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Freund O, Melloul A, Fried S, Kleinhendler E, Unterman A, Gershman E, Elis A, Bar-Shai A. Management of acute exacerbations of COPD in the emergency department and its associations with clinical variables. Intern Emerg Med 2024:10.1007/s11739-024-03592-w. [PMID: 38602629 DOI: 10.1007/s11739-024-03592-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 03/19/2024] [Indexed: 04/12/2024]
Abstract
Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is a common cause for emergency department (ED) visits. Still, large scale studies that assess the management of AECOPD in the ED are limited. Our aim was to evaluate treatment characteristics of AE-COPD in the ED on a national scale. A prospective study as part of the COPD Israeli survey, conducted between 2017 and 2019, in 13 medical centers. Patients hospitalized with AECOPD were included and interviewed. Clinical data related to their ED and hospital stay were collected. 344 patients were included, 38% females, mean age of 70 ± 11 years. Median (IQR) time to first ED treatment was 59 (23-125) minutes and to admission 293 (173-490) minutes. Delayed ED treatment (> 1 h) was associated with older age (p = 0.01) and lack of a coded diagnosis of COPD in hospital records (p = 0.01). Long ED length-of-stay (> 5 h) was linked with longer hospitalizations (p = 0.01). Routine ED care included inhalations of short-acting bronchodilators (246 patients, 72%) and systemic steroids (188 patients, 55%). Receiving routine ED care was associated with its continuation during hospitalization (p < 0.001). In multivariate analysis, predictors for patients not receiving routine care were obesity (adjusted odds ratio 0.5, 95% CI 0.3-0.8, p = 0.01) and fever (AOR 0.3, 95% CI 0.1-0.6, p < 0.01), while oxygen saturation < 91% was an independent predictor for ED routine treatment (AOR 3.6, 95% CI 2.1-6.3, p < 0.01). Our findings highlight gaps in the treatment of AECOPD in the ED on a national scale, with specific predictors for their occurrence.
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Affiliation(s)
- Ophir Freund
- The Institute of Pulmonary Medicine, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel.
- Internal Medicine B, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel.
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Ariel Melloul
- The Institute of Pulmonary Medicine, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sabrina Fried
- The Institute of Pulmonary Medicine, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eyal Kleinhendler
- The Institute of Pulmonary Medicine, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Avraham Unterman
- The Institute of Pulmonary Medicine, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Evgeni Gershman
- The Institute of Pulmonary Medicine, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Avishay Elis
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Internal Medicine C, Rabin Medical Center, Kfar Saba, Israel
| | - Amir Bar-Shai
- The Institute of Pulmonary Medicine, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Fiore M, Ricci M, Rosso A, Flacco ME, Manzoli L. Chronic Obstructive Pulmonary Disease Overdiagnosis and Overtreatment: A Meta-Analysis. J Clin Med 2023; 12:6978. [PMID: 38002593 PMCID: PMC10672453 DOI: 10.3390/jcm12226978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 10/31/2023] [Accepted: 11/06/2023] [Indexed: 11/26/2023] Open
Abstract
This meta-analysis of observational studies aimed at estimating the overall prevalence of overdiagnosis and overtreatment in subjects with a clinical diagnosis of Chronic Obstructive Pulmonary Disease (COPD). MedLine, Scopus, Embase and Cochrane databases were searched, and random-effect meta-analyses of proportions were stratified by spirometry criteria (Global Initiative for COPD (GOLD) or Lower Limit of Normal (LLN)), and setting (hospital or primary care). Forty-two studies were included. Combining the data from 39 datasets, including a total of 23,765 subjects, the pooled prevalence of COPD overdiagnosis, according to the GOLD definition, was 42.0% (95% Confidence Interval (CI): 37.3-46.8%). The pooled prevalence according to the LLN definition was 48.2% (40.6-55.9%). The overdiagnosis rate was higher in primary care than in hospital settings. Fourteen studies, including a total of 8183 individuals, were included in the meta-analysis estimating the prevalence of COPD overtreatment. The pooled rates of overtreatment according to GOLD and LLN definitions were 57.1% (40.9-72.6%) and 36.3% (17.8-57.2%), respectively. When spirometry is not used, a large proportion of patients are erroneously diagnosed with COPD. Approximately half of them are also incorrectly treated, with potential adverse effects and a massive inefficiency of resources allocation. Strategies to increase the compliance to current guidelines on COPD diagnosis are urgently needed.
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Affiliation(s)
- Matteo Fiore
- Section of Hygiene and Preventive Medicine, University of Bologna, 40126 Bologna, Italy; (M.F.); (M.R.)
| | - Matteo Ricci
- Section of Hygiene and Preventive Medicine, University of Bologna, 40126 Bologna, Italy; (M.F.); (M.R.)
| | - Annalisa Rosso
- Department of Environmental and Prevention Sciences, University of Ferrara, 44121 Ferrara, Italy; (A.R.); (M.E.F.)
| | - Maria Elena Flacco
- Department of Environmental and Prevention Sciences, University of Ferrara, 44121 Ferrara, Italy; (A.R.); (M.E.F.)
| | - Lamberto Manzoli
- Section of Hygiene and Preventive Medicine, University of Bologna, 40126 Bologna, Italy; (M.F.); (M.R.)
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Sim M, Yii A, Xu X, Bahety P, Loh CH, Navarro Rojas AA, Milea D, Tee A. Characteristics of Patients with Chronic Obstructive Pulmonary Disease Treated with Long-Acting Bronchodilators in a Real-World Setting in Singapore: A Single-Center Observational Study. Int J Chron Obstruct Pulmon Dis 2022; 17:1349-1363. [PMID: 35711173 PMCID: PMC9192350 DOI: 10.2147/copd.s357820] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 05/19/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction There is limited real-world evidence regarding clinical practice for chronic obstructive pulmonary disease (COPD) in Singapore. We compared baseline clinical characteristics and evaluated outcomes in patients with COPD who initiated treatment with either a long-acting muscarinic antagonist (LAMA) or a LAMA and a long-acting β2-agonist (LAMA+LABA). Methods This was a single-center observational study at Changi General Hospital, Singapore. Routine clinical data (hospital visits, case management, lung function, laboratory/imaging results, medication orders) were collected and compiled into a data warehouse. Eligible patients with COPD were ≥40 years old and newly prescribed LAMA or LAMA+LABA during the enrollment period. Patient characteristics in the baseline period (6 months) were compared between treatments. Clinical worsening was measured as a composite endpoint, defined as the first of a change in maintenance treatment class or a moderate-to-severe exacerbation during follow-up (12 months). Results In total, 261 patients were included in the baseline period (LAMA: 73; LAMA+LABA: 188). In the baseline period, patients receiving LAMA+LABA versus LAMA had significantly lower body mass index, higher COPD Assessment Test score and worse lung function, and numerically higher exacerbation history. Prevalence of comorbidities was similar between treatment groups. In follow-up, high rates of clinical worsening were observed regardless of treatment regimen (LAMA: 38/73 [52%]; LAMA+LABA: 86/188 [46%]). Median time-to-clinical worsening was 340 days for the LAMA cohort and the raw median 154 days (interquartile range: 44–225) for the LAMA+LABA cohort. Median medication dispensation rate (0.86; interquartile range: 0.56–1.00) was similar between treatments. Conclusion Patients initiating treatment with LAMA+LABA had more severe COPD than patients prescribed LAMA. The proportion of patients experiencing clinical worsening was similarly high in both cohorts, suggesting that early identification and treatment optimization are necessary.
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Affiliation(s)
- Marcus Sim
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore, Singapore
| | - Anthony Yii
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore, Singapore
| | - Xiaomeng Xu
- Value Evidence & Outcomes, Greater China and Intercontinental, GSK, Singapore, Singapore
| | | | - Chee Hong Loh
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore, Singapore
| | | | - Dominique Milea
- Value Evidence & Outcomes, Greater China and Intercontinental, GSK, Singapore, Singapore
| | - Augustine Tee
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore, Singapore
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Issac H, Keijzers G, Yang IA, Lea J, Taylor M, Moloney C. Development of an Electronic Interdisciplinary Chronic Obstructive Pulmonary Disease (COPD) Proforma (E-ICP) to Improve Interdisciplinary Guideline Adherence in the Emergency Department: Modified Delphi Study. Int J Chron Obstruct Pulmon Dis 2022; 17:1089-1106. [PMID: 35573657 PMCID: PMC9091474 DOI: 10.2147/copd.s358254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 04/11/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Hancy Issac
- School of Nursing and Midwifery, University of Southern Queensland, Toowoomba, QLD, Australia
- Centre of Health Research, University of Southern Queensland, Toowoomba, QLD, Australia
- Correspondence: Hancy Issac, School of Nursing and Midwifery, University of Southern Queensland, Toowoomba, QLD, Australia, Email
| | - Gerben Keijzers
- Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast, QLD, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD, Australia
- School of Medicine, Griffith University, Gold Coast, QLD, Australia
| | - Ian A Yang
- Thoracic Medicine, The Prince Charles Hospital, Brisbane, QLD, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Jackie Lea
- School of Nursing and Midwifery, University of Southern Queensland, Toowoomba, QLD, Australia
- Centre of Health Research, University of Southern Queensland, Toowoomba, QLD, Australia
| | - Melissa Taylor
- School of Nursing and Midwifery, University of Southern Queensland, Toowoomba, QLD, Australia
- Centre of Health Research, University of Southern Queensland, Toowoomba, QLD, Australia
| | - Clint Moloney
- School of Nursing and Midwifery, University of Southern Queensland, Toowoomba, QLD, Australia
- College of Health and Biomedicine, Nursing and Midwifery, Victoria University, Melbourne, VIC, Australia
- Institute for Health and Sport, Victoria University, Melbourne, VIC, Australia
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Issac H, Moloney C, Taylor M, Lea J. Mapping of Modifiable Factors with Interdisciplinary Chronic Obstructive Pulmonary Disease (COPD) Guidelines Adherence to the Theoretical Domains Framework: A Systematic Review. J Multidiscip Healthc 2022; 15:47-79. [PMID: 35046662 PMCID: PMC8759995 DOI: 10.2147/jmdh.s343277] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 12/16/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND COPD guidelines non-concordance is a challenge frequently highlighted by respiratory experts. Despite the provision of comprehensive evidence-based national and international guidelines, the COPD burden to frontline healthcare services has increased in the last decade. Suboptimal guidelines concordance can be disruptive to health-related quality of life (HRQoL), hastening pulmonary function decline and surging overall morbidity and mortality. A lack of concordance with guidelines has created an escalating economic burden on health-care systems. Identifying interdisciplinary interventions to facilitate improved adherence to guidelines may significantly reduce re-admissions, enhance HRQoL amongst patients and their families, and facilitate economic efficiency. MATERIALS AND METHODS This review adhered to the Joanna Briggs Institute (JBI) methodology for mixed methods systematic reviews and the PRISMA ScR reporting guidelines. Two independent reviewers screened abstracts and full text articles in consonance with inclusion criteria. The convergent integrative JBI method collated quantitative, qualitative and mixed methods studies from nine databases. JBI critical appraisal tools were utilised to assess the quality of research papers. The theoretical domains framework (TDF) along with a specifically developed COPD data extraction tool were adopted as a priori to collect and collate data. Identified barriers and corresponding clinical behavioural change solutions were categorised using TDF domains and behavior change wheel (BCW) to provide future research and implementation recommendations. RESULTS Searches returned 1068 studies from which 37 studies were included (see Figure 1). COPD recommendations identified to be discordant with clinical practice included initiating non-invasive ventilation, over- or under-prescription of corticosteroids and antibiotics, and a lack of discharging patients with a smoking cessation plan or pulmonary rehabilitation. TDF domains with highest frequency scores were knowledge, environmental resources, and clinical behaviour regulation. Electronic order sets/digital proforma with guideline resources at point of care and easily accessible digital community referrals to target both pharmacological and non-pharmacological management appear to be a solution to improve concordance. CONCLUSION Implementation of consistent quality improvement intervention within hospitals for patients with COPD may exclude any implementation gap and prevent readmissions. Electronic proformas with digital referrals will assist with future evaluation audits to prioritise and target interventions to improve guidelines concordance. ETHICS AND DISSEMINATION Ethical approval is not required, and results dissemination will occur through peer-reviewed publication. PROSPERO REGISTRATION NUMBER CRD42020156267.
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Affiliation(s)
- Hancy Issac
- School of Nursing and Midwifery, University of Southern Queensland, Toowoomba, Australia
- Centre for Health Research, University of Southern Queensland, Toowoomba, Australia
| | - Clint Moloney
- School of Nursing and Midwifery, University of Southern Queensland, Toowoomba, Australia
- College of Health and Biomedicine, Nursing and Midwifery, Victoria University, Melbourne, Australia
- Clinical Community Health and Wellbeing, Research Institute for Health and Sport, Victoria University, Melbourne, Australia
| | - Melissa Taylor
- School of Nursing and Midwifery, University of Southern Queensland, Toowoomba, Australia
- Centre for Health Research, University of Southern Queensland, Toowoomba, Australia
| | - Jackie Lea
- School of Nursing and Midwifery, University of Southern Queensland, Toowoomba, Australia
- Centre for Health Research, University of Southern Queensland, Toowoomba, Australia
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Associated factors, assessment, management, and outcomes of patients who present to the emergency department for acute exacerbation of chronic obstructive pulmonary disease: A scoping review. Respir Med 2022; 193:106747. [DOI: 10.1016/j.rmed.2022.106747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 01/11/2022] [Accepted: 01/17/2022] [Indexed: 12/24/2022]
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Issac H, Taylor M, Moloney C, Lea J. Exploring Factors Contributing to Chronic Obstructive Pulmonary Disease (COPD) Guideline Non-Adherence and Potential Solutions in the Emergency Department: Interdisciplinary Staff Perspective. J Multidiscip Healthc 2021; 14:767-785. [PMID: 33854328 PMCID: PMC8039430 DOI: 10.2147/jmdh.s276702] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Accepted: 02/04/2021] [Indexed: 12/01/2022] Open
Abstract
Purpose Acute exacerbations of chronic obstructive pulmonary disease (COPD) have a significant and prolonged impact on health-related quality of life, patient outcomes, and escalation of pulmonary function decline. COPD-X guidelines published in 2003 subsist to facilitate a shift from the emphasis on pharmacological treatment to a more holistic multi-disciplinary interventions approach. Despite the existing comprehensive recommendations, readmission rates have increased in the last decade. Evidence to date has reported sub-optimal COPD guidelines adherence in emergency departments. This qualitative study explored contributing factors to interdisciplinary staff non-adherence and utilisation of COPD-X guidelines in a major Southern Queensland Emergency Department. Methods Semi-structured qualitative interviews with interdisciplinary staff were conducted in an emergency department. A purposive sample of doctors, nurses, physiotherapists, pharmacist and a social worker were recruited. Interviews were digitally recorded, de-identified and transcribed verbatim. Data analysis followed a coding process against the Theoretical Domains Framework (TDF) to examine implementation barriers and potential solutions. Identified factors affecting non-adherence and underutilisation of guidelines were then mapped to the capability, opportunity, motivation, behaviour model (COM-B) and behaviour change wheel (BCW) to inform future implementation recommendations. Results Prominent barriers influencing the clinical uptake of COPD guidelines were identified using TDF analysis and included knowledge, professional role clarity, clinical behaviour regulation, memory, attention, and decision process, beliefs about departmental capabilities, environmental context and resources. Potential interventions included education, training, staffing, funding and time-efficient digitalised referrals and systems management reminders to prevent COPD readmissions, remissions and improve patient health-related quality of life. Conclusion Implementation strategies such as electronic interdisciplinary COPD proforma that facilitates a multimodal approach with appropriate patient/staff resources and referrals prior to discharge from an ED require further exploration. Greater clarity around which components of the COPD X guidelines must be applied in ED settings needs to stem from future research.
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Affiliation(s)
- Hancy Issac
- School of Nursing and Midwifery, University of Southern Queensland, Toowoomba, Australia
| | - Melissa Taylor
- School of Nursing and Midwifery, University of Southern Queensland, Toowoomba, Australia
| | - Clint Moloney
- School of Nursing and Midwifery, University of Southern Queensland, Toowoomba, Australia
| | - Jackie Lea
- School of Nursing and Midwifery, University of Southern Queensland, Toowoomba, Australia
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Issac H, Moloney C, Taylor M, Lea J. Mapping of modifiable barriers and facilitators with interdisciplinary chronic obstructive pulmonary disease (COPD) guidelines concordance within hospitals to the Theoretical Domains Framework: a mixed methods systematic review protocol. BMJ Open 2020; 10:e036060. [PMID: 32690740 PMCID: PMC7375635 DOI: 10.1136/bmjopen-2019-036060] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
INTRODUCTION Multifarious chronic obstructive pulmonary disease (COPD) guidelines have been published by local, national and global respiratory societies. These guidelines subsume holistic evidence based on recommendations to diagnose, treat, prevent and manage acute exacerbation with COPD. Despite the existing comprehensive recommendations, readmission rates and hospitalisations have increased in the last decade. Evidence to date has reported suboptimal clinical guidelines concordance. Acute exacerbations of COPD (AECOPD) is a common hospital presentation due to varied causes such as infective exacerbations, worsening disease condition, medication non-adherence, lack of education and incomprehensive discharge planning. AECOPD directly and indirectly causes economic burden, disrupts health-related quality of life (HRQol), hasten lung function decline and increases overall morbidity and mortality. COPD being a multimodal chronic disease, consistent interdisciplinary interventions from the time of admission to discharge may reduce readmissions and enhance HRQol among these patients and their families. METHODS AND ANALYSIS This protocol adheres to the Joanna Briggs Institute methodology for mixed methods systematic reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews reporting guidelines. Qualitative, quantitative and mixed methods studies will append this study to explore determinants of COPD guidelines concordance. Comprehensive three-tier search strategies will be used to search nine databases (COCHRANE, EBSCO HOST, MEDLINE, SCIENCE DIRECT, JBI, SCOPUS, WEB OF SCIENCE, WILEY and DARE) in May 2020. Two independent reviewers will screen abstracts and full-text articles in consonance with inclusion criteria. The convergent integrative method narrative review will contribute a deeper understanding of any discrepancies found in the existing evidence. Quality of the studies will be reported and Theoretical Domains Framework (TDF) will be used as a priori to synthesis data. Identified barriers, facilitators and corresponding clinical behavioural change solutions will be categorised using TDF indicators to provide future research and implementation recommendations. ETHICS AND DISSEMINATION Ethical approval is not required and results dissemination will occur through peer-reviewed publication.
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Affiliation(s)
- Hancy Issac
- School of Nursing and Midwifery, University of Southern Queensland, Toowoomba, Queensland, Australia
| | - Clint Moloney
- School of Nursing and Midwifery, University of Southern Queensland, Toowoomba, Queensland, Australia
| | - Melissa Taylor
- School of Nursing and Midwifery, University of Southern Queensland, Toowoomba, Queensland, Australia
| | - Jackie Lea
- School of Nursing and Midwifery, University of Southern Queensland, Toowoomba, Queensland, Australia
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