Feasibility of a Novel Real-Time Provider Teaching Intervention in Acute Exacerbation of Chronic Obstructive Pulmonary Disease

Background

It is not known whether an intervention using real-time provider teaching in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) improves provider knowledge and/or patient outcomes.

Objective

To pilot the combination of a novel, real-time provider teaching intervention delivered by subspecialists to Internal Medicine trainees with a traditional patient education and medication reconciliation (PEMR) intervention and to assess the impact of these interventions on provider knowledge regarding COPD and patient care.

Methods

This was a single-center, nonrandomized, quality-improvement study. Patients admitted with AECOPD were prospectively identified between June 19 and November 20, 2019. Patients with asthma, lung cancer, or interstitial lung disease were excluded. The primary care team received a novel intervention featuring in-person, real-time teaching, covering Global Initiative on Chronic Obstructive Lung Disease COPD groups and management, including pulmonary rehabilitation referral. Providers completed a knowledge assessment before and after their real-time teaching session. Provider knowledge scores before and after teaching were compared using McNemar's test. Patients received a traditional PEMR intervention from a nurse practitioner and/or clinical pharmacist. A retrospective chart review was conducted for 50 historical control patients admitted with AECOPD to obtain preintervention rates of discharge on long-acting bronchodilators and referral to pulmonary rehabilitation. The proportions of patients discharged on long-acting bronchodilators and referred to pulmonary rehabilitation in the intervention group were compared with the preintervention historical control patients using chi-square testing.

Results

Seventy-one providers caring for patients with AECOPD received real-time teaching. Postintervention, there was significant improvement in knowledge scores pertaining to Global Initiative on Chronic Obstructive Lung Disease groups and exacerbation risk (81% correct vs. 43% on pretest; P < 0.001) and guideline-directed treatment (83% correct vs. 28% on pretest; P < 0.001). Out of 44 eligible patients, 75% (n = 33 patients) received the PEMR intervention. Ninety percent of patients (n = 40 patients) were discharged on any long-acting inhaler, similar to the group of preintervention control subjects. Pulmonary rehabilitation referrals were made for 50% of patients (n = 22 patients) compared with 6% of preintervention control subjects (n = 3 patients; P < 0.001).

Conclusion

In this single-center quality-improvement study, the combination of a novel, real-time provider teaching intervention and a traditional PEMR intervention improved provider knowledge and was associated with increased referrals to pulmonary rehabilitation.

Continuity of Care Assessment Within a Vertically Integrated Care Management Organization Before and After COPD-Related Exacerbations

Background

There is currently little research describing patient experience and continuity of care immediately prior, during, and following an acute exacerbation of chronic obstructive pulmonary disease (AECOPD). This analysis examined clinical characteristics, chronic obstructive pulmonary disease (COPD)‑related medication patterns and outpatient visits before and after an AECOPD.

Methods

This retrospective analysis used electronic health records, medical claims, and pharmacy dispensing data for patients within the Kaiser Permanente Northwest Health System. Patients with ≥1 AECOPD between January 1, 2015 and December 31, 2017 were identified. The most recent AECOPD was considered the index date. An AECOPD was defined as an inpatient hospitalization with a primary diagnosis of COPD, or respiratory failure with a secondary diagnosis of COPD, or an outpatient visit with a primary diagnosis of COPD and dispensing of respiratory-related antibiotics and/or oral corticosteroids ±5 days of the visit. Eligible patients were: ≥40 years old; ≥2 encounters within 12 months of each other or ≥1 hospitalization with primary or secondary COPD diagnosis, chronic bronchitis, or emphysema prior to index; and continuously enrolled ±90 days relative to index. COPD-related inhaled maintenance medication, rescue inhalers, oral corticosteroid use, and ambulatory visits were assessed 90-days pre- and post-index.

Results

There were 2829 patients included (mean [standard deviation] age: 69.0 [10.5] years) who had an AECOPD (7% severe; 93% moderate). The percentage of patients on inhaled maintenance therapy increased from 60.6% pre-AECOPD to 68.8% post-AECOPD and increased from 60.0% to 87.4% among patients who experienced a severe AECOPD. COPD-related ambulatory visits increased more than four-fold for primary care and more than doubled for pulmonologist visits in the post-AECOPD period.

Conclusion

The low proportion of patients observed with changes to controller and rescue medication (particularly following a moderate AECOPD), yet higher utilization of COPD-related ambulatory visits before and after an AECOPD suggests that there is opportunity to improve pharmacotherapy management.

Redundant medication use during acute exacerbation of chronic obstructive pulmonary disease in hospitalized patients

Background Few clinical studies have evaluated redundant therapy during an exacerbation of chronic obstructive pulmonary disease in hospitalized patients, but clinical practice guidelines endorse this practice. Objective The aim of this study is to measure the frequency of redundant therapy and explore its association with clinical outcomes, adverse effects, and cost among adults hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Setting Six hospitals within an academic health system in the United States. Method A retrospective cohort study of adults with a principal diagnosis of acute exacerbation of chronic obstructive pulmonary disease between January 1, 2016 and March 31, 2016 was performed. Main outcome measure The primary outcome was the proportion of patients who received redundant therapy during inpatient management of acute exacerbation of chronic obstructive pulmonary disease. Results Overall, 137 patients were included and 99 (72.7%) received redundant medication therapy. Redundant therapy was not associated with significant differences in clinical outcomes such as median hospital length of stay, 30-day readmission, tachycardia, thrush, psychiatric symptoms or urinary retention in the univariate or multivariate analyses. The median medication acquisition cost per patient was nearly 11-fold higher among those receiving redundant medication therapy [$135.14 (49.21) vs 12.50 (17.02); p < 0.001]. After controlling for confounding variables using multivariate linear regression, the cost of redundant medication therapy was $50.20 higher on average (p < 0.001). Conclusion Redundant inhaled therapy for acute exacerbation of chronic obstructive pulmonary disease in the hospital setting was not associated with improved clinical outcomes or more adverse effects but did significantly increase medication cost. The findings of this study should be considered exploratory.

Nonantibiotic Pharmacological Treatment of Severe Chronic Obstructive Pulmonary Disease Exacerbations

Severe, acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are a rapid deterioration of the respiratory symptoms of patients with COPD, requiring hospital admission and escalation of pharmacological and nonpharmacological care including the more severe cases of respiratory failure and admission to an intensive care unit (ICU). These events severely impact patients' quality of life and prognosis. This review will describe the nonantibiotic, pharmacological treatment options available for critically ill patients with AECOPD. The aim of treatment is to alleviate symptoms, improve patient's functional and respiratory status, reduce mortality, reduce the risk or the duration of invasive mechanical ventilation, and prevent reexacerbations. Inhaled bronchodilators (i.e., short-acting β2-agonists and anticholinergics) and systemic corticosteroids are the main drugs used in the treatment of AECOPD. These drugs are also used in the treatment of stable COPD and in the treatment of AECOPD patients in the non-ICU or community setting. Other drugs are essentially only used in the ICU setting such as inhaled anesthetic agents, ketamine, intravenous methylxanthines, and magnesium. Finally, recently developed drugs, such as the specific phosphodiesterase-4 inhibitors, may play a role in the prevention of relapsing AECOPD following a critical event than the treatment of the exacerbation itself. Although they significantly improve the survival of critically ill patients with AECOPD, none of available drugs, alone or combined, is able to significantly modify the prognosis of patients with COPD. This remains an open challenge for the current and future generations of researchers and clinicians.

Medication management patterns among Medicare beneficiaries with chronic obstructive pulmonary disease who initiate nebulized arformoterol treatment

Purpose: Global evidence-based treatment strategies for chronic obstructive pulmonary disease (COPD) recommend using long-acting bronchodilators (LABDs) as maintenance therapy. However, COPD patients are often undertreated. We examined COPD treatment patterns among Medicare beneficiaries who initiated arformoterol tartrate, a nebulized long-acting beta2 agonist (LABA), and identified the predictors of initiation. Methods: Using a 100% sample of Medicare administrative data, we identified beneficiaries with a COPD diagnosis (ICD-9 490-492.xx, 494.xx, 496.xx) between 2010 and 2014 who had ≥1 year of continuous enrollment in Parts A, B, and D, and ≥2 COPD-related outpatient visits within 30 days or ≥1 hospitalization(s). After applying inclusion/exclusion criteria, three cohorts were identified: (1) study group beneficiaries who received nebulized arformoterol (n=11,886), (2) a subset of the study group with no LABD use 90 days prior to initiating arformoterol (n=5,542), and (3) control group beneficiaries with no nebulized LABA use (n=220,429). Logistic regression was used to evaluate predictors of arformoterol initiation. Odds ratios (ORs), 95% confidence intervals (CIs), and p values were computed. Results: Among arformoterol users, 47% (n=5,542) had received no LABDs 90 days prior to initiating arformoterol. These beneficiaries were being treated with a nebulized (50%) or inhaled (37%) short-acting bronchodilator or a systemic corticosteroid (46%), and many received antibiotics (37%). Compared to controls, beneficiaries who initiated arformoterol were significantly more likely to have had an exacerbation, a COPD-related hospitalization, and a pulmonologist or respiratory therapist visit prior to initiation (all p<0.05). Beneficiaries with moderate/severe psychiatric comorbidity or dual-eligible status were significantly less likely to initiate arformoterol, as compared to controls (all p<0.05). Conclusion: Medicare beneficiaries who initiated nebulized arformoterol therapy had more exacerbations and hospitalizations than controls 90 days prior to initiation. Findings revealed inadequate use of maintenance medications, suggesting a lack of compliance with evidence-based treatment guidelines.

In vivo experimental models of infection and disease

Human and animal models continue to play a crucial role in research to understand host immunity to rhinovirus (RV) and identify disease mechanisms. Human models have provided direct evidence that RV infection is capable of exacerbating chronic respiratory diseases and identified immunological processes that correlate with clinical disease outcomes. Mice are the most commonly used nonhuman experimental RV infection model. Although semipermissive, under defined experimental conditions sufficient replication occurs to induce host immune responses that recapitulate immunity and disease during human infection. The capacity to use genetically modified mouse strains and drug interventions has shown the mouse model to be an invaluable research tool defining causal relationships between host immunity and disease and supporting development of new treatments. Used in combination the insights achieved from human and animal experimental infection models provide complementary insights into RV biology and yield novel therapeutic options to reduce the burden of RV-induced disease.

Management of severe acute exacerbations of COPD: an updated narrative review

Background

Patients with chronic obstructive pulmonary disease (COPD) may experience an acute worsening of respiratory symptoms that results in additional therapy; this event is defined as a COPD exacerbation (AECOPD). Hospitalization for AECOPD is accompanied by a rapid decline in health status with a high risk of mortality or other negative outcomes such as need for endotracheal intubation or intensive care unit (ICU) admission. Treatments for AECOPD aim to minimize the negative impact of the current exacerbation and to prevent subsequent events, such as relapse or readmission to hospital.

Main body

In this narrative review, we update the scientific evidence about the in-hospital pharmacological and non-pharmacological treatments used in the management of a severe AECOPD. We review inhaled bronchodilators, steroids, and antibiotics for the pharmacological approach, and oxygen, high flow nasal cannulae (HFNC) oxygen therapy, non-invasive mechanical ventilation (NIMV) and pulmonary rehabilitation (PR) as non-pharmacological treatments. We also review some studies of non-conventional drugs that have been proposed for severe AECOPD.

Conclusion

Several treatments exist for severe AECOPD patients requiring hospitalization. Some treatments such as steroids and NIMV (in patients admitted with a hypercapnic acute respiratory failure and respiratory acidosis) are supported by strong evidence of their efficacy. HFNC oxygen therapy needs further prospective studies. Although antibiotics are preferred in ICU patients, there is a lack of evidence regarding the preferred drugs and optimal duration of treatment for non-ICU patients. Early rehabilitation, if associated with standard treatment of patients, is recommended due to its feasibility and safety. There are currently few promising new drugs or new applications of existing drugs.

Searching for biomarkers of chronic obstructive pulmonary disease using proteomics: The current state

Detection of proteins which may be potential biomarkers of disorders represents a big step forward in understanding the molecular mechanisms that underlie pathological processes. In this context proteomics plays the important role of opening a path for the identification of molecular signatures that can potentially assist in early diagnosis of several clinical disturbances. Aim of this report is to provide an overview of the wide variety of proteomic strategies that have been applied to the investigation of chronic obstructive pulmonary disease (COPD), a severe disorder that causes an irreversible damage to the lungs and for which there is no cure yet. The results in this area published over the past decade show that proteomics indeed has the ability of monitoring alterations in expression profiles of proteins from fluids/tissues of patients affected by COPD and healthy controls. However, these data also suggest that proteomics, while being an attractive tool for the identification of novel pathological mediators of COPD, remains a technique mainly generated and developed in research laboratories. Great efforts dedicated to the validation of these biological signatures will result in the proof of their clinical utility.