC3437423 DOI: 10.1136/bmjopen-2012-000869] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2012] [Accepted: 07/27/2012] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVES To identify the differential effects of patient, health service, temporal and geographic factors on length of stay (LOS) for chronic obstructive pulmonary disease (COPD)-related admissions. DESIGN We used stratified Cox proportional hazard model to evaluate the association between LOS and patient, health service, temporal and geographical factors. SETTING Patients resident in Blackpool, North West England, admitted to the local hospital with COPD. PARTICIPANTS We used the Admitted Patient Care General Episode Commissioning Dataset for the period 1 April 2005-31 March 2010. We analysed records of admission spells among patients resident in Blackpool aged 40 years or older admitted with a primary diagnosis of COPD. RESULTS There were 2410 admissions meeting the inclusion criteria over the period. These admissions were attributed to 1172 COPD patients, an average of 2.06 admissions per patient. The median LOS was 6 days (95% CI 6 to 6) while the mean was 9.8 days (95% CI 9.1 to 10.5). Patients were 22% more likely to be discharged earlier in 2009/2010 compared with 2005/2006 (adjusted HR 1.22; p=0.0100). LOS was associated with socioeconomic deprivation with those in the most deprived areas being 35% less likely to be discharged earlier compared with those from the least deprived areas (adjusted HR 0.65; p=0.0010). CONCLUSIONS LOS among COPD patients have reduced over the period of the study. Age, deprivation, Charlson index, specialty of admission and cause of exacerbations were independently associated with LOS. Though there were no significant associations between LOS and season of admission and distance from hospital, there were significant variations in LOS associated with these variables based on selected patient characteristics.
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Affiliation(s)
| | | | - Lynn Donkin
- Public Health Department, NHS Blackpool, Blackpool, UK
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Lykkegaard J, Søndergaard J, Kragstrup J, Rømhild Davidsen J, Knudsen T, Andersen M. All Danish first-time COPD hospitalisations 2002–2008: Incidence, outcome, patients, and care. Respir Med 2012; 106:549-56. [DOI: 10.1016/j.rmed.2011.11.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2011] [Revised: 11/02/2011] [Accepted: 11/02/2011] [Indexed: 11/29/2022]
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