Management of acute COPD exacerbations in Australia: do we follow the guidelines?

Global mortality and readmission rates following COPD exacerbation-related hospitalisation: a meta-analysis of 65 945 individual patients

Background

Exacerbations of COPD (ECOPD) have a major impact on patients and healthcare systems across the world. Precise estimates of the global burden of ECOPD on mortality and hospital readmission are needed to inform policy makers and aid preventive strategies to mitigate this burden. The aims of the present study were to explore global in-hospital mortality, post-discharge mortality and hospital readmission rates after ECOPD-related hospitalisation using an individual patient data meta-analysis (IPDMA) design.

Methods

A systematic review was performed identifying studies that reported in-hospital mortality, post-discharge mortality and hospital readmission rates following ECOPD-related hospitalisation. Data analyses were conducted using a one-stage random-effects meta-analysis model. This study was conducted and reported in accordance with the PRISMA-IPD statement.

Results

Data of 65 945 individual patients with COPD were analysed. The pooled in-hospital mortality rate was 6.2%, pooled 30-, 90- and 365-day post-discharge mortality rates were 1.8%, 5.5% and 10.9%, respectively, and pooled 30-, 90- and 365-day hospital readmission rates were 7.1%, 12.6% and 32.1%, respectively, with noticeable variability between studies and countries. Strongest predictors of mortality and hospital readmission included noninvasive mechanical ventilation and a history of two or more ECOPD-related hospitalisations <12 months prior to the index event.

Conclusions

This IPDMA stresses the poor outcomes and high heterogeneity of ECOPD-related hospitalisation across the world. Whilst global standardisation of the management and follow-up of ECOPD-related hospitalisation should be at the heart of future implementation research, policy makers should focus on reimbursing evidence-based therapies that decrease (recurrent) ECOPD.

Knowledge of recommended antibiotic treatments for community-acquired infections in general medical practice: a cross-sectional study in Occitanie region, France

To assess and analyse the knowledge of recommended antibiotic treatments, focusing on the appropriate drugs and treatment durations for the most common community-acquired infections in general medical practice in Occitanie region, France. A web-based survey was conducted over a 3-month period, from October, 2018 to January, 2019. All participants answered directly through the online platform. For the analysis of overtreatment risk, a score based system was adopted and two scores were produced: the duration score and the treatment score. 413 general practitioners completed the survey. The overall rate of concordance with guidelines in terms of both drug choice and treatment length was 2974/4956 (60%) answers. Diseases with at least 70% good answers included cystitis, group A streptococcal pharyngitis, and bacterial superficial skin infections. Diseases with fewer than 50% good answers included pyelonephritis, dog bite wounds, and community-acquired pneumonia in patients aged ≥ 65 years. Factors associated with the risk of overtreatment were age > 40 years, country setting and hospital employment. Knowledge of treatment durations is satisfactory with 60% of recommendations being met. However, varying levels were observed according to different diseases. This study highlighted a very high rate of adherence when recommendations were clear. In contrast, low levels of adherence were observed when recommendations were ambiguous or when conflicting guidelines existed.

General practice management of COPD patients following acute exacerbations: a qualitative study

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.

General practice care following acute exacerbations of COPD: A survey of Australian general practitioners

Acute exacerbations of COPD (AECOPDs) are one of the leading causes of preventable hospital admissions in Australia. Exacerbations are the strongest predictor for future exacerbations. The period immediately following an exacerbation is a high-risk period for recurrence and critical time to intervene. The aim of this study was to identify current general practice care for patients following an AECOPD in Australia and gain insights into knowledge of evidence-based care. A cross-sectional survey was created and disseminated electronically to Australian general practitioners (GPs). Data were analysed descriptively. Comparisons between groups were made using Chi squared tests. From 64 responses, 47% were familiar with the COPD-X Plan. Only 50% described reviewing patients within seven days of discharge mostly related to a lack of awareness of the hospital admission. 50% of surveyed GPs reported hospital discharge summaries did not provide the information they required. Smoking, immunisation and medications were regularly assessed by >90% respondents at follow-up visits, while referrals to pulmonary rehabilitation, and evaluation of spirometry and oxygen therapy were not prioritised. GPs appear to require support to increase their familiarity with COPD guidelines and inform evidence-based clinical practice. The handover/communication process from hospital to primary care appears an important area for future improvement.

Characterising hospitalisation risk for chronic obstructive pulmonary disease exacerbations: Bedside and outpatient clinic assessments of easily measured variables

OBJECTIVE

To identify the characteristics of people with chronic obstructive pulmonary disease (COPD) who require hospitalisation for exacerbations.

METHODS

People with COPD were recruited either during hospitalisation or from out-patient respiratory medicine clinics. Hospital admissions were tracked throughout the 5-months recruitment period. For participants who were admitted, hospital readmissions were tracked for at least 30 days following discharge. Participants were grouped as either needing; (i) no hospital admission during the study period (no admission; ø-A), (ii) one or more hospital admissions during the study period but no readmission within 30 days of discharge (no rapid readmission; ø-RR) or (iii) one or more hospital admissions with a readmission within 30 days of discharge (rapid readmission; RR).

RESULTS

Compared with the ø-A group (n=211), factors that independently increased the risk of ø-RR (n=146) and/or RR (n=57) group membership were being aged >60 years, identifying as an Indigenous person (relative risk ratio, 95% confidence interval 7.8 [1.8 to 34.0]) and the use of a support person or community service for activities of daily living (1.5 [1.0 to 2.4]. A body mass index ≥25 kg/m2 was protective.

CONCLUSIONS

Variables recorded at the bedside or in clinic provided information on hospitalisation risk.

Implementation of an integrated respiratory palliative care service for patients with advanced lung disease

Objectives This study describes the model of care provided by an integrated respiratory and palliative care service for patients with advanced lung disease, and assesses the potential impact of the service on acute hospital utilisation and cost. Methods This study implemented an integrated specialist care service at a single tertiary teaching hospital in Melbourne, Victoria, Australia. The service provided disease-orientated care, alongside symptom management and advance care planning, and comprised both outpatient clinic (OPC) and home visit (HV) capacity for those with barriers to accessing OPC. Acute hospital utilisation and hospital cost were analysed with a paired t -test 90 days before/after the first physician review. Results Between April 2017 and 2019, 51 patients received 59 HVs, whereas between July 2018 and 2020, 58 patients received 206 OPC reviews. Acute hospital admissions decreased by 51% in the HV cohort (P  < 0.05) and by 46% in the OPC cohort (P  = 0.01); total bed days of acute admissions decreased by 29% in the HV cohort (P  = n.s.), and by 60% in the OPC cohort (P  < 0.05); and specialist outpatient clinic attendances decreased in the OPC cohort by 55% (P  < 0.01). There was a decrease in hospital cost for the HV cohort by 3% (cost savings of A$18 579), and in the OPC cohort by 23% (cost savings of A$109 149). Conclusions This model of care provided specialist respiratory management with seamless integration of palliative care, with the capacity for home visits. There was a decrease in acute hospital utilisation and overall cost savings observed in both HV and OPC cohorts.

The Impact of the Pay-for-Performance Program on the Outcome of COPD Patients in Taiwan After One Year

Objective

To investigate the impact of a multidisciplinary intervention on the clinical outcomes of patients with COPD.

Methods

This study retrospectively extracted the data of patients enrolled in the national pay-for-performance (P4P) program for COPD in four hospitals. Only COPD patients who received regular follow-up for at least one year in the P4P program between September 2018 and December 2020 were included.

Results

A total of 1081 patients were included in this study. Among them, 424 (39.2%), 287 (26.5%), 179 (16.6%), and 191 (17.7%) patients were classified as COPD Groups A, B, C, and D, respectively. Dual therapy with long-acting β2-agonist (LABA)/long-acting muscarinic antagonist (LAMA) was the most used inhaled bronchodilator at baseline (n = 477, 44.1%) patients, followed by LAMA monotherapy (n = 195, 18.0%), triple therapy with inhaled corticosteroid (ICS)/LABA/LAMA (n = 184, 17.0%), and ICS/LABA combination (n = 165, 15.3%). After one year of intervention, 374 (34.6%) and 323 (29.9%) patients had their pre- and post-bronchodilator-forced expiratory volume in one second (FEV1) increase of more than 100 mL. Both the COPD Assessment Test (CAT) and modified British Medical Research Council (mMRC) scores had a mean change of −2.2 ± 5.5 and −0.3 ± 0.9, respectively. The improvement in pulmonary function and symptom score were observed across four groups. The decreased number of exacerbations was only observed in Groups C and D, and not in Groups A and B.

Conclusion

This real-world study demonstrated that the intervention in the P4P program could help improve the clinical outcome of COPD patients. It also showed us a different view on the use of dual therapy, which has a lower cost in Taiwan.

Mapping of Modifiable Factors with Interdisciplinary Chronic Obstructive Pulmonary Disease (COPD) Guidelines Adherence to the Theoretical Domains Framework: A Systematic Review

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.

Therapeutic gases used in balneotherapy and rehabilitation medicine - scientific relevance in the last ten years (2011 – 2020) - Synthetic literature review

ABSTRACT: Background. The medical relevance of therapeutic gases can range from use in burns and stroke victims to hypoxia therapy in children. However, medical gases such as oxygen, hydrogen, helium and xenon have recently come under increased exploration for their potential therapeutic use on various brain disease states, including traumatic brain injuries, hypoxia-ischemia and, cerebral hemorrhages. Objective. This synthetic review aims to rigorously select related articles and identify within their content the main possible uses of therapeutic gases and physiological mechanisms. The objective of this article is to present the various therapeutic mechanisms that have been proposed in the current literature and the medical relevance of various therapeutic gases used in balneotherapy or medical rehabilitation. Methods. To elaborate our synthesis review, we have searched for relevant open access articles in 6 international databases: Cochrane, Elsevier, NCBI/PubMed, NCBI/PMC, PEDro, and ISI Web of Knowledge/Science, published from January 2011 until December 2020. The contextually quested keywords combinations/ syntaxes used specified on this page. The eligible articles were analyzed in detail regarding pathologies addressed by therapeutic gases. All articles with any design (reviews, randomized controlled trials, non-randomized controlled trials, case-control studies, cross-sectional studies), if eligible according to the above-mentioned selection methodology, containing in the title or abstract the above-mentioned combinations, were included in the analysis. Articles were excluded in the second phase if they did not reach the relevance criterion. Results. Our search identified, first, 225 articles. After eliminating the duplicates, remained 180 articles. In the second phase, we applied a relevance criterion. Although our team - including the authors of this paper – have quite long and consistent expertise in achieving systematic literature reviews, the marked heterogeneity of both the item composing the subject we have approached and inherently the wase of presentations in the respective quite vast and diverse domain of medical gases, prevented us to fulfil, at least regarding this initial work, a systematic literature review. Instead, we succeeded to make a hopefully interesting and valuable narrative synthetic-related literature review. At the end of the second phase, 63 articles passed the relevance criterion and were included in this synthetic review. Conclusions. Therapeutic gases are not fully understood and used adequately for sanogenic or medical purposes. More research is needed to fully understand the mechanisms and importance of therapeutic gases. The link between balneotherapy and medical rehabilitation regarding the usage of therapeutical gases emphasises the unity for this medical speciality. Keywords: "Therapeutic gas"/ "Oxygen therapy"/ "Carbon dioxide"/ "CO2 therapy"/ "Carbon monoxide"/ "Mofette"/ "Hydrogen Sulfide"/ "H2S"/ "Helium"/ "Xenon"/ "Ozone therapy"/ "Radon"/ "Hydrogen therapy"/ "Nitric oxide"/ "Heliox" AND "Rehabilitation".

OPTImising the implementation of pulMonary rehAbiLitation in people with chronic obstructive pulmonary disease (the OPTIMAL study): mixed methods study protocol

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a common respiratory condition characterised by dyspnoea during daily life. As the disease progresses, people with COPD can experience poor quality of life, reduced exercise capacity, worsening of symptoms and increased hospital admissions. Pulmonary rehabilitation, which includes exercise training, optimises both psychological and physical function, reduces symptoms and mitigates healthcare utilisation in people with COPD. There is, however, a gap in implementation of pulmonary rehabilitation programs, with global access limited to a small fraction of people with COPD. The overall aim of this study is to gather evidence that will optimise the implementation of pulmonary rehabilitation in people with COPD living in Perth, Western Australia.

METHODS

This is a mixed methods study protocol informed by a critical realist perspective. The study will comprise four phases. In Phase 1, we will quantify target behaviours of healthcare professionals and people with COPD which are related to the implementation of pulmonary rehabilitation at three tertiary hospitals. In Phase 2, we will conduct semi-structured interviews to explore the determinants of these target behaviours from the perspectives of healthcare professionals, people with COPD and their primary support person. In Phase 3, knowledge gained in Phases 1 and 2 will be used by healthcare professionals and people with COPD to co-create, field test and apply strategies that optimise these target behaviours. In Phase 4, we will re-quantify these target behaviours to determine the influence of co-created strategies. The cost effectiveness of implementing the co-created strategies will be explored by an economic analysis.

DISCUSSION

Understanding current clinical practice and the determinants of target behaviours pertaining to the implementation of pulmonary rehabilitation is crucial when developing strategies that successfully bridge the pulmonary rehabilitation implementation gap. If co-created strategies are effective, more people with COPD living in Perth, Western Australia will have access to pulmonary rehabilitation enabling them to derive the health benefits associated with this intervention.