Chronic obstructive pulmonary disease exacerbations in emergency departments: predictors of outcome

Platelet-to-Lymphocyte Ratio (PLR), Neutrophil-to-Lymphocyte Ratio (NLR), Monocyte-to-Lymphocyte Ratio (MLR), and Eosinophil-to-Lymphocyte Ratio (ELR) as Biomarkers in Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease (AECOPD)

Purpose

The study comprehensively evaluated the prognostic roles of the platelet-to-lymphocyte ratio (PLR), neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), basophil-to-lymphocyte ratio (BLR), and eosinophil-to-lymphocyte ratio (ELR) in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD).

Patients and Methods

Six hundred and nineteen patients with AECOPD and 300 healthy volunteers were retrospectively included into the study. The clinical characteristics of the patients with AECOPD and the complete blood counts (CBCs) of the healthy volunteers were collected. The associations of PLR, NLR, MLR, BLR, and ELR with airflow limitation, hospital length of stay (LOS), C-reactive protein (CRP), and in-hospital mortality in patients with AECOPD were analyzed.

Results

Compared with the healthy volunteers, PLR, NLR, MLR, BLR, and ELR were all elevated in COPD patients under stable condition. PLR, NLR, MLR, and BLR were further elevated while ELR was lowered during exacerbation. In the patients with AECOPD, PLR, NLR, and MLR were positively correlated with hospital LOS as well as CRP. In contrast, ELR was negatively correlated with hospital LOS as well as CRP. Elevated PLR, NLR, and MLR were all associated with more severe airflow limitation in AECOPD. Elevated PLR, NLR, and MLR were all associated with increased in-hospital mortality while elevated ELR was associated with decreased in-hospital mortality. Binary logistic regression analysis showed that smoking history, FEV1% predicted, pneumonia, pulmonary heart disease (PHD), uric acid (UA), albumin, and MLR were significant independent predictors ofin-hospital mortality. These predictors along with ELR were used to construct a nomogram for predicting in-hospital mortality in AECOPD. The nomogram had a C-index of 0.850 (95% CI: 0.799-0.901), and the calibration curve, decision curve analysis (DCA), and clinical impact curve (CIC) further demonstrated its good predictive value and clinical applicability.

Conclusion

In summary, PLR, NLR, MLR, and ELR served as useful biomarkers in patients with AECOPD.

Safety and Efficacy of Inpatient Pulmonary Rehabilitation for Patients Hospitalized with an Acute Exacerbation of Chronic Obstructive Pulmonary Disease: Systematic Review and Meta-analyses

Rationale: Pulmonary rehabilitation (PR) during hospitalization for acute exacerbations of chronic obstructive pulmonary disease (AECOPD) occurs during a period of disease instability for the patient, and the safety and efficacy of PR, specifically during the hospitalization period, have not been established. Objective: The purpose of this review is to determine the safety and efficacy of PR during the hospitalization phase for individuals with AECOPD. Methods: Scientific databases were searched up to August 2022 for randomized controlled trials that compared in-hospital PR with usual care. PR programs commenced during the hospitalization and included a minimum of two sessions. Titles and abstracts followed by full-text screening and data extraction were conducted independently by two reviewers. The intervention effect estimates were calculated through meta-analysis using a random-effect model. Results: A total of 27 studies were included (n = 1,317). The meta-analysis showed that inpatient PR improved the 6-minute-walk distance by 105 m (P < 0.001). Inpatient PR improved the performance on the five-repetition sit-to-stand test by -7.02 seconds (P = 0.03). Quality of life (QOL), as measured by the 5-level EuroQoL Group-5 dimension version (EQ-ED-5L) and the St. George's Respiratory Questionnaire, was significantly improved by the intervention. Inpatient PR increased lower limb muscle strength by 33.35 N (P < 0.001). There was no change in the length of stay. Only one serious adverse event related to the intervention was reported. Conclusions: This review suggests that it is safe and effective to provide PR during hospitalization for individuals with AECOPD. In-hospital PR improves functional exercise capacity, QOL, and lower limb strength without prolonging the hospital length of stay.

Socioeconomic and Clinical Predictors of Mortality in Patients with Acute Dyspnea

Background

Factors predicting long-term prognosis in patients with acute dyspnea may guide both acute management and follow-up. The aim of this study was to identify socioeconomic and clinical risk factors for all-cause mortality among acute dyspnea patients admitted to an Emergency Department.

Methods

We included 798 patients with acute dyspnea admitted to the ED of Skåne University Hospital, Malmö, Sweden from 2013 to 2016. Exposures were living in the immigrant-dense urban part of Malmö (IDUD), country of birth, annual income, comorbidities, smoking habits, medical triage priority and severity of dyspnea. Mean follow-up time was 2.2 years. Exposures were related to risk of all-cause mortality using Cox proportional hazard model.

Results

During follow-up 40% died. In models adjusted for age and gender, low annual income, previous or ongoing smoking, certain comorbidities, high medical triage priority and severe dyspnea were all significantly associated with increased mortality. After adjusting for age, gender and all significant exposures, the lowest quintile of income, ongoing or previous smoking, history of serious infection, anemia, hip fracture, high medical triage priority and severe dyspnea significantly and independently predicted mortality. In contrast, neither country of birth nor living in IDUD predicted a mortality risk.

Conclusion

Apart from several clinical risk factors, low annual income predicts two-year mortality risk in patients with acute dyspnea. This is not the case for country of birth and living in IDUD. Our results underline the wide range of mortality risk factors in acute dyspnea patients. Knowledge of patients' annual income as well as certain clinical features may aid risk stratification and determining the need of follow-up both in hospital and after discharge from an ED.

A Computer Application to Predict Adverse Events in the Short-Term Evolution of Patients With Exacerbation of Chronic Obstructive Pulmonary Disease

Background

Chronic obstructive pulmonary disease (COPD) is a common chronic disease. Exacerbations of COPD (eCOPD) contribute to the worsening of the disease and the patient’s evolution. There are some clinical prediction rules that may help to stratify patients with eCOPD by their risk of poor evolution or adverse events. The translation of these clinical prediction rules into computer applications would allow their implementation in clinical practice.

Objective

The goal of this study was to create a computer application to predict various outcomes related to adverse events of short-term evolution in eCOPD patients attending an emergency department (ED) based on valid and reliable clinical prediction rules.

Methods

A computer application, Prediction of Evolution of patients with eCOPD (PrEveCOPD), was created to predict 2 outcomes related to adverse events: (1) mortality during hospital admission or within a week after an ED visit and (2) admission to an intensive care unit (ICU) or an intermediate respiratory care unit (IRCU) during the eCOPD episode. The algorithms included in the computer tool were based on clinical prediction rules previously developed and validated within the Investigación en Resultados y Servicios de Salud COPD study. The app was developed for Windows and Android systems, using Visual Studio 2008 and Eclipse, respectively.

Results

The PrEveCOPD computer application implements the prediction models previously developed and validated for 2 relevant adverse events in the short-term evolution of patients with eCOPD. The application runs under Windows and Android systems and it can be used locally or remotely as a Web application. Full description of the clinical prediction rules as well as the original references is included on the screen. Input of the predictive variables is controlled for out-of-range and missing values. Language can be switched between English and Spanish. The application is available for downloading and installing on a computer, as a mobile app, or to be used remotely via internet.

Conclusions

The PrEveCOPD app shows how clinical prediction rules can be summarized into simple and easy to use tools, which allow for the estimation of the risk of short-term mortality and ICU or IRCU admission for patients with eCOPD. The app can be used on any computer device, including mobile phones or tablets, and it can guide the clinicians to a valid stratification of patients attending the ED with eCOPD.

Trial Registration

ClinicalTrials.gov NCT00102401; https://clinicaltrials.gov/ct2/show/results/NCT02434536 (Archived by WebCite at http://www.webcitation.org/76iwTxYuA)

International Registered Report Identifier (IRRID)

RR2-10.1186/1472-6963-11-322

Prolonged stay predictors in patients admitted with chronic obstructive pulmonary disease acute exacerbation

Objectives:

The study aimed to identify the factors related to prolonged stay in those patients admitted with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) to our hospital.

Methods:

We conducted a retrospective study by reviewing the medical records of all patients admitted with AECOPD to the University Hospital Complex of Santiago de Compostela in 2007 and 2008. To identify variables independently associated with length of stay, we conducted a logistic regression including those variables which proved to be significant in the univariate analysis.

Results:

Six hundred and sixty-one patients were assessed; 76.6% were male and the mean age was 74.5 years (standard deviation [SD]: 11.48). The mean stay was 11.9 days (SD: 8) and 24% of all patients required prolonged stay. Factors associated with prolonged mean stay in multivariate analysis were admission to the Intensive Care Unit (odds ratio [OR], 14.7), hospitalization by internal medicine (OR, 2.1), and use of noninvasive mechanical ventilation (OR, 1.75).

Conclusions:

Prolonged stay in AECOPD is primarily related to the unit patients are admitted to, and to the need for more intensive care.

[Prognostic factors of early 30-day mortality in elderly patients admitted to an emergency department]

OBJECTIVE

The main aim of this study was to identify the variables related to early mortality in the elderly at the time of admission to the emergency department.

METHODOLOGY

Using probability sampling, the study included patients 60 years old or older of both genders who were admitted for observation to the emergency department of the University Hospital of Nariño, ¿Colombia? in 2015. Using a questionnaire designed for this study, some multidimensional features that affect the health of the elderly were collected (demographic, clinical, psychological, functional, and social variables). The patients were then followed-up for 30 days in order to determine the mortality rate during this time. Univariate and multivariate logistic regressions and survival analysis were performed.

RESULTS

Data were collected from 246 patients, with a mean age of 75.27 years and the majority female. The 30-day mortality rate was 15%. The variables most associated with death were: being female, temperature problems, initial diagnosis of neoplasia, and unable to walk independently in the emergency department.

CONCLUSION

It is possible to determine the multidimensional factors present in the older patient admitted to an emergency department that could affect their 30-day mortality prognosis. and which should be intervened.

Mid-regional pro-adrenomedullin and copeptin to predict short-term prognosis of COPD exacerbations: a multicenter prospective blinded study

BACKGROUND

Exacerbations of COPD (ECOPD) are a frequent cause of emergency room (ER) visits. Predictors of early outcome could help clinicians in orientation decisions. In the current study, we investigated whether mid-regional pro-adrenomedullin (MR-proADM) and copeptin, in addition to clinical evaluation, could predict short-term outcomes.

PATIENTS AND METHODS

This prospective blinded observational study was conducted in 20 French centers. Patients admitted to the ER for an ECOPD were considered for inclusion. A clinical risk score was calculated, and MR-proADM and copeptin levels were determined from a venous blood sample. The composite primary end point comprised 30-day death or transfer to the intensive care unit or a new ER visit.

RESULTS

A total of 379 patients were enrolled in the study, of whom 277 were eventually investigated for the primary end point that occurred in 66 (24%) patients. In those patients, the median (interquartile range [IQR]) MR-proADM level was 1.02 nmol/L (0.77-1.48) versus 0.83 nmol/L (0.63-1.07) in patients who did not meet the primary end point (P=0.0009). In contrast, copeptin levels were similar in patients who met or did not meet the primary end point (P=0.23). MR-proADM levels increased with increasing clinical risk score category: 0.74 nmol/L (0.57-0.89), 0.83 nmol/L (0.62-1.12) and 0.95 nmol/L (0.75-1.29) for the low-, intermediate- and high-risk categories, respectively (P<0.001). MR-proADM was independently associated with the primary end point (odds ratio, 1.65; 95% confidence interval [CI], 1.10-2.48; P=0.015). MR-proADM predicted the occurrence of primary end point with a sensitivity of 46% (95% CI, 33%-58%) and a specificity of 79% (95% CI, 74-84).

CONCLUSION

MR-proADM but not copeptin was significantly associated with outcomes at 30 days, even after adjustment for clinical risk category. Overall, MR-proADM, alone or combined with the clinical risk score, was a moderate strong predictor of short-term outcomes.

One-year and long-term mortality in patients hospitalized for chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality worldwide. Identifying potentially-modifiable predictors of mortality could help optimize COPD patient management. The aim of this study is to determine long-term mortality following hospitalization due to acute exacerbations of COPD (AECOPD), as well as AECOPD mortality predictors.

METHODS

We conducted a retrospective study by reviewing the medical records of all patients admitted with AECOPD in the University Hospital Complex of Santiago de Compostela in 2007 and 2008. In order to identify variables independently associated with mortality, we conducted a multivariate Cox proportional hazard regression analysis including those variables which proved to be significant in the univariate analysis.

RESULTS

Seven hundred and fifty seven patients were assessed. Patient mean age was 74.8 years and males accounted for 77% of all patients. Mean stay was 12.2 days. Three point six percent of all patients required intensive care. As for mortality rates, 1-year mortality was 26.2%, and 5-year mortality was 64.3%. In both scenarios, the most frequent causes of death were respiratory and cardiovascular disorders. Factors independently associated with mortality were older age, hospitalization by internal medicine (IMU), length of stay, the need for mechanical ventilation (MV) or noninvasive mechanical ventilation (NIV), early readmission, and history of atrial fibrillation (AF) and dementia.

CONCLUSIONS

In patients with COPD, age, exacerbation severity and comorbidity have long-term prognostic significance.

Precipitating causes and outcomes of chronic obstructive pulmonary disease exacerbation at a tertiary care center in northeast Thailand

Background: Acute exacerbation of chronic obstructive pulmonary disease (COPD) is a leading cause of hospitalization and economic burden. Frequent exacerbations impair quality of life and effect decline of lung function.

Objective: We evaluated characteristics of COPD patients with frequent exacerbations. The precipitating causes, outcomes, hospital stay, and cost of admission were also determined.

Methods: The study population included COPD patients admitted because of acute COPD exacerbation at Srinagarind Hospital between 1 January 2006 and 31 December 2010.

Results: Over the 5-year period, 183 patients were admitted. Their mean age was 74.9 (SD 9.28) years and the male to female ratio was 170:13. Most patients (144; 79%) had one exacerbation per year and 39 (21%) had more than one per year. The group with more exacerbations, had a higher stage of the disease than those with only one exacerbation (p = 0.023), but there was no significant difference in the mortality rate (18% vs 14%, p = 0.53). A total of 245 episodes of acute exacerbation of COPD occurred in 183 patients. The mean duration of symptoms was 4.1 (SD 3.46) days. Forty-seven percent presented with Anthonisen type III, 42.4% with Anthonisen type II, and 10.6% with Anthonisen type I exacerbations. For 44 exacerbations (18%), the precipitating causes were not determined. The most common precipitating cause was pneumonia, which occurred in 90 episodes (36.7%). The second common was bronchitis (27.8%); followed by heart failure (8.2%), infected bronchiectasis (5.3%), diarrhea (1.2%), acute urinary retention (0.8%), unstable angina (0.4%), pneumothorax (0.4%), urinary tract infection (0.4%), atrial fibrillation (0.4%) and drug induced cough (0.4%). The organisms responsible for respiratory tract infection were identified in 31% cases of pneumonia and 18% of bronchitis cases. The top three common pathogens for pneumonia were Pseudomonas aeruginosa (9%), Acinetobacter baumannii (8%), and Klebsiella pneumoniae (8%). The top three common pathogens for bronchitis were P aeruginosa (7%), Haemophilus influenza (6%), and K pneumoniae (4%). About one quarter (25.3%) of acute exacerbations were complicated by respiratory failure. The mean duration of admission was 17.3 days (range 1-682 days). The mean cost of admission per exacerbation was 80,010 Thai baht (US $2,666) (range, 2,779-3,433,108 baht). The total cost for 245 exacerbations was 19.6 million baht ($653,000).

Conclusion: Respiratory tract infections were common causes of COPD exacerbation and one quarter of which developed respiratory failure. Preventive measures such as vaccination, smoking cessation, lung rehabilitation, and appropriate drug use are helpful.

A clinical in-hospital prognostic score for acute exacerbations of COPD

Background

The use of a severity score to help orientation decisions could improve the efficiency of care for acute exacerbations of COPD (AECOPD). We previously developed a score (‘2008 score’, based on age, dyspnea grade at steady state and number of clinical signs of severity) predicting in-hospital mortality in patients with AECOPD visiting emergency departments (EDs). External validity of this score remained to be assessed.

Objectives

To test the predictive properties of the ‘2008 score’ in a population of patients hospitalized in medical respiratory wards for AECOPD, and determine whether a new score specifically derived from this population would differ from the previous score in terms of components or predictive performance.

Methods

Data from a cohort study in 1824 patients hospitalized in a medical ward for an AECOPD were analyzed. Patients were categorized using the 2008 score and its predictive characteristics for in-hospital mortality rates were assessed. A new score was developed using multivariate logistic regression modeling in a randomly selected derivation population sample followed by testing in the remaining population (validation sample). Robustness of results was assessed by case-by-case validation.

Results

The 2008 score was characterized by a c-statistic at 0.77, a sensitivity of 69% and a specificity of 76% for prediction of in-hospital mortality. The new score comprised the same variables plus major cardiac comorbidities and was characterized by a c-statistic of 0.78, a sensitivity of 77% and specificity of 66%.

Conclusions

A score using simple clinical variables has robust properties for predicting the risk of in-hospital death in patients hospitalized for AECOPD. Adding cardiac comorbidities to the original score increased its sensitivity while decreasing its specificity.

Electronic supplementary material

The online version of this article (doi:10.1186/s12931-014-0099-9) contains supplementary material, which is available to authorized users.

Validity of criteria for hospital admission in exacerbations of COPD

AIMS

To validate a previously developed set of explicit criteria for the appropriateness of hospital admission among these patients using the RAND/UCLA Appropriateness Methodology (RAM).

METHODS

We conducted a prospective cohort study of patients experiencing symptoms of COPD exacerbation seen in the emergency departments (ED) of 16 hospitals belonging to the Spanish National Health Service. Sociodemographic and clinical variables needed to assess appropriateness were recorded. Main outcomes were mortality, severe COPD evolution, complications at follow up, and three patient-reported measures: dyspnoea level, capacity for physical activity and perceived health status.

RESULTS

Appropriately admitted patients were more likely to die (6.70% vs. 2.68%, p = 0.0102) than inappropriately admitted patients, and were more likely to develop severe evolution (27.09% vs. 6.08%, p < 0.0001) and complications (18.72% vs. 11.92%, p = 0.0244). Among discharged patients, no significant differences were observed in clinical outcomes. All patients exhibited worse dyspnoea and capacity for physical activity after exacerbation, but changes among appropriately admitted patients were less than among appropriately discharged patients.

CONCLUSION

Our appropriateness criteria identified patients in worse condition at ED arrival who were more likely to benefit from admission in terms of mortality and COPD evolution.

Predictive score for mortality in patients with COPD exacerbations attending hospital emergency departments

BACKGROUND

Limited information is available about predictors of short-term outcomes in patients with exacerbation of chronic obstructive pulmonary disease (eCOPD) attending an emergency department (ED). Such information could help stratify these patients and guide medical decision-making. The aim of this study was to develop a clinical prediction rule for short-term mortality during hospital admission or within a week after the index ED visit.

METHODS

This was a prospective cohort study of patients with eCOPD attending the EDs of 16 participating hospitals. Recruitment started in June 2008 and ended in September 2010. Information on possible predictor variables was recorded during the time the patient was evaluated in the ED, at the time a decision was made to admit the patient to the hospital or discharge home, and during follow-up. Main short-term outcomes were death during hospital admission or within 1 week of discharge to home from the ED, as well as at death within 1 month of the index ED visit. Multivariate logistic regression models were developed in a derivation sample and validated in a validation sample. The score was compared with other published prediction rules for patients with stable COPD.

RESULTS

In total, 2,487 patients were included in the study. Predictors of death during hospital admission, or within 1 week of discharge to home from the ED were patient age, baseline dyspnea, previous need for long-term home oxygen therapy or non-invasive mechanical ventilation, altered mental status, and use of inspiratory accessory muscles or paradoxical breathing upon ED arrival (area under the curve (AUC) = 0.85). Addition of arterial blood gas parameters (oxygen and carbon dioxide partial pressures (PO2 and PCO2)) and pH) did not improve the model. The same variables were predictors of death at 1 month (AUC = 0.85). Compared with other commonly used tools for predicting the severity of COPD in stable patients, our rule was significantly better.

CONCLUSIONS

Five clinical predictors easily available in the ED, and also in the primary care setting, can be used to create a simple and easily obtained score that allows clinicians to stratify patients with eCOPD upon ED arrival and guide the medical decision-making process.

Factors associated with a prolonged length of stay after acute exacerbation of chronic obstructive pulmonary disease (AECOPD)

Background

Early identification of patients with a prolonged stay due to acute exacerbation of chronic obstructive pulmonary disease (COPD) may reduce risk of adverse event and treatment costs. This study aimed to identify predictors of prolonged stay after acute exacerbation of COPD based on variables on admission; the study also looked to establish a prediction model for length of stay (LOS).

Methods

We extracted demographic and clinical data from the medical records of 599 patients discharged after an acute exacerbation of COPD between March 2006 and December 2008 at Oslo University Hospital, Aker. We used logistic regression analyses to assess predictors of a length of stay above the 75th percentile and assessed the area under the receiving operating characteristic curve to evaluate the model’s performance.

Results

We included 590 patients (54% women) aged 73.2±10.8 years (mean ± standard deviation) in the analyses. Median LOS was 6.0 days (interquartile range [IQR] 3.5–11.0). In multivariate analysis, admission between Thursday and Saturday (odds ratio [OR] 2.24 [95% CI 1.60–3.51], P<0.001), heart failure (OR 2.26, 95% CI 1.34–3.80), diabetes (OR 1.90, 95% CI 1.07–3.37), stroke (OR 1.83, 95% CI 1.04–3.21), high arterial PCO₂ (OR 1.26 [95% CI 1.13–1.41], P<0.001), and low serum albumin level (OR 0.92 [95% CI 0.87–0.97], P=0.001) were associated with a LOS >11 days. The statistical model had an area under the receiver operating characteristic curve of 0.73.

Conclusion

Admission between Thursday and Saturday, heart failure, diabetes, stroke, high arterial PCO₂, and low serum albumin level were associated with a prolonged LOS. These findings may help physicians to identify patients that will need a prolonged LOS in the early stages of admission. However, the predictive model exhibited suboptimal performance and hence is not ready for clinical use.

Day-to-day measurement of patient-reported outcomes in exacerbations of chronic obstructive pulmonary disease

Background

Exacerbations of chronic obstructive pulmonary disease (COPD) are a major burden to patients and to society. Little is known about the possible role of day-to-day patient-reported outcomes during an exacerbation. This study aims to describe the day-to-day course of patient-reported health status during exacerbations of COPD and to assess its value in predicting clinical outcomes.

Methods

Data from two randomized controlled COPD exacerbation trials (n = 210 and n = 45 patients) were used to describe both the feasibility of daily collection of and the day-to-day course of patient-reported outcomes during outpatient treatment or admission to hospital. In addition to clinical parameters, the BORG dyspnea score, the Clinical COPD Questionnaire (CCQ), and the St George’s Respiratory Questionnaire were used in Cox regression models to predict treatment failure, time to next exacerbation, and mortality in the hospital study.

Results

All patient-reported outcomes showed a distinct pattern of improvement. In the multivariate models, absence of improvement in CCQ symptom score and impaired lung function were independent predictors of treatment failure. Health status and gender predicted time to next exacerbation. Five-year mortality was predicted by age, forced expiratory flow in one second % predicted, smoking status, and CCQ score. In outpatient management of exacerbations, health status was found to be less impaired than in hospitalized patients, while the rate and pattern of recovery was remarkably similar.

Conclusion

Daily health status measurements were found to predict treatment failure, which could help decision-making for patients hospitalized due to an exacerbation of COPD.

Application of appropriateness criteria for hospitalization in COPD exacerbation

The IRYSS-COPD appropriateness study was developed in 16 hospitals belonging to the Spanish National Health Service from June 2008 to September 2010 (n = 2,877). The objectives were to apply a set of explicit criteria for the appropriateness of hospital admission created by the RAND/UCLA methodology to patients evaluated in the emergency department (ED) for exacerbations of COPD. This is a prospective cohort study. We explored the relationship between appropriateness of admission as defined by the explicit criteria and the final decision to admit or discharge. A total of 2,877 patients were included for analysis; of these, 1,747 (60.7 %) were admitted and 1,130 (39.3 %) were discharged from the ED to home. Among patients classified by the explicit criteria as appropriate for hospital admission, 81.3 % were admitted, compared with 64.81 % of those classified as uncertain and 48.65 % of those classified as inappropriate for admission. Severity of exacerbation was the most influencing variable in the decision. Application of our explicit criteria for appropriate hospital admission among a large sample of patients experiencing an exacerbation of COPD in the ED setting suggests that these criteria could be used as the basis for clinical decision-making and health-care assessment.

Eight-step method to build the clinical content of an evidence-based care pathway: the case for COPD exacerbation

BACKGROUND

Optimization of the clinical care process by integration of evidence-based knowledge is one of the active components in care pathways. When studying the impact of a care pathway by using a cluster-randomized design, standardization of the care pathway intervention is crucial. This methodology paper describes the development of the clinical content of an evidence-based care pathway for in-hospital management of chronic obstructive pulmonary disease (COPD) exacerbation in the context of a cluster-randomized controlled trial (cRCT) on care pathway effectiveness.

METHODS

The clinical content of a care pathway for COPD exacerbation was developed based on recognized process design and guideline development methods. Subsequently, based on the COPD case study, a generalized eight-step method was designed to support the development of the clinical content of an evidence-based care pathway.

RESULTS

A set of 38 evidence-based key interventions and a set of 24 process and 15 outcome indicators were developed in eight different steps. Nine Belgian multidisciplinary teams piloted both the set of key interventions and indicators. The key intervention set was judged by the teams as being valid and clinically applicable. In addition, the pilot study showed that the indicators were feasible for the involved clinicians and patients.

CONCLUSIONS

The set of 38 key interventions and the set of process and outcome indicators were found to be appropriate for the development and standardization of the clinical content of the COPD care pathway in the context of a cRCT on pathway effectiveness. The developed eight-step method may facilitate multidisciplinary teams caring for other patient populations in designing the clinical content of their future care pathways.

Advance care planning in chronic obstructive pulmonary disease: barriers and opportunities

PURPOSE OF REVIEW

Experts in palliative care have increasingly recognized the global epidemic of chronic obstructive pulmonary disease (COPD), its astonishing rise in prevalence, and its profound impact on patients' quality of life and functional capacity. Unfortunately, patients with COPD receive less advance care planning (ACP) and palliative care as compared with patients with other diseases with similar prognoses. This review highlights recent advances in identifying barriers to ACP and opportunities for providing more effective and timely palliative care.

RECENT FINDINGS

Patients with COPD identify dyspnea as their most disabling symptom. Disease-directed care provides only partial relief from dyspnea, which eventually becomes refractory and requires transition to palliative care. Throughout all stages of COPD, however, integrating palliative care with disease-directed treatments improves patients' well being and functional capacities. Observational studies have identified multiple barriers to effective ACP. Because of the unique disease trajectory of COPD, professional groups have proposed new models for palliative care specifically tailored to COPD.

SUMMARY

Patients with COPD benefit from better integration of palliative and disease-specific care throughout the course of their disease from diagnosis to death. Pulmonary rehabilitation may provide a platform for coordinating integrated care. Health agencies will increasingly expect better coordination of services for patients with this progressive, disabling, and eventually terminal disease.