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General practice management of COPD patients following acute exacerbations: a qualitative study. Br J Gen Pract 2023; 73:e186-e195. [PMID: 36823067 PMCID: PMC9975965 DOI: 10.3399/bjgp.2022.0342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Accepted: 10/24/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Exacerbations are the strongest risk factor for future exacerbations for patients living with chronic obstructive pulmonary disease (COPD). The period immediately following exacerbation is a high-risk period for recurrence and hospital admission, and is a critical time to intervene. GPs are ideally positioned to deliver this care. AIM To explore perceptions of GPs regarding the care of patients following exacerbations of COPD and to identify factors affecting the provision of evidence-based care. DESIGN AND SETTING A descriptive qualitative study was undertaken involving semi-structured, in-depth interviews with Australian GPs who volunteered to participate following a national survey of general practice care for COPD patients following exacerbations. METHOD Interviews were conducted via the Zoom video conference platform, which were audio-recorded and transcribed verbatim. QSR NVivo was used to support data management, coding, and inductive thematic analysis. RESULTS Eighteen GPs completed interviews. Six key themes were identified: 1) GPs' perceptions and knowledge in the management of COPD patients following exacerbation and admission to hospital; 2) pharmacological management; 3) consultation time; 4) communication between healthcare professionals; 5) access to other health services; and 6) patient compliance. CONCLUSION Delivery of post-exacerbation care to COPD patients is affected by GPs, patients, and health service-related factors. The care of COPD patients may be further improved by supporting GPs to overcome identified barriers.
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Westley-Wise V, Lago L, Mullan J, Facci F, Zingel R, Eagar K. Trends in unplanned readmissions over 15 years: a regional Australian perspective. AUST HEALTH REV 2019; 44:241-247. [PMID: 30827332 DOI: 10.1071/ah18072] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 11/19/2018] [Indexed: 11/23/2022]
Abstract
Objective The aim of this study was to assess 15-year trends in unplanned readmissions in an Australian regional health service. Methods Drawing on data held in the Illawarra Health Information Platform (IHIP), this longitudinal retrospective study of adults admitted to hospital between 2001-02 and 2015-16 assessed rates of unplanned all-cause readmissions within 30 days ('early') and 1-6 months ('late') following discharge. Rates were compared over time and between patient groups. Results Age-adjusted early readmission rates declined over the 15 years by an average of 1.3% per annum, whereas late readmission rates increased by an average of 0.6% per annum. Together, there was an overall decline in readmission rates. The entire decline in early readmission rates and a reversal of the increasing trend in late readmission rates occurred since 2010-11. Similar trends occurred across age groups, but were most pronounced among those aged ≥75 years. Conclusions The decline in readmissions since 2010-11 suggests that the region has achieved improvements in discharge planning and in continuity between hospitals and community-based care. These improvements have occurred across broad patient groups. The longitudinal and linked data held in the IHIP provides a unique opportunity to examine patterns of service utilisation at a regional level. What is known about the topic? Published reports of longitudinal trends in readmissions are typically limited by short study periods and narrow criteria used to define study populations and readmissions. Australian longitudinal data suggest rates of early readmission have remained relatively unchanged in recent years, despite the focus on readmission rates as a metric to assess the quality and continuity of care. What does this paper add? This unique longitudinal study reports on long-term readmission trends over 15 years to hospitals within a single geographic area, with trends reported for both early (30-day) and late (1- to 6-month) readmissions by age group and major diagnostic categories. The findings reflect more complex patterns than are typically reported in cross-sectional and more limited longitudinal studies. What are the implications for practitioners? The results suggest improvements at a regional level that may be associated with care during the initial hospitalisation and discharge (reflected particularly in early readmissions) and in the community (reflected particularly in late readmissions). Future investigations will explore specific patient groups and the effects of specific initiatives, services and models of care to better predict those at risk of readmission and to inform translation locally and further afield. The relationship between readmissions and the use of ambulatory services (primary care, emergency department and out-patient) also warrants further investigation.
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Affiliation(s)
- Victoria Westley-Wise
- Illawarra Shoalhaven Local Health District, Level 1, 67-71 King Street, Warrawong, NSW 2502, Australia. ; ; and Centre for Health Services Research Illawarra Shoalhaven Population, University of Wollongong, Building 234, Innovation Campus, Wollongong, NSW 2522, Australia. , ; and Corresponding author.
| | - Luise Lago
- Centre for Health Services Research Illawarra Shoalhaven Population, University of Wollongong, Building 234, Innovation Campus, Wollongong, NSW 2522, Australia. ,
| | - Judy Mullan
- Centre for Health Services Research Illawarra Shoalhaven Population, University of Wollongong, Building 234, Innovation Campus, Wollongong, NSW 2522, Australia. ,
| | - Franca Facci
- Illawarra Shoalhaven Local Health District, Level 1, 67-71 King Street, Warrawong, NSW 2502, Australia. ;
| | - Rebekah Zingel
- Illawarra Shoalhaven Local Health District, Level 1, 67-71 King Street, Warrawong, NSW 2502, Australia. ;
| | - Kathy Eagar
- Australian Health Services Research Institute, University of Wollongong, Building 234, Innovation Campus, Wollongong, NSW 2522, Australia.
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The ratchet effect: dramatic and sustained changes in health care utilization following admission to hospital with chronic disease. Med Care 2014; 52:901-8. [PMID: 25054825 PMCID: PMC4174034 DOI: 10.1097/mlr.0000000000000185] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Supplemental Digital Content is available in the text. Objective: To describe the previously unexamined association between admissions to hospital with chronic disease and changes in all-cause health service utilization over time. Research Design: A cohort study examining the population of Western Australia with hospitalizations for chronic disease from 2002 to 2010. A “rolling” clearance period is used to define “cardinal events,” that is, a disease-specific diagnosis upon hospital admission, where such an event has not occurred in the previous 2 years. Changes in the rate of cardinal events associated with diagnoses of heart failure, type 2 diabetes, chronic obstructive pulmonary disease, cataract with diabetes, asthma, and dialysis are examined. Health service utilization (defined as inpatient days or emergency department presentations) 6 years preceding and 4 years following such events is presented. Results: Cardinal events make up 40%–60% of all chronic disease admissions. A previously undescribed ratchet effect following cardinal events specifically associated with type 2 diabetes, heart failure, and chronic obstructive pulmonary disease is observed. This involves a 2- to 3-fold increase in inpatient days and emergency department presentations that are sustained for at least 4 years. Conclusions: Cardinal events represent an important reference point to understand the impact of chronic disease on health service utilization. Events that herald such a marked transition in health service demand have not been previously described.
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Philip J, Lowe A, Gold M, Brand C, Miller B, Douglass J, Sundararajan V. Palliative care for patients with chronic obstructive pulmonary disease: exploring the landscape. Intern Med J 2014; 42:1053-7. [PMID: 24020345 DOI: 10.1111/j.1445-5994.2012.02830.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Patients with chronic obstructive pulmonary disease experience a substantial symptom burden, high levels of psychosocial need and significant mortality. This epidemiological study reveals that the majority of patients are cared for in the public hospital system (64%) and generally die in hospital (72%) with a number of identifiable predictors of 6-month mortality. Our results suggest that palliative care services need to be redirected from a community-based admission focus to a model that is responsive to emergency and acute care hospital systems.
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Affiliation(s)
- J Philip
- Centre for Palliative Care, St Vincent's Hospital and University of Melbourne Palliative Medicine, St Vincent's Hospital School of Population Health, University of Melbourne Murdoch Childrens Research Institute, Royal Children's Hospital Palliative Care Service Department of Allergy, Immunology and Respiratory Medicine, The Alfred Hospital Centre for Research Excellence in Patient Safety (CREPS) Department of Clinical Epidemiology, Biostatistics and Health Services Research, Melbourne University and Melbourne HealthDepartments of Medicine Medicine, Southern Clinical School, Monash University, Melbourne, Victoria, Australia
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Osadnik CR, McDonald CF, Miller BR, Hill CJ, Tarrant B, Steward R, Chao C, Stodden N, Oliveira CC, Gagliardi N, Holland AE. The effect of positive expiratory pressure (PEP) therapy on symptoms, quality of life and incidence of re-exacerbation in patients with acute exacerbations of chronic obstructive pulmonary disease: a multicentre, randomised controlled trial. Thorax 2013; 69:137-43. [PMID: 24005444 DOI: 10.1136/thoraxjnl-2013-203425] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Positive expiratory pressure (PEP) is a technique used to enhance sputum clearance during acute exacerbations of chronic obstructive pulmonary disease (AECOPD). The impact of PEP therapy during acute exacerbations on clinically important outcomes is not clear. This study sought to determine the effect of PEP therapy on symptoms, quality of life and future exacerbations in patients with AECOPD. METHODS 90 inpatients (58 men; mean age 68.6 years, FEV(1) 40.8% predicted) with AECOPD and sputum expectoration were randomised to receive usual care (including physical exercise)±PEP therapy. The Breathlessness, Cough and Sputum Scale (BCSS), St George's Respiratory Questionnaire (SGRQ) and BODE index (Body mass index, airflow Obstruction, Dyspnoea, Exercise tolerance) were measured at discharge, 8 weeks and 6 months following discharge, and analysed via linear mixed models. Exacerbations and hospitalisations were recorded using home diaries. RESULTS There were no significant between-group differences over time for BCSS score [mean (SE) at discharge 5.2 (0.4) vs 5.0 (0.4) for PEP and control group, respectively; p=0.978] or SGRQ total score [41.6 (2.6) vs 40.8 (2.8) at 8 weeks, p=0.872]. Dyspnoea improved more rapidly in the PEP group over the first 8 weeks (p=0.006), however these benefits were not observed at 6 months. Exacerbations (p=0.986) and hospitalisations (p=0.359) did not differ between groups. CONCLUSIONS We found no evidence that PEP therapy during AECOPD improves important short-term or long-term outcomes. There does not appear to be a routine role for PEP therapy in the management of such individuals.
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Affiliation(s)
- Christian R Osadnik
- School of Physiotherapy, La Trobe University, , Melbourne, Victoria, Australia
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Lash TL, Johansen MB, Christensen S, Baron JA, Rothman KJ, Hansen JG, Sørensen HT. Hospitalization Rates and Survival Associated with COPD: A Nationwide Danish Cohort Study. Lung 2010; 189:27-35. [DOI: 10.1007/s00408-010-9274-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2010] [Accepted: 11/27/2010] [Indexed: 12/19/2022]
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Einarsdóttir K, Preen DB, Sanfilippo FM, Reeve R, Emery JD, Holman CDJ. Mortality in Western Australian seniors with chronic respiratory diseases: a cohort study. BMC Public Health 2010; 10:385. [PMID: 20591200 PMCID: PMC2910678 DOI: 10.1186/1471-2458-10-385] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2009] [Accepted: 07/01/2010] [Indexed: 11/10/2022] Open
Abstract
Background Relatively few studies have examined survival by pharmacotherapy level and the effects of patient characteristics on mortality by pharmacotherapy level in older chronic respiratory disease (CRD) patients. This study aimed to investigate these issues in older (≥ 65) CRD patients in Western Australia. Methods We identified 108,312 patients ≥ 65 years with CRD during 1992-2006 using linked medical, pharmaceutical, hospital and mortality databases held by the Commonwealth and State governments. Pharmacotherapy classification levels were designed by a clinical consensus panel. Cox regression was used to investigate the study aim. Results Patients using only short acting bronchodilators experienced similar, but slightly worse survival than patients in the highest pharmacotherapy level group using high dose inhaled corticosteroids (ICS) ± long acting bronchodilators (LABs) ± oral steroids. Patients using low to medium dose ICS ± LABs experienced relatively better survival. Also, male gender was associated with all-cause mortality in all patients (HR = 1.72, 95% CI 1.65-1.80) and especially in those in the highest pharmacotherapy level group (HR = 1.97, 95%CI = 1.84-2.10). The P-value of interaction between gender and pharmacotherapy level for the effect on all-cause death was significant (0.0003). Conclusions Older patients with CRD not using ICS experienced the worst survival in this study and may benefit from an escalation in therapeutic regime. Males had a higher risk of death than females, which was more pronounced in the highest pharmacotherapy level group. Hence, primary health care should more actively direct disease management to mild-to-moderate disease patients.
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Affiliation(s)
- Kristjana Einarsdóttir
- Centre for Health Services Research, School of Population Health, The University of Western Australia, 35 Stirling Highway, Crawley, 6009 Perth, Australia.
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Hutchinson A, Brand C, Irving L, Roberts C, Thompson P, Campbell D. Acute care costs of patients admitted for management of chronic obstructive pulmonary disease exacerbations: contribution of disease severity, infection and chronic heart failure. Intern Med J 2010; 40:364-71. [DOI: 10.1111/j.1445-5994.2010.02195.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Velthove KJ, Leufkens HG, Schweizer RC, van Solinge WW, Souverein PC. Medication changes prior to hospitalization for obstructive lung disease: a case-crossover study. Ann Pharmacother 2010; 44:267-73. [PMID: 20071496 DOI: 10.1345/aph.1m513] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Hospitalizations have always been seen as a solid outcome parameter in pharmacoepidemiology. However, the period leading to hospitalization and prehospital management of the patient are equally important. OBJECTIVE To evaluate medication changes in the period prior to hospitalization for obstructive lung disease and to quantify the association between medication use and the risk of hospitalization. METHODS We conducted a case-crossover study using the PHARMO record linkage system, which contains drug dispensing data from community pharmacies and hospital admission data. Patients included in the study were adults hospitalized for obstructive lung disease between 2005 and 2007. The index date of the case period was the date of hospitalization, and control moments were set at 3, 6, 9, and 12 months before admission. For each patient, all prescriptions prior to the date of hospitalization were identified. Medication use was ascertained in a 90-day time window prior to each case or control moment. RESULTS We identified 1481 patients who were hospitalized for obstructive lung disease. It appeared that respiratory medication use increased in the 90 days prior to hospitalization. Hospitalization was associated with the use of 3 or more respiratory drugs (OR 2.2; 95% CI 1.8 to 2.8), systemic glucocorticoids (OR 4.5; 95% CI 3.8 to 5.4), and antibiotics (OR 3.1; 95% CI 2.7 to 3.6). CONCLUSIONS The use of systemic glucocorticoids, antibiotics, and other respiratory drugs increased prior to hospitalization for obstructive lung disease. These results could be indicative of the development and/or treatment of an exacerbation. There is a need for markers to detect exacerbations in an early phase in order to start treatment as early as possible and possibly prevent hospitalizations for obstructive lung disease.
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Affiliation(s)
- Karin J Velthove
- Division of Pharmacoepidemiology and Pharmacotherapy, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, The Netherlands
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