1
|
Ghosh R, Das M, Mondal S, Banerjee A, Roy L, Das AK, Pal D, Bhattacharya SS, Bhattacharyya M, Pal SK. Targeted Redox Balancing through Pulmonary Nanomedicine Delivery Reverses Oxidative Stress Induced Lung Inflammation. ChemMedChem 2024; 19:e202400037. [PMID: 38459687 DOI: 10.1002/cmdc.202400037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 03/03/2024] [Accepted: 03/08/2024] [Indexed: 03/10/2024]
Abstract
Non-invasive delivery of drugs is important for the reversal of respiratory diseases essentially by-passing metabolic pathways and targeting large surface area of drug absorption. Here, we study the inhalation of a redox nano medicine namely citrate functionalized Mn3O4 (C-Mn3O4) duly encapsulated in droplet evaporated aerosols for the balancing of oxidative stress generated by the exposure of Chromium (VI) ion, a potential lung carcinogenic agent. Our optical spectroscopic in-vitro experiments demonstrates the efficacy of redox balancing of the encapsulated nanoparticles (NP) for the maintenance of a homeostatic condition. The formation of Cr-NP complex as an excretion of the heavy metal is also demonstrated through optical spectroscopic and high resolution transmission optical microscopy (HRTEM). Our studies confirm the oxidative stress mitigation activity of the Cr-NP complex. A detailed immunological assay followed by histopathological studies and assessment of mitochondrial parameters in pre-clinical mice model with chromium (Cr) induced lung inflammation establishes the mechanism of drug action to be redox-buffering. Thus, localised delivery of C-Mn3O4 NPs in the respiratory tract via aerosols can act as an effective nanotherapeutic agent against oxidative stress induced lung inflammation.
Collapse
Affiliation(s)
- Ria Ghosh
- Department of Biochemistry, University of Calcutta, 35, Ballygunge Circular Rd, Kolkata, 700019, India
- Department of Chemical and Biological Sciences, S. N. Bose National Centre for Basic Sciences, Block JD, Sector III, Salt Lake, Kolkata, 700 106, India
| | - Monojit Das
- Department of Zoology, Vidyasagar University, Rangamati, Midnapore, 721102, India
- Department of Zoology, Uluberia College, University of Calcutta, Uluberia, Howrah, 711315, India
| | - Susmita Mondal
- Department of Chemical and Biological Sciences, S. N. Bose National Centre for Basic Sciences, Block JD, Sector III, Salt Lake, Kolkata, 700 106, India
| | - Amrita Banerjee
- Department of Physics, Jadavpur University, 188, Raja S.C. Mallick Rd, Kolkata, 700032, India
| | - Lopamudra Roy
- Department of Applied Optics and Photonics, University of Calcutta, 92, Acharya Prafulla Chandra Rd, Machuabazar, Kolkata, 700009, India
| | - Anjan Kumar Das
- Department of Pathology, Coochbehar Government Medical College and Hospital, Kotwali, Coochbehar, 736101, India
| | - Debasish Pal
- Department of Zoology, Uluberia College, University of Calcutta, Uluberia, Howrah, 711315, India
| | | | - Maitree Bhattacharyya
- Department of Biochemistry, University of Calcutta, 35, Ballygunge Circular Rd, Kolkata, 700019, India
| | - Samir Kumar Pal
- Department of Chemical and Biological Sciences, S. N. Bose National Centre for Basic Sciences, Block JD, Sector III, Salt Lake, Kolkata, 700 106, India
| |
Collapse
|
2
|
Pitchai A, Buhman K, Shannahan JH. Lipid mediators of inhalation exposure-induced pulmonary toxicity and inflammation. Inhal Toxicol 2024; 36:57-74. [PMID: 38422051 PMCID: PMC11022128 DOI: 10.1080/08958378.2024.2318389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 02/07/2024] [Indexed: 03/02/2024]
Abstract
Many inhalation exposures induce pulmonary inflammation contributing to disease progression. Inflammatory processes are actively regulated via mediators including bioactive lipids. Bioactive lipids are potent signaling molecules involved in both pro-inflammatory and resolution processes through receptor interactions. The formation and clearance of lipid signaling mediators are controlled by multiple metabolic enzymes. An imbalance of these lipids can result in exacerbated and sustained inflammatory processes which may result in pulmonary damage and disease. Dysregulation of pulmonary bioactive lipids contribute to inflammation and pulmonary toxicity following exposures. For example, inhalation of cigarette smoke induces activation of pro-inflammatory bioactive lipids such as sphingolipids, and ceramides contributing to chronic obstructive pulmonary disease. Additionally, exposure to silver nanoparticles causes dysregulation of inflammatory resolution lipids. As inflammation is a common consequence resulting from inhaled exposures and a component of numerous diseases it represents a broadly applicable target for therapeutic intervention. With new appreciation for bioactive lipids, technological advances to reliably identify and quantify lipids have occurred. In this review, we will summarize, integrate, and discuss findings from recent studies investigating the impact of inhaled exposures on pro-inflammatory and resolution lipids within the lung and their contribution to disease. Throughout the review current knowledge gaps in our understanding of bioactive lipids and their contribution to pulmonary effects of inhaled exposures will be presented. New methods being employed to detect and quantify disruption of pulmonary lipid levels following inhalation exposures will be highlighted. Lastly, we will describe how lipid dysregulation could potentially be addressed by therapeutic strategies to address inflammation.
Collapse
Affiliation(s)
- Arjun Pitchai
- School of Health Sciences, College of Health and Human Sciences, Purdue University, West Lafayette, IN, United States
| | - Kimberly Buhman
- Department of Nutrition, College of Health and Human Sciences, Purdue University, West Lafayette, IN, United States
| | - Jonathan H. Shannahan
- School of Health Sciences, College of Health and Human Sciences, Purdue University, West Lafayette, IN, United States
| |
Collapse
|
3
|
Wu WB, Lee IT, Lin YJ, Wang SY, Hsiao LD, Yang CM. Silica Nanoparticles Shed Light on Intriguing Cellular Pathways in Human Tracheal Smooth Muscle Cells: Revealing COX-2/PGE 2 Production through the EGFR/Pyk2 Signaling Axis. Biomedicines 2024; 12:107. [PMID: 38255212 PMCID: PMC10813532 DOI: 10.3390/biomedicines12010107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 01/02/2024] [Accepted: 01/03/2024] [Indexed: 01/24/2024] Open
Abstract
The use of manufactured silica nanoparticles (SiNPs) has become widespread in everyday life, household products, and various industrial applications. While the harmful effects of crystalline silica on the lungs, known as silicosis or chronic pulmonary diseases, are well understood, the impact of SiNPs on the airway is not fully explored. This study aimed to investigate the potential effects of SiNPs on human tracheal smooth muscle cells (HTSMCs). Our findings revealed that SiNPs induced the expression of cyclooxygenase-2 (COX-2) mRNA/protein and the production of prostaglandin E2 (PGE2) without causing cytotoxicity. This induction was transcription-dependent, as confirmed by cell viability assays and COX-2 luciferase reporter assays. Further analysis, including Western blot with pharmacological inhibitors and siRNA interference, showed the involvement of receptor tyrosine kinase (RTK) EGF receptor (EGFR), non-RTK Pyk2, protein kinase Cα (PKCα), and p42/p44 MAPK in the induction process. Notably, EGFR activation initiated cellular signaling that led to NF-κB p65 phosphorylation and translocation into the cell nucleus, where it bound and stimulated COX-2 gene transcription. The resulting COX-2 protein triggered PGE2 production and secretion into the extracellular space. Our study demonstrated that SiNPs mediate COX-2 up-regulation and PGE2 secretion in HTSMCs through the sequential activation of the EGFR/Pyk2/PKCα/p42/p44MAPKs-dependent NF-κB signaling pathway. Since PGE2 can have both physiological bronchodilatory and anti-inflammatory effects, as well as pathological pro-inflammatory effects, the increased PGE2 production in the airway might act as a protective compensatory mechanism and/or a contributing factor during airway exposure to SiNPs.
Collapse
Affiliation(s)
- Wen-Bin Wu
- School of Medicine, Fu Jen Catholic University, New Taipei City 242062, Taiwan;
- Graduate Institute of Biomedical and Pharmaceutical Science, Fu Jen Catholic University, New Taipei City 242062, Taiwan; (S.-Y.W.); (L.-D.H.)
| | - I-Ta Lee
- School of Dentistry, College of Oral Medicine, Taipei Medical University, Taipei 110301, Taiwan;
| | - Yan-Jyun Lin
- Institute of Translational Medicine and New Drug Development, College of Medicine, China Medical University, Taichung 406040, Taiwan;
| | - Ssu-Ying Wang
- Graduate Institute of Biomedical and Pharmaceutical Science, Fu Jen Catholic University, New Taipei City 242062, Taiwan; (S.-Y.W.); (L.-D.H.)
| | - Li-Der Hsiao
- Graduate Institute of Biomedical and Pharmaceutical Science, Fu Jen Catholic University, New Taipei City 242062, Taiwan; (S.-Y.W.); (L.-D.H.)
| | - Chuen-Mao Yang
- Graduate Institute of Biomedical and Pharmaceutical Science, Fu Jen Catholic University, New Taipei City 242062, Taiwan; (S.-Y.W.); (L.-D.H.)
| |
Collapse
|
4
|
Chow R, So OW, Im JHB, Chapman KR, Orchanian-Cheff A, Gershon AS, Wu R. Predictors of Readmission, for Patients with Chronic Obstructive Pulmonary Disease (COPD) - A Systematic Review. Int J Chron Obstruct Pulmon Dis 2023; 18:2581-2617. [PMID: 38022828 PMCID: PMC10664718 DOI: 10.2147/copd.s418295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 08/08/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Chronic obstructive pulmonary disease (COPD) is the third-leading cause of death globally and is responsible for over 3 million deaths annually. One of the factors contributing to the significant healthcare burden for these patients is readmission. The aim of this review is to describe significant predictors and prediction scores for all-cause and COPD-related readmission among patients with COPD. Methods A search was conducted in Ovid MEDLINE, Ovid Embase, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials, from database inception to June 7, 2022. Studies were included if they reported on patients at least 40 years old with COPD, readmission data within 1 year, and predictors of readmission. Study quality was assessed. Significant predictors of readmission and the degree of significance, as noted by the p-value, were extracted for each study. This review was registered on PROSPERO (CRD42022337035). Results In total, 242 articles reporting on 16,471,096 patients were included. There was a low risk of bias across the literature. Of these, 153 studies were observational, reporting on predictors; 57 studies were observational studies reporting on interventions; and 32 were randomized controlled trials of interventions. Sixty-four significant predictors for all-cause readmission and 23 for COPD-related readmission were reported across the literature. Significant predictors included 1) pre-admission patient characteristics, such as male sex, prior hospitalization, poor performance status, number and type of comorbidities, and use of long-term oxygen; 2) hospitalization details, such as length of stay, use of corticosteroids, and use of ventilatory support; 3) results of investigations, including anemia, lower FEV1, and higher eosinophil count; and 4) discharge characteristics, including use of home oxygen and discharge to long-term care or a skilled nursing facility. Conclusion The findings from this review may enable better predictive modeling and can be used by clinicians to better inform their clinical gestalt of readmission risk.
Collapse
Affiliation(s)
- Ronald Chow
- University Health Network, University of Toronto, Toronto, ON, Canada
| | - Olivia W So
- University Health Network, University of Toronto, Toronto, ON, Canada
| | - James H B Im
- The Hospital for Sick Children, Toronto, ON, Canada
| | - Kenneth R Chapman
- University Health Network, University of Toronto, Toronto, ON, Canada
| | | | - Andrea S Gershon
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Robert Wu
- University Health Network, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
5
|
Rojas JC, Chokkara S, Zhu M, Lindenauer PK, Press VG. Care Quality for Patients with Chronic Obstructive Pulmonary Disease in the Readmission Penalty Era. Am J Respir Crit Care Med 2023; 207:29-37. [PMID: 35916652 PMCID: PMC9952855 DOI: 10.1164/rccm.202203-0496oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 08/02/2022] [Indexed: 02/03/2023] Open
Abstract
Rationale: Chronic obstructive pulmonary disease (COPD) is the fifth-leading cause of admissions and third-leading cause of readmissions among U.S. adults. Recent policies instituted financial penalties for excessive COPD readmissions. Objectives: To evaluate changes in the quality of care for patients hospitalized for COPD after implementation of the Hospital Readmissions Reduction Program (HRRP). Methods: We conducted a retrospective cohort study of patients older than 40 years of age hospitalized for COPD across 995 U.S. hospitals (Premier Healthcare Database). Measurements and Main Results: Quality of care before and after HRRP implementation was measured via adherence to recommended inpatient care treatments for acute exacerbations of COPD (recommended care, nonrecommended care, "ideal care" [all recommended and no nonrecommended care]). We included 662,842 pre-HRRP (January 2010-September 2014) and 285,508 post-HRRP (October 2014-December 2018) admissions. Recommended care increased at a rate of 0.16% per month pre-HRRP and 0.01% per month post-HRRP (P < 0.001). Nonrecommended care decreased at a rate of 0.15% per month pre-HRRP and 0.13% per month post-HRRP. Ideal care increased at a rate of 0.24% per month pre-HRRP and 0.11% per month post-HRRP (P < 0.001). Conclusions: The pre-HRRP trends toward improving care quality for inpatient COPD care slowed after HRRP implementation. This suggests that financial penalties for readmissions did not stimulate higher quality of care for patients hospitalized with COPD. It remains unclear what policies or approaches will be effective to ensure high care quality for patients hospitalized with COPD exacerbations.
Collapse
Affiliation(s)
- Juan C. Rojas
- Department of Medicine, University of Chicago, Chicago, Illinois; and
| | - Sukarn Chokkara
- Department of Medicine, University of Chicago, Chicago, Illinois; and
| | - Mengqi Zhu
- Department of Medicine, University of Chicago, Chicago, Illinois; and
| | - Peter K. Lindenauer
- Department of Healthcare Delivery and Population Sciences, University of Massachusetts Chan Medical School – Baystate, Springfield, Massachusetts
| | - Valerie G. Press
- Department of Medicine, University of Chicago, Chicago, Illinois; and
| |
Collapse
|
6
|
Kendra ME, Kakwani A, Uppala A, Mansukhani R, Pigott DK, Soubra M, Jacobson J, Cerrone F, Farrell M, Chiu S, Lieder K, Tonzola D, Shah CV, Cherian S. Impact of a COPD care bundle on hospital readmission rates. J Am Pharm Assoc (2003) 2023; 63:269-274. [PMID: 36335072 DOI: 10.1016/j.japh.2022.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 09/16/2022] [Accepted: 10/04/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is one of the leading causes of mortality worldwide and contributes considerably to morbidity and health care costs. In October 2014, the Centers for Medicare and Medicaid Services introduced financial penalties followed by bundled payments for care improvement initiatives in patients hospitalized with COPD. OBJECTIVES This study seeks to evaluate whether an evidence-based interprofessional COPD care bundle focused on inpatient, transitional, and outpatient care would reduce hospital readmission rates. METHODS A pre- and postintervention analysis comparing readmission rates after a hospitalization for COPD in subjects who received standard of care versus an interprofessional team-led COPD care bundle was conducted. The primary outcome was 30-day all-cause readmissions; secondary outcomes included 60- and 90-day all-cause readmissions, escalation of pharmacotherapy, interprofessional interventions, and hospital length of stay. RESULTS A total of 189 subjects were included in the control arm and 127 subjects in the COPD care bundle arm. A reduction in 30-day all-cause readmissions between the control arm and COPD care bundle arm (21.7% vs. 11.8%, P = 0.017) was seen. Similar outcomes were seen in 60-day (18% vs. 8.7%, P = 0.013) and 90-day all-cause readmissions (19.6% vs. 4.7%, P < 0.001). Pharmacists consulted with 68.5% of subjects and assisted with access to outpatient medications in 45.7% of subjects in the COPD care bundle arm. An escalation in maintenance therapy occurred more often in the COPD care bundle arm (22.2% vs. 44.9%, P < 0.001) than the control arm. CONCLUSIONS An interprofessional team-led COPD care bundle resulted in significant reductions in all-cause hospital readmissions at 30, 60, and 90 days.
Collapse
|
7
|
Kwok J. Evaluating a Pharmacist-Initiated Care Bundle for Patients with Chronic Obstructive Pulmonary Disease. Can J Hosp Pharm 2022; 75:302-308. [PMID: 36246446 PMCID: PMC9524560 DOI: 10.4212/cjhp.3226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Background Chronic obstructive pulmonary disease (COPD) is a cause of significant morbidity and mortality, and management of patients with this complex disease remains a challenge. Pharmacists work within an interdisciplinary health care team to coordinate services and ensure that standards of care are met. A pharmacist-initiated care bundle provided in the outpatient setting has shown promising results in improving COPD management. Objective To evaluate, in the acute care setting, the effectiveness of a pharmacist-initiated COPD care bundle in improving compliance with health care measures known to improve outcomes in patients with COPD. Methods This retrospective chart review included patients with acute exacerbation of COPD admitted from May 14, 2019, to February 29, 2020. Completion rates for the 6 individual components of the COPD care bundle were compared between patients who did and did not receive the pharmacist-initiated intervention. A subgroup of 22 patients received the following additional interventions: documentation of the modified Medical Research Council score, assessment of COPD medications, and vaccination review and administration. Results A total of 106 patients were included in the analysis, 53 patients in each of the control and intervention groups. The pharmacist-initiated intervention increased completion rates for the overall COPD care bundle from 2% to 17% (p = 0.003), for provision of the COPD flare-up action plan from 4% to 79% (p < 0.001), and for provision of smoking cessation education from 0% to 36% (p = 0.04); however, there was no significant difference in assessment by a respiratory therapist. For the subgroup that received additional interventions, vaccination reviews were conducted for 21 (96%) of the 22 patients, which led to 9 (41%) receiving a guideline-recommended vaccine. Conclusions Pharmacist involvement in initiation of the care bundle significantly increased completion rates for the activities included in the care bundle.
Collapse
|
8
|
Kayalar O, Oztay F, Yildirim M, Ersen E. Dysregulation of E-cadherin in pulmonary cell damage related with COPD contributes to emphysema. Toxicol Ind Health 2022; 38:330-341. [DOI: 10.1177/07482337221095638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Air pollution, especially at chronic exposure to high concentrations, is a respiratory risk factor for the development of chronic obstructive pulmonary disease (COPD). E-cadherin, a cell–cell adhesion protein, is involved in the integrity of the alveolar epithelium. Causes of E-cadherin decreases in emphysematous areas with pulmonary cell damage related to COPD are not well understood. We aimed to determine the molecules causing the decrease of E-cadherin and interactions between these molecules. In emphysematous and non-emphysematous areas of lungs from COPD patients (n = 35), levels of E-cadherin, HDACs, Snail, Zeb1, active-β-catenin, p120ctn, and Kaiso were determined by using Western Blot. The interactions of HDAC1, HDAC2, and p120ctn with transcription co-activators and Kaiso were examined by co-immunoprecipitation experiments. The methylation status of the CDH1 promoter was investigated. E-cadherin, Zeb1, Kaiso, and active-β-catenin were decreased in emphysema, while HDAC1, HDAC2, and p120ctn2 were increased. Snail, Zeb1, Twist, active-β-catenin, Kaiso, and p120ctn co-precipitated with HDAC1 and HDAC2. E-cadherin, Kaiso, and active-β-catenin co-precipitated with p120ctn. HDAC1–Snail and HDAC2–Kaiso interactions were increased in emphysema, but p120ctn-E-cadherin interaction was decreased. The results show that HDAC1–Snail and HDAC2–Kaiso interactions are capable of decreasing the E-cadherin in emphysema. The decreased interaction of p120ctn/E-cadherin leads to E-cadherin destruction. The decreased E-cadherin and its induced degradation in pneumocytes cause impaired repair and disintegrity of the epithelium. Approaches to suppress HDAC1–Snail and HDAC2–Kaiso interactions may help the protection of alveolar epithelial integrity by increasing the E-cadherin stability in pneumocytes.
Collapse
Affiliation(s)
- Ozgecan Kayalar
- Science Faculty, Department of Biology, Istanbul University, Istanbul, Turkey
- School of Medicine, Koc University Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Turkey
| | - Fusun Oztay
- Science Faculty, Department of Biology, Istanbul University, Istanbul, Turkey
| | - Merve Yildirim
- Science Faculty, Department of Biology, Istanbul University, Istanbul, Turkey
| | - Ezel Ersen
- Department of Chest Surgery, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| |
Collapse
|
9
|
Tsao M, Laikijrung C, Tran A, Pon T, Roach D, Liu B, Le K. Optimizing quality of care in patients admitted with chronic obstructive pulmonary disease exacerbation. Chron Respir Dis 2022; 19:14799731211073348. [PMID: 35041553 PMCID: PMC8777359 DOI: 10.1177/14799731211073348] [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] [Indexed: 11/16/2022] Open
Abstract
Objectives: Adherence to Global Initiative for Chronic Obstructive
Lung Disease (GOLD) guidelines in acute exacerbation of chronic obstructive
pulmonary disease (AECOPD) treatment is variable in the inpatient setting. This
study evaluates appropriateness of therapy in patients admitted to an academic
medical center for AECOPD. Methods: This was a single-center,
retrospective, observational study. The primary endpoint was proportion of
patients who received appropriate AECOPD treatment within 24 h. Secondary
endpoints included mean length of stay (LOS) and time to administration (TTA) of
pharmacotherapy, 30-day readmission rates, and proportions of various ancillary
care received. Data were analyzed using descriptive and inferential statistics.
Results: Of 533 screened admissions, 163 were included. Of
those included, 55% (n = 90) received guideline-based therapy
within 24 h of presentation. This group had significantly shorter mean LOS (3.48
± 2.61 vs 4.53 ± 3.40 days, p = .026), fewer COPD-related
readmissions (7 vs 14, p = .036), and numerically fewer
all-cause readmissions (14 vs 19, p = .11). Mean LOS and TTA
were 3.95 ± 3.02 days and 8.47 ± 12.77 h, respectively. Discussion:
Timely and guideline-based delivery of medications was associated with shorter
length of stay and fewer COPD-related readmissions. Establishing a standardized
care plan through order set implementation may be one strategy to improve care
and outcomes in AECOPD patients.
Collapse
Affiliation(s)
- Megan Tsao
- Department of Pharmacy, 8785University of California, San Francisco, San Francisco, CA, USA
| | - Chananid Laikijrung
- Department of Pharmacy, 8785University of California, San Francisco, San Francisco, CA, USA
| | - Alan Tran
- Department of Pharmacy, 8785University of California, San Francisco, San Francisco, CA, USA
| | - Tiffany Pon
- Department of Pharmacy, 8785University of California, San Francisco, San Francisco, CA, USA.,Department of Pharmacy, University of California, Davis Medical Center, Sacramento, CA, USA
| | - Denise Roach
- Department of Pharmacy, 8785University of California, San Francisco, San Francisco, CA, USA.,Department of Pharmacy, University of California, Davis Medical Center, Sacramento, CA, USA
| | - Bo Liu
- Department of Pharmacy, 8785University of California, San Francisco, San Francisco, CA, USA.,Department of Pharmacy, University of California, Davis Medical Center, Sacramento, CA, USA
| | - Kathie Le
- Department of Pharmacy, 8785University of California, San Francisco, San Francisco, CA, USA.,Department of Pharmacy, University of California, Davis Medical Center, Sacramento, CA, USA
| |
Collapse
|
10
|
Wirth IM, Penz ED, Marciniuk DD. Examination of COPD management in patients hospitalized with an acute exacerbation of COPD. CANADIAN JOURNAL OF RESPIRATORY, CRITICAL CARE, AND SLEEP MEDICINE 2022. [DOI: 10.1080/24745332.2020.1719941] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Ingrid M. Wirth
- Division of Respirology, Critical Care, and Sleep Medicine, Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Erika D. Penz
- Division of Respirology, Critical Care, and Sleep Medicine, Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
- Respiratory Research Center, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Darcy D. Marciniuk
- Division of Respirology, Critical Care, and Sleep Medicine, Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
- Respiratory Research Center, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| |
Collapse
|
11
|
Potential to Decrease Hospital Readmission Reduction Program Penalty Through Pharmacist Discharge Visits. J Healthc Manag 2022; 67:25-37. [PMID: 34982747 DOI: 10.1097/jhm-d-20-00164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
SUMMARY
Collapse
|
12
|
Myers LC, Cash R, Liu VX, Camargo CA. Reducing Readmissions for Chronic Obstructive Pulmonary Disease in Response to the Hospital Readmissions Reduction Program. Ann Am Thorac Soc 2021; 18:1506-1513. [PMID: 33476524 PMCID: PMC8489864 DOI: 10.1513/annalsats.202007-786oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 01/21/2021] [Indexed: 11/20/2022] Open
Abstract
Rationale: In August 2013, the Hospital Readmission Reduction Program announced financial penalties on hospitals with higher than expected risk-adjusted 30-day readmission rates for Medicare beneficiaries hospitalized for chronic obstructive pulmonary disease (COPD) exacerbation. In October 2014, penalties were imposed. We hypothesized that penalties would be associated with decreased readmissions after COPD hospitalizations. Objectives: To determine whether the announcement and enactment of financial penalties for COPD were associated with decreases in hospital readmissions for COPD. Methods: We used data from California's Office of Statewide Health Planning and Development to examine unplanned 30-day all-cause and COPD-related readmissions after COPD hospitalization. The preannouncement period was January 2010 to July 2013. The postannouncement period was August 2013 to September 2014. The postenactment period was October 2014 to December 2017. Using interrupted time series, we investigated the immediate change after the intervention (level change) and differences in the preintervention and postintervention trends (slope change). Results: We identified 333,429 index hospitalizations for COPD from 449 California hospitals. Overall, 69% of patients had Medicare insurance. For all-cause readmissions, the level change at announcement was 0.16% (95% confidence interval [CI], -1.07 to 1.38; P = 0.80); the change in slope between preannouncement and postannouncement periods was -0.01% (95% CI, -0.15 to 0.13; P = 0.92). The level change at enactment was 0.29% (95% CI, -1.11 to 1.69; P = 0.68); the change in slope between postannouncement and postenactment was 0.04% (95% CI, -0.10 to 0.18; P = 0.57). For patients with COPD-related readmissions, the level change at the time of the announcement was 0.09% (95% CI, -0.68 to 0.85; P = 0.83); the change in slope was 0.003% (95% CI, -0.08 to 0.09; P = 0.94). The level change at the time of the enactment was 0.22% (95% CI, -0.69 to 1.12; P = 0.64); the change in slope was -0.02% (95% CI, -0.10 to 0.07; P = 0.72). Conclusions: We did not detect decreases in either all-cause or COPD-related readmission rates at either time point. Although this would suggest that the Hospital Readmission Reduction Program penalty was ineffective for COPD, COPD readmissions had decreased at an earlier time point (October 2012) when penalties were announced for conditions other than COPD. Based on this, we believe early, broad interventions decreased readmissions, such that no difference was seen at this later time points despite institution of COPD-specific penalties.
Collapse
Affiliation(s)
- Laura C. Myers
- Division of Research, Kaiser Permanente Northern California, Oakland, California; and
| | - Rebecca Cash
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Vincent X. Liu
- Division of Research, Kaiser Permanente Northern California, Oakland, California; and
| | - Carlos A. Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
13
|
Vijayakumar VK, Mustafa T, Nore BK, Garatun-Tjeldstø KY, Næss Ø, Johansen OE, Aarli BB. Role of a Digital Clinical Decision-Support System in General Practitioners' Management of COPD in Norway. Int J Chron Obstruct Pulmon Dis 2021; 16:2327-2336. [PMID: 34413641 PMCID: PMC8370595 DOI: 10.2147/copd.s319753] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 07/19/2021] [Indexed: 11/23/2022] Open
Abstract
Background The study investigated if a web-based clinical decision–support system (CDSS) tool would improve general practitioners’ (GPs) accuracy of diagnosis and classification of patients with chronic obstructive pulmonary disease (COPD), and whether nonpharmacological and pharmacological treatment would be better aligned with the COPD guidelines. Methods GPs were randomized to either a single use of the CDSS or continuing standard of care. The clinical recommendations of the CDSS were based on the GOLD guidelines and provided suggestions for treatment and management of COPD. Data were collected digitally from GPs and patients in both groups using a tablet computer. A follow-up questionnaire was sent to the GPs 1 year after the conclusion of the study. Results A total of 25 GPs (31% women, mean age 41 years) participated, 12 randomized to using the CDSS tool and 13 followed standard of care when assessing their next five to ten COPD patients. In sum, 149 patients with presumed COPD were included (88 CDSS group, 61 standard-of-care group). In the CDSS group, no COPD misdiagnoses occurred, 98% received vaccine recommendations, and all smokers (n=39) received smoking-cessation advice. The standard-of-care group had 23% misdiagnosis (P<0.001), only 67% received vaccine recommendations (P<0.001), and 87% smoking-cessation advice (P=0.022. All told, 31% of patients did not receive medication as recommended according to guidelines, with no significant differences between the groups. GPs rated the CDSS as very useful. Mean usage time was 3 minutes, 26 seconds. A majority (13 of 19, 68%) of the GPs continued using the CDSS after the conclusion of the study. CAT score identified twice as many patients as having more symptoms than the mMRC, indicating the added value of the multi-item questionnaire. Conclusion Use of the CDSS was associated with preventing misdiagnosis of COPD and improved adherence to recommended nonpharmacological measures, but a single use did not improve pharmacological treatment considerations. ![]()
Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use: https://youtu.be/6_qLDwt1JSc
Collapse
Affiliation(s)
- Varun Kumar Vijayakumar
- Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Tehmina Mustafa
- Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,Department of Thoracic Medicine, Haukeland University Hospital, Bergen, Norway
| | | | | | | | - Odd Erik Johansen
- Department of Medical Research, Bærum Hospital, Vestre Viken Hospital Trust, Gjettum, Norway
| | - Bernt Bøgvald Aarli
- Department of Thoracic Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| |
Collapse
|
14
|
Sharpe I, Bowman M, Kim A, Srivastava S, Jalink M, Wijeratne DT. Strategies to Prevent Readmissions to Hospital for COPD: A Systematic Review. COPD 2021; 18:456-468. [PMID: 34378468 DOI: 10.1080/15412555.2021.1955338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Patients with chronic obstructive pulmonary disease (COPD) experience high rates of hospital readmissions, placing substantial clinical and economic strain on the healthcare system. Therefore, it is essential to implement evidence-based strategies for preventing these readmissions. The primary objective of our systematic review was to identify and describe the domains of existing primary research on strategies aimed at reducing hospital readmissions among adult patients with COPD. We also aimed to identify existing gaps in the literature to facilitate future research efforts. A total of 843 studies were captured by the initial search and 96 were included in the final review (25 randomized controlled trials, 37 observational studies, and 34 non-randomized interventional studies). Of the included studies, 72% (n = 69) were considered low risk of bias. The majority of included studies (n = 76) evaluated patient-level readmission prevention strategies (medication and other treatments (n = 25), multi-modal (n = 19), follow-up (n = 16), telehealth (n = 8), education and coaching (n = 8)). Fewer assessed broader system- (n = 13) and policy-level (n = 7) strategies. We observed a trend toward reduced all-cause readmissions with the use of medication and other treatments, as well as a trend toward reduced COPD-related readmissions with the use of multi-modal and broader scale system-level interventions. Notably, much of this evidence supported shorter-term (30-day) readmission outcomes, while little evidence was available for longer-term outcomes. These findings should be interpreted with caution, as considerable between-study heterogeneity was also identified. Overall, this review identified several evidence-based interventions for reducing readmissions among patients with COPD that should be targeted for future research.Supplemental data for this article is available online at https://doi.org/10.1080/15412555.2021.1955338 .
Collapse
Affiliation(s)
- Isobel Sharpe
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada
| | - Meghan Bowman
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada
| | - Andrew Kim
- Division of General Internal Medicine, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Siddhartha Srivastava
- Division of General Internal Medicine, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Matthew Jalink
- Division of General Internal Medicine, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Don Thiwanka Wijeratne
- Division of General Internal Medicine, Department of Medicine, Queen's University, Kingston, ON, Canada
| |
Collapse
|
15
|
Kinnear B, Kelleher M, Sall D, Schauer DP, Warm EJ, Kachelmeyer A, Martini A, Schumacher DJ. Development of Resident-Sensitive Quality Measures for Inpatient General Internal Medicine. J Gen Intern Med 2021; 36:1271-1278. [PMID: 33105001 PMCID: PMC8131459 DOI: 10.1007/s11606-020-06320-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/20/2020] [Accepted: 10/14/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Graduate medical education (GME) training has long-lasting effects on patient care quality. Despite this, few GME programs use clinical care measures as part of resident assessment. Furthermore, there is no gold standard to identify clinical care measures that are reflective of resident care. Resident-sensitive quality measures (RSQMs), defined as "measures that are meaningful in patient care and are most likely attributable to resident care," have been developed using consensus methodology and piloted in pediatric emergency medicine. However, this approach has not been tested in internal medicine (IM). OBJECTIVE To develop RSQMs for a general internal medicine (GIM) inpatient residency rotation using previously described consensus methods. DESIGN The authors used two consensus methods, nominal group technique (NGT) and a subsequent Delphi method, to generate RSQMs for a GIM inpatient rotation. RSQMs were generated for specific clinical conditions found on a GIM inpatient rotation, as well as for general care on a GIM ward. PARTICIPANTS NGT participants included nine IM and medicine-pediatrics (MP) residents and six IM and MP faculty members. The Delphi group included seven IM and MP residents and seven IM and MP faculty members. MAIN MEASURES The number and description of RSQMs generated during this process. KEY RESULTS Consensus methods resulted in 89 RSQMs with the following breakdown by condition: GIM general care-21, diabetes mellitus-16, hyperkalemia-14, COPD-13, hypertension-11, pneumonia-10, and hypokalemia-4. All RSQMs were process measures, with 48% relating to documentation and 51% relating to orders. Fifty-eight percent of RSQMs were related to the primary admitting diagnosis, while 42% could also be related to chronic comorbidities that require management during an admission. CONCLUSIONS Consensus methods resulted in 89 RSQMs for a GIM inpatient service. While all RSQMs were process measures, they may still hold value in learner assessment, formative feedback, and program evaluation.
Collapse
Affiliation(s)
- Benjamin Kinnear
- Department of Pediatrics, University of Cincinnati College of Medicine, , Cincinnati, OH, USA. .,Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Matthew Kelleher
- Department of Pediatrics, University of Cincinnati College of Medicine, , Cincinnati, OH, USA.,Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Dana Sall
- Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Daniel P Schauer
- Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Eric J Warm
- Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Andrea Kachelmeyer
- Department of Pediatrics, University of Cincinnati College of Medicine, , Cincinnati, OH, USA
| | - Abigail Martini
- Department of Pediatrics, University of Cincinnati College of Medicine, , Cincinnati, OH, USA
| | - Daniel J Schumacher
- Department of Pediatrics, University of Cincinnati College of Medicine, , Cincinnati, OH, USA
| |
Collapse
|
16
|
Press VG, Myers LC, Feemster LC. Preventing COPD Readmissions Under the Hospital Readmissions Reduction Program: How Far Have We Come? Chest 2021; 159:996-1006. [PMID: 33065106 PMCID: PMC8501005 DOI: 10.1016/j.chest.2020.10.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 09/10/2020] [Accepted: 10/01/2020] [Indexed: 01/06/2023] Open
Abstract
The Hospital Readmissions Reduction Program (HRRP) was developed and implemented by the Centers for Medicare & Medicaid Services to curb the rate of 30-day hospital readmissions for certain common, high-impact conditions. In October 2014, COPD became a target condition for which hospitals were penalized for excess readmissions. The appropriateness, utility, and potential unintended consequences of the metric have been a topic of debate since it was first enacted. Nevertheless, there is evidence that hospital policies broadly implemented in response to the HRRP may have been responsible for reducing the rate of readmissions following COPD hospitalizations even before it was added as a target condition. Since the addition of the COPD condition to the HRRP, several predictive models have been developed to predict COPD survival and readmissions, with the intention of identifying modifiable risk factors. A number of interventions have also been studied, with mixed results. Bundled care interventions using the electronic health record and patient education interventions for inhaler education have been shown to reduce readmissions, whereas pulmonary rehabilitation, follow-up visits, and self-management programs have not been consistently shown to do the same. Through this program, COPD has become recognized as a public health priority. However, 5 years after COPD became a target condition for HRRP, there continues to be no single intervention that reliably prevents readmissions in this patient population. Further research is needed to understand the long-term effects of the policy, the role of competing risks in measuring quality, the optimal postdischarge care for patients with COPD, and the integrated use of predictive modeling and advanced technologies to prevent COPD readmissions.
Collapse
Affiliation(s)
- Valerie G Press
- Section of General Internal Medicine University of Chicago Medicine.
| | - Laura C Myers
- Divisions of Research and Pulmonary/Critical Care Medicine, Kaiser Permanente Northern California
| | - Laura C Feemster
- Division of Pulmonary, Critical Care, and Sleep Medicine, VA Puget Sound Health Care System
| |
Collapse
|
17
|
Iversen BR, Rodkjær LØ, Bregnballe V, Løkke A. The impact on severe exacerbations of establishing a cross-sectorial lung team for patients with COPD at high risk of exacerbating: a pilot study. Eur Clin Respir J 2021; 8:1882029. [PMID: 34992763 PMCID: PMC8725673 DOI: 10.1080/20018525.2021.1882029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background: Exacerbation in Chronic obstructive pulmonary disease (COPD) becomes more frequent with advancing disease severity and often the patients end up being hospitalized. Objective: To evaluate the impact on exacerbations of establishing a cross-sectorial lung team (CLT) for patients with COPD at high risk of exacerbating. Methods: In total, 49 patients with severe COPD were affiliated to a CLT for 6 months. On request from the participants, the CLT was available for telephone calls and home visits day and night to initiate treatment and give advice. Data regarding hospitalizations were collected 3 years prior to the intervention year to predict future numbers of admissions and length of stay. These predictions were compared with the observed data. COPD assessment test (CAT) was conducted before and after intervention. Results: Observed risk of hospitalization (0.54 (95% CI 0.32; 0.90), p = 0.0192)) and length of hospital stay due to COPD (0.41 (95% CI 0.22; 0.76), p = 0.0046)) were significantly lower during the intervention period than predicted. A numerical but non-significant improvement in the total CAT score of 1.10 (95%CI: –0.71;2.91), p = 0.226)) was observed. Conclusion: Affiliation to a CLT seemed to lower the burden of COPD exacerbations in a high-risk population.
Collapse
Affiliation(s)
- Birgit Refsgaard Iversen
- Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark
- Research Centre for Patient Involvement (ResCenPI), Aarhus University and Central Denmark Region, Aarhus, Denmark
| | - Lotte Ørneborg Rodkjær
- Research Centre for Patient Involvement (ResCenPI), Aarhus University and Central Denmark Region, Aarhus, Denmark
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
- Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Vibeke Bregnballe
- Research Centre for Patient Involvement (ResCenPI), Aarhus University and Central Denmark Region, Aarhus, Denmark
- Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Anders Løkke
- Department of Medicine, Vejle, Little Belt Hospital, Vejle, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| |
Collapse
|
18
|
Gunasekaran K, Ahmad M, Rehman S, Thilagar B, Gopalratnam K, Ramalingam S, Paramasivam V, Arora A, Chandran A. Impact of a Positive Viral Polymerase Chain Reaction on Outcomes of Chronic Obstructive Pulmonary Disease (COPD) Exacerbations. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17218072. [PMID: 33147795 PMCID: PMC7662648 DOI: 10.3390/ijerph17218072] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 10/19/2020] [Accepted: 10/28/2020] [Indexed: 12/23/2022]
Abstract
Introduction: More than 15 million adults in the USA have chronic obstructive pulmonary disease. Chronic obstructive pulmonary disease (COPD) places a high burden on the healthcare system. Many hospital admissions are due to an exacerbation, which is suspected to be from a viral cause. The purpose of this analysis was to compare the outcomes of patients with a positive and negative respiratory virus panel who were admitted to the hospital with COPD exacerbations. Methods: This retrospective cohort study was conducted in the Geisinger Healthcare System. The dataset included 2729 patient encounters between 1 January 2006 and 30 November 2017. Hospital length of stay was calculated as the discrete number of calendar days a patient was in the hospital. Patient encounters with a positive and negative respiratory virus panel were compared using Pearson’s chi-square or Fisher’s exact test for categorical variables and Student’s t-test or Wilcoxon rank-sum tests for continuous variables. Results: There were 1626 patients with a total of 2729 chronic obstructive pulmonary disease exacerbation encounters. Nineteen percent of those encounters (n = 524) had a respiratory virus panel performed during their admission. Among these encounters, 161 (30.7%) had positive results, and 363 (69.3%) had negative results. For encounters with the respiratory virus panel, the mean age was 64.5, 59.5% were female, 98.9% were white, and the mean body mass index was 26.6. Those with a negative respiratory virus panel had a higher median white blood cell count (11.1 vs. 9.9, p = 0.0076). There were no other statistically significant differences in characteristics between the two groups. Respiratory virus panel positive patients had a statistically significant longer hospital length of stay. There were no significant differences with respect to being on mechanical ventilation or ventilation-free days. Conclusion: This study shows that a positive respiratory virus panel is associated with increased length of hospital stay. Early diagnosis of chronic obstructive pulmonary disease exacerbation patients with positive viral panel would help identify patients with a longer length of stay.
Collapse
Affiliation(s)
- Kulothungan Gunasekaran
- Division of Pulmonary Diseases and Critical Care, Yale-New Haven Health Bridgeport Hospital, 267 Grant Street, Bridgeport, CT 06610, USA;
- Correspondence: ; Tel.: +1-203-384-5009; Fax: +1-203-330-7498
| | - Mudassar Ahmad
- Division of Pulmonary Diseases and Critical Care, St. Peter’s University Hospital, New Brunswick, NJ 08901, USA;
| | - Sana Rehman
- Department of Medicine, Shaikh Khalifa Bin Zayed Al-Nahyan Medical and Dental College, Lahore 53720, Pakistan;
| | - Bright Thilagar
- Division of Hospital Medicine, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI 48202, USA;
| | - Kavitha Gopalratnam
- Division of Pulmonary Diseases and Critical Care, Yale-New Haven Health Bridgeport Hospital, 267 Grant Street, Bridgeport, CT 06610, USA;
| | - Sathish Ramalingam
- Division of Hospital Medicine, Lovelace Medical Center, 601 Dr. Martin Luther King Jr. Ave NE, Albuquerque, NM 87102, USA;
| | - Vijayakumar Paramasivam
- Division of Nephrology, Baystate Medical Center, 759 Chestnut St, Springfield, MA 01199, USA;
| | - Ashish Arora
- Division of Pulmonary Diseases and Critical Care, Saint Mary’s Hospital, 56 Franklin St, Waterbury, CT 06610, USA;
| | - Arul Chandran
- Division of Pulmonary Diseases and Critical Care, Hurley Medical Center, G-3252 Beecher Road, Flint, MI 48532, USA;
| |
Collapse
|
19
|
Bollmeier SG, Hartmann AP. Management of chronic obstructive pulmonary disease: A review focusing on exacerbations. Am J Health Syst Pharm 2020; 77:259-268. [PMID: 31930287 PMCID: PMC7005599 DOI: 10.1093/ajhp/zxz306] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Purpose Chronic obstructive pulmonary disease (COPD) is a significant cause of morbidity and mortality in the United States. Exacerbations— acute worsening of COPD symptoms—can be mild to severe in nature. Increased healthcare resource use is common among patients with frequent exacerbations, and exacerbations are a major cause of the high 30-day hospital readmission rates associated with COPD. Summary This review provides a concise overview of the literature regarding the impact of COPD exacerbations on both the patient and the healthcare system, the recommendations for pharmacologic management of COPD, and the strategies employed to improve patient care and reduce hospitalizations and readmissions. COPD exacerbations significantly impact patients’ health-related quality of life and disease progression; healthcare costs associated with severe exacerbation-related hospitalization range from $7,000 to $39,200. Timely and appropriate maintenance pharmacotherapy, particularly dual bronchodilators for maximizing bronchodilation, can significantly reduce exacerbations in patients with COPD. Additionally, multidisciplinary disease-management programs include pulmonary rehabilitation, follow-up appointments, aftercare, inhaler training, and patient education that can reduce hospitalizations and readmissions for patients with COPD. Conclusion Maximizing bronchodilation by the appropriate use of maintenance therapy, together with multidisciplinary disease-management and patient education programs, offers opportunities to reduce exacerbations, hospitalizations, and readmissions for patients with COPD.
Collapse
Affiliation(s)
- Suzanne G Bollmeier
- Division of Ambulatory Care Pharmacy, St. Louis College of Pharmacy, St. Louis, MO
| | | |
Collapse
|
20
|
End-of-Life Spending and Healthcare Utilization Among Older Adults with Chronic Obstructive Pulmonary Disease. Am J Med 2020; 133:817-824.e1. [PMID: 31883772 PMCID: PMC7319886 DOI: 10.1016/j.amjmed.2019.11.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 11/19/2019] [Accepted: 11/19/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND End-of-life spending and healthcare utilization among older adults with COPD have not been previously described. METHODS We examined data on Medicare beneficiaries aged 65 years or older with chronic obstructive pulmonary disease (COPD) who died during the period of 2013-2014. End-of-life measures were retrospectively reviewed for 2 years prior to death. Hospital referral regions (HRRs) were categorized into quintiles of age-sex-race-adjusted overall spending during the last 2 years of life. Geographic quintile variation in spending and healthcare utilization was examined across the continuum. RESULTS We investigated data on 146,240 decedents with COPD from 306 HRRs. Age-sex-race-adjusted overall spending per decedent during the last 2 years of life varied significantly nationwide ($61,271±$11,639 per decedent; range: $48,288±$3,665 to $79,453±$9,242). Inpatient care accounted for 40.2% of spending ($24,626±$6,192 per decedent). Overall, 82%±4% of decedents were admitted to the hospital for 13.7±3.1 days, and 55%±11% were admitted to an intensive care unit for 5.4±2.5 days. Compared with HRRs in the lowest spending quintile, HRRs in the highest spending quintile had a 1.5-fold longer hospital length of stay. Skilled nursing facilities accounted for 11.6% of spending ($7101±$2403 per decedent), and these facilities were utilized by 38%±7% of decedents for 18.7±4.9 days. Hospice accounted for 10.3% of spending ($6,307±$2,201 per decedent) and was utilized by 47%±9% of decedents for 39.7±14.8 days. Significant geographic variation in hospice utilization existed nationwide. CONCLUSIONS End-of-life spending and healthcare utilization among older adults with COPD varied substantially nationwide. Decedents with COPD frequently utilized acute care near the end of life. Hospice utilization was higher than expected, with significant geographic disparities.
Collapse
|
21
|
Costs of Treatment of Severe COPD Exacerbation in Serbia. SERBIAN JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2020. [DOI: 10.2478/sjecr-2018-0010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
The main objective of this investigation was to determine and summarize the economic burden of severe COPD exacerbations that required hospitalization and the difference in the costs of treatment between patients with frequent (at least two exacerbations in one year) and infrequent exacerbation.
Our results suggested that significantly more resources had to be spent to treat patients with at least two hospitalizations during the study related to the use of medications primarily affecting the respiratory system (corticosteroids, p = 0.013, theophylline, p = 0.007) and total hospital stay (31336.68 ± 19140 RSD/517.53 ± 316.1 EUR versus 23650.15 ± 14956.0 RSD/390.59 ± 247 EUR, p=0.002) compared to patients who stayed in a semi-intensive care unit (12875.35 ± 20742.54 RSD versus 4310.62 ± 9779.78 RSD/ 212.64 ± 342.57 EUR versus 71.19 ± 161.51 EUR, p=0.006). Based on the total number of days in the hospital, the costs of the drugs, the materials used and services provided, patients from the frequent exacerbation group had significantly higher costs (80034.1 ± 36823.7 RSD/1321.78 ± 608.15 EUR versus 69425.5 ± 34083.1 RSD/1146.58 ± 562.89 EUR) comparedthan patients in the infrequent exacerbation group (p=0.039).
Our results indicate that significantly more funds will be spent treating the deterioration of patients who stay longer in the hospital or in the semi-intensive care unit. Their condition will require a significantly greater use of drugs that are primarily used to treat the respiratory system and, therefore, will utiliseutilize significantly more resources.
Collapse
|
22
|
Crisafulli E, Manco A, Torres A. How may we improve clinical outcomes for patients hospitalized with acute exacerbations of chronic obstructive pulmonary disease? A narrative review about possible therapeutic and preventive strategies. Expert Rev Respir Med 2020; 14:493-500. [PMID: 32077337 DOI: 10.1080/17476348.2020.1732823] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: In a subset of chronic obstructive pulmonary disease (COPD)patients the course of the disease is complicated by a severe acute exacerbations (AECOPD) that may require hospitalization, at which time negative outcomes may occur up to 30 days after discharge. Several predictors of negative outcomes have been documented.Areas covered: We considered five negative outcomes related to patients hospitalized with AECOPD: treatment failure, noninvasive mechanical ventilation (NIMV) failure, prolonged length of hospital stay (LHS), short-term mortality (≤ 90 days from admission and including the in-hospital mortality), and early readmission (≤30 days from discharge). Possible therapeutic and preventive strategies to improve these outcomes are outlined and discussed.Expert opinion: Several strategies have been proposed to improve outcomes. Among these, steroid or antibiotic use may reduce the risks of treatment failure or of prolonged hospital stay. We note that operator-related factors may influence the outcome of NIMV. However, little has been documented about the short-term mortality or early readmission rates. In general, few interventions consistently improve negative outcomes and prognosis of AECOPD.
Collapse
Affiliation(s)
- Ernesto Crisafulli
- Department of Medicine, Respiratory Medicine Unit and Section of Internal Medicine, University of Verona and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Alessandra Manco
- Department of Medicine and Surgery, Respiratory Disease and Lung Function Unit, University of Parma, Parma, Italy
| | - Antoni Torres
- Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) - University of Barcelona - Ciber de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| |
Collapse
|
23
|
Morais LDA, Cavalcante SYIEDS, Conde MB, Rabahi MF. Evaluating the disease and treatment information provided to patients with chronic obstructive pulmonary disease at the time of discharge according to GOLD discharge guidelines. EINSTEIN-SAO PAULO 2019; 18:eAO4706. [PMID: 31826076 PMCID: PMC6905159 DOI: 10.31744/einstein_journal/2020ao4706] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 02/01/2019] [Indexed: 11/10/2022] Open
Abstract
Objective To evaluate the disease and treatment information provided to patients with chronic obstructive pulmonary disease at hospital discharge. Methods This was a cross-sectional study including hospitalized patients with chronic obstructive pulmonary disease at three tertiary hospitals. The study was based on seven items of the Global Initiative for Obstructive Lung Disease (GOLD) discharge guidelines. Two hospitals in this study had a Medical Residency Program in Pulmonology, and one did not have the program. Results Fifty-four patients were evaluated. Large amounts of information were provided concerning effective pharmacological maintenance (item 1), blood gas evaluation/measurement of oxygen saturation (item 2), assessment of inhalation technique (item 4), and maintenance therapy (item 5). Less information was provided regarding comorbidity management planning (item 3), the completion of antibiotic/corticosteroid therapy (item 6) and follow-up with the attending physician or specialist (item 7) had less information. We observed significant differences between hospitals for items 1, 4 and 7, and better performance in hospitals with medical residency in pulmonology. Conclusion Hospitalized patients with chronic obstructive pulmonary disease received little to no information about the seven items addressed by GOLD discharge guidelines. This finding suggests that these guidelines should be used more often by clinicians in hospital with or without medical residency in pulmonology. The lack of specialized care resulted in insufficient amount of information for patients with chronic obstructive pulmonary disease at discharge.
Collapse
|
24
|
Gentene AJ, Guido MR, Woolf B, Dalhover A, Boesken TA, Mueller EW, Zafar MA. Multidisciplinary Team Utilizing Pharmacists in Multimodal, Bundled Care Reduce Chronic Obstructive Pulmonary Disease Hospital Readmission Rates. J Pharm Pract 2019; 34:110-116. [PMID: 31769330 DOI: 10.1177/0897190019889440] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is a major contributor of morbidity and mortality in the United States resulting in high hospitalization and readmission rates. For health systems, identifying an effective strategy to reduce COPD readmissions has remained difficult. Multiple COPD care bundles have been developed with varying degrees of success. Bundles that were multidisciplinary and included pharmacists were successful in reducing readmissions. OBJECTIVE To describe and assess a multidisciplinary, 5-element, COPD care bundle that was implemented in an academic, urban safety-net hospital to reduce COPD readmissions and the role of pharmacists in bundle implementation. METHODS A multidisciplinary team collaborated to develop a 5-element COPD care bundle that met unmet patient needs. The bundle elements included the following, with pharmacy responsible for the first two: optimization of COPD inhalers, 30-day supply of insurance-compatible inhalers, individualized patient inhaler teaching, provision of standardized discharge instructions, and scheduling of a 15-day discharge follow-up appointment. Bundle was implemented with multiple Plan-Do-Study-Act (PDSA) cycles to develop intra- and interdepartment processes. RESULTS Prior to bundle implementation, the health system COPD readmission rates were 22.7%. Reliable implementation of the bundle reduced readmissions to 14.7% over a 6-month period. Pharmacy adherence to completion of the bundle was over 95% over 2 years of bundle use. CONCLUSION Pharmacists have a crucial role in hospital-based transitions of care to reduce COPD readmissions.
Collapse
Affiliation(s)
- Anthony J Gentene
- Department of Pharmacy Services, 24267University of Cincinnati Medical Center, Cincinnati, OH.,Division of Pharmacy Practice and Administration, 24267University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Maria Rose Guido
- Department of Pharmacy Services, 24267University of Cincinnati Medical Center, Cincinnati, OH.,Division of Pharmacy Practice and Administration, 24267University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Brittany Woolf
- Department of Pharmacy Services, 24267University of Cincinnati Medical Center, Cincinnati, OH.,Division of Pharmacy Practice and Administration, 24267University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Amber Dalhover
- Department of Pharmacy Services, 24267University of Cincinnati Medical Center, Cincinnati, OH
| | - Timmi Anne Boesken
- Department of Pharmacy Services, 24267University of Cincinnati Medical Center, Cincinnati, OH
| | - Eric W Mueller
- Department of Pharmacy Services, 24267University of Cincinnati Medical Center, Cincinnati, OH.,Division of Pharmacy Practice and Administration, 24267University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Muhammad Ahsan Zafar
- Division of Pulmonary and Critical Care, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| |
Collapse
|
25
|
Abstract
Chronic obstructive pulmonary disease (COPD), the umbrella term used to describe chronic lung diseases that cause limitations in lung airflow, is predicted to be the third leading cause of death by 2030. COPD is said to affect 3 million people in the UK, resulting in approximately 30 000 deaths each year. Related healthcare costs continue to escalate, not least because of increasing readmission rates associated with COPD emergencies. The use of care bundles to streamline care is becoming more popular in an attempt to tackle this issue. An integrative literature review was carried out to examine the effectiveness of the use of care bundles. The findings highlighted inconsistencies in the components of bundles, leading to inherent difficulties in assessing which specific component of the bundles led to positive outcomes. The results of this attempt to establish the effectiveness of care bundles in reducing readmission rates and quality of care were inconclusive. The authors recommend further research to investigate the individual components in the bundles and to introduce internationally agreed care bundles for the management of COPD.
Collapse
Affiliation(s)
- Charlotte Lloyd
- Clinical Nurse Educator, Calderdale and Huddersfield NHS Foundation Trust
| | | |
Collapse
|
26
|
Epstein D, Barak-Corren Y, Isenberg Y, Berger G. Clinical Decision Support System: A Pragmatic Tool to Improve Acute Exacerbation of COPD Discharge Recommendations. COPD 2019; 16:18-24. [DOI: 10.1080/15412555.2019.1593342] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Danny Epstein
- Department of Internal Medicine "B", Rambam Health Care Campus, Haifa, Israel
| | - Yuval Barak-Corren
- Predictive Medicine Group, Boston Children’s Hospital, Boston, MA, USA
- Shaare Tzedek Medical Center, Jerusalem, Israel
| | - Yoni Isenberg
- Department of Internal Medicine "B", Rambam Health Care Campus, Haifa, Israel
| | - Gidon Berger
- Department of Internal Medicine "B", Rambam Health Care Campus, Haifa, Israel
- Division of Pulmonary Medicine, Rambam Health Care Campus, Haifa, Israel
- The Rappaport's Faculty of Medicine, The Technion Institute, Haifa, Israel
| |
Collapse
|
27
|
Insights about the economic impact of chronic obstructive pulmonary disease readmissions post implementation of the hospital readmission reduction program. Curr Opin Pulm Med 2019; 24:138-146. [PMID: 29210750 DOI: 10.1097/mcp.0000000000000454] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Chronic obstructive pulmonary disease (COPD) affects over 12 million adults in the United States and is the third leading cause of 30-day readmissions. COPD is costly with almost $50 billion in direct costs annually. Total COPD costs can be up to double the identified direct costs because of comorbid disease and numerous indirect costs such as absenteeism. Acute exacerbations of COPD (AECOPD) are responsible for up to 70% of COPD-related healthcare costs; hospital readmissions alone account for over $15 billion annually. In this review, we aim to describe insights about the economic impact of COPD readmissions based on articles published over the last 18 months. RECENT FINDINGS Interventions aimed at reducing readmission, particularly those using interdisciplinary teams with bundled care interventions, were uniformly successful at improving the quality of care provided and demonstrating improved process measures. However, success at reducing readmissions and cost savings based on these interventions varied across the studies. SUMMARY The literature to date points to factors and conditions that may place patients at higher risk of readmissions and may lead to higher costs. Interventions aimed at reducing readmissions after index admissions for AECOPD have demonstrated variable results. Most interventions did not reflect cost-based analyses.
Collapse
|
28
|
Breyer-Kohansal R, Hartl S, Breyer MK, Schrott A, Studnicka M, Neunhäuserer D, Fülöp G, Burghuber OC. The European COPD audit : Adherence to guidelines, readmission risk and hospital care for acute exacerbations in Austria. Wien Klin Wochenschr 2019; 131:97-103. [PMID: 30689047 DOI: 10.1007/s00508-019-1441-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Accepted: 01/05/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are the major reason for COPD hospitalization and increased risk for readmissions. The organizational structure of Austrian hospitals provides the opportunity to investigate the impact of specialized respiratory care compared to general care on adherence to guidelines and readmission in AECOPD. METHODS The data from the European COPD audit, a prospective observational non-interventional cohort trial were analyzed. In total, 823 patients admitted due to AECOPD in 26 hospitals (specialized respiratory care vs. general care) within Austria were included. Patients characteristics and outcomes (length of stay, readmission rate, and mortality) were analyzed in relation to hospital resources (personnel and equipment) and adherence to international guidelines. RESULTS Patients admitted to general care had more comorbidities (Charlson comorbidity index: 2.6 ± 1.7 vs. 2.0 ± 1.4; p < 0.05) and a shorter length of stay (10.7 ± 7.8 days vs. 12.0 ± 10.2 days; p < 0.05). Patients admitted to specialized respiratory care more often underwent blood gas analysis and non-invasive ventilation (98.4% vs. 81.5% and 68.6% vs. 26.7%, p < 0.01; respectively). In multivariate analysis, the risk for AECOPD readmission was lower (odds ratio, OR 0.72 [0.51;0.91]; p < 0.05) in patients admitted to specialized respiratory care. CONCLUSION A greater adherence to COPD guidelines with respect to blood gas analysis and non-invasive ventilation and decreased AECOPD readmission risk was observed for patients admitted to specialized respiratory care. Adherence to guidelines may have the potential to decrease COPD readmission rates.
Collapse
Affiliation(s)
- Robab Breyer-Kohansal
- 1st Department of Respiratory and Critical Care Medicine, Ludwig Boltzmann Institute for COPD and Respiratory Epidemiology, Otto Wagner Hospital, Sanatoriumstraße 2, 1140, Vienna, Austria.
| | - Sylvia Hartl
- 2nd Department of Respiratory and Critical Care Medicine, Otto Wagner Hospital, Vienna, Austria.,Faculty of Medicine, Sigmund Freud University, Vienna, Austria
| | - Marie-Kathrin Breyer
- 1st Department of Respiratory and Critical Care Medicine, Ludwig Boltzmann Institute for COPD and Respiratory Epidemiology, Otto Wagner Hospital, Sanatoriumstraße 2, 1140, Vienna, Austria
| | | | - Michael Studnicka
- University Clinic of Respiratory Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Daniel Neunhäuserer
- University Clinic of Respiratory Medicine, Paracelsus Medical University, Salzburg, Austria
| | | | - Otto Chris Burghuber
- 1st Department of Respiratory and Critical Care Medicine, Ludwig Boltzmann Institute for COPD and Respiratory Epidemiology, Otto Wagner Hospital, Sanatoriumstraße 2, 1140, Vienna, Austria.,Faculty of Medicine, Sigmund Freud University, Vienna, Austria
| |
Collapse
|
29
|
Crisafulli E, Ielpo A, Barbeta E, Ceccato A, Huerta A, Gabarrús A, Soler N, Chetta A, Torres A. Clinical variables predicting the risk of a hospital stay for longer than 7 days in patients with severe acute exacerbations of chronic obstructive pulmonary disease: a prospective study. Respir Res 2018; 19:261. [PMID: 30591055 PMCID: PMC6307152 DOI: 10.1186/s12931-018-0951-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Accepted: 11/23/2018] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) patients may experience an acute exacerbation (AECOPD) that requires hospitalisation. The length of hospital stay (LHS) has a great economic impact on the health-care system. Knowing the predictors of prolonged LHS could help to identify possible interventions. METHODS We performed a prospective study to identify the clinical predictors of prolonged LHS in patients hospitalised for AECOPD. We divided the study sample by LHS into normal (≤7 days) and prolonged LHS (> 7 days) groups. Outcomes were the need for non-invasive and invasive mechanical ventilation (NIMV and IMV), intensive care unit (ICU) admission, and the 3-year mortality. RESULTS We enrolled 437 patients, of which 213 and 224 had normal LHS and prolonged LHS, respectively. Patients with a prolonged LHS had more prior hospitalisations for AECOPD, a worse mMRC (modified Medical Research Council) dyspnoea score, a higher prevalence of long-term oxygen therapy and a higher rate of congestive heart disease. During the current admission, this group also tended to require NIMV, IMV and ICU admission and the mortality risks at 6 months, 1 year and 3 years were higher. In the multivariate regression analysis, an mMRC dyspnoea score ≥ 2 (odds ratio-OR 2.24; 95% confidence interval-CI 1.34 to 3.74; p = 0.002) and the presence of acute respiratory acidosis (OR 2.75; 95% CI 1.49 to 5.05; p = 0.001) predicted a prolonged LHS at admission. CONCLUSIONS The presence of an mMRC ≥2 and acute respiratory acidosis at admission independently increased the risk of a prolonged LHS for AECOPD.
Collapse
Affiliation(s)
- Ernesto Crisafulli
- Department of Medicine and Surgery, Respiratory Disease and Lung Function Unit, University of Parma, Parma, Italy
| | - Antonella Ielpo
- Department of Medicine and Surgery, Respiratory Disease and Lung Function Unit, University of Parma, Parma, Italy
| | - Enric Barbeta
- Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Ciber de Enfermedades Respiratorias (CIBERES), Villarroel 170, 08036, Barcelona, Spain
| | - Adrian Ceccato
- Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Ciber de Enfermedades Respiratorias (CIBERES), Villarroel 170, 08036, Barcelona, Spain
| | - Arturo Huerta
- Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Ciber de Enfermedades Respiratorias (CIBERES), Villarroel 170, 08036, Barcelona, Spain
| | - Albert Gabarrús
- Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Ciber de Enfermedades Respiratorias (CIBERES), Villarroel 170, 08036, Barcelona, Spain
| | - Néstor Soler
- Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Ciber de Enfermedades Respiratorias (CIBERES), Villarroel 170, 08036, Barcelona, Spain
| | - Alfredo Chetta
- Department of Medicine and Surgery, Respiratory Disease and Lung Function Unit, University of Parma, Parma, Italy
| | - Antoni Torres
- Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Ciber de Enfermedades Respiratorias (CIBERES), Villarroel 170, 08036, Barcelona, Spain. .,Icrea Academia, Barcelona, Spain.
| |
Collapse
|
30
|
Gómez-Angelats E, Sánchez C. Care Bundles after Discharging Patients with Chronic Obstructive Pulmonary Disease Exacerbation from the Emergency Department. Med Sci (Basel) 2018; 6:E63. [PMID: 30087300 PMCID: PMC6164584 DOI: 10.3390/medsci6030063] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 08/02/2018] [Accepted: 08/06/2018] [Indexed: 12/02/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is the second leading cause of emergency department (ED) admissions to hospital, and nearly a third of patients with acute exacerbation (AE) of COPD are re-admitted to hospital within 28 days after discharge. It has been suggested that nearly a third of COPD admissions could be avoided through the implementation of evidence-based care interventions. A COPD discharge bundle is a set of evidence-based practices, aimed at improving patient outcomes after discharge from AE COPD; body of evidence supports the usefulness of discharge care bundles after AE of COPD, although there is a lack of consensus of what interventions should be implemented. On the other hand, the implementation of those interventions also involves different challenges. Important care gaps remain regarding discharge care bundles for patients with acute exacerbation of COPD discharged from EDs There is an urgent need for investigations to guide future implementation of care bundles for those patients discharged from EDs.
Collapse
Affiliation(s)
- Elisenda Gómez-Angelats
- Emergency Department, Hospital Clínic de Barcelona, C/Villarroel 170, 08036 Barcelona, Spain.
| | - Carolina Sánchez
- Emergencies Group: Processes and Pathologies, Institut d'Investigacions Biomèdiques August Pi i Sunyer, C/Rosselló 149, 08036 Barcelona, Spain.
| |
Collapse
|
31
|
Gulati S, Zouk AN, Kalehoff JP, Wren CS, Davison PN, Kirkpatrick DP, Bhatt SP, Dransfield MT, Wells JM. The use of a standardized order set reduces systemic corticosteroid dose and length of stay for individuals hospitalized with acute exacerbations of COPD: a cohort study. Int J Chron Obstruct Pulmon Dis 2018; 13:2271-2278. [PMID: 30100717 PMCID: PMC6067788 DOI: 10.2147/copd.s165665] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Systemic corticosteroids (SC) are an integral part of managing acute exacerbations of COPD (AECOPD). However, the optimal dose and duration vary widely in clinical practice. We hypothesized that the use of a “PowerPlan” order set in the electronic health system (EHS) that includes a 5-day SC order would be associated with a reduced steroid dose and length of stay (LOS) for individuals hospitalized with AECOPD. Patients and methods We conducted a retrospective cohort study of Medicare recipients discharged with an AECOPD diagnosis from our University Hospital from 2014 to 2016. Our EHS-based “COPD PowerPlan” order set included admission, laboratory, pharmacy, and radiology orders for managing AECOPD. The default SC option included intravenous methyl-prednisolone for 24 hours followed by oral prednisone for 4 days. The primary endpoint was the difference in cumulative steroid dose between the PowerPlan and the usual care group. Secondary endpoints included hospital LOS and readmission rates. Results The 250 patients included for analysis were 62±11 years old, 58% male, with an FEV1 55.1%±23.6% predicted. The PowerPlan was used in 72 (29%) patients. Cumulative steroid use was decreased by 31% in the PowerPlan group (420±224 vs 611±462 mg, P<0.001) when compared with usual care. PowerPlan use was independently associated with decreased LOS (3 days; IQR 2–4 days vs 4 days; IQR 3–6 days, P=0.022) without affecting 30- and 90-day readmission rates. Conclusion Use of a standardized EHS-based order set to manage AECOPD was associated with a reduction in steroid dose and hospital LOS.
Collapse
Affiliation(s)
- Swati Gulati
- Department of Medicine, University of Alabama at Birmingham (UAB), Birmingham, AL, USA, .,Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham (UAB), Birmingham, AL, USA, .,UAB Lung Health Center, Birmingham, AL, USA,
| | - Aline N Zouk
- Department of Medicine, University of Alabama at Birmingham (UAB), Birmingham, AL, USA, .,Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham (UAB), Birmingham, AL, USA, .,UAB Lung Health Center, Birmingham, AL, USA,
| | - Jonathan P Kalehoff
- Division of Internal Medicine, University of Alabama at Birmingham (UAB), Birmingham, AL, USA
| | | | - Peter N Davison
- University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | - Denay Porter Kirkpatrick
- Department of Medicine, University of Alabama at Birmingham (UAB), Birmingham, AL, USA, .,Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham (UAB), Birmingham, AL, USA, .,UAB Lung Health Center, Birmingham, AL, USA,
| | - Surya P Bhatt
- Department of Medicine, University of Alabama at Birmingham (UAB), Birmingham, AL, USA, .,Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham (UAB), Birmingham, AL, USA, .,UAB Lung Health Center, Birmingham, AL, USA,
| | - Mark T Dransfield
- Department of Medicine, University of Alabama at Birmingham (UAB), Birmingham, AL, USA, .,Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham (UAB), Birmingham, AL, USA, .,UAB Lung Health Center, Birmingham, AL, USA, .,Birmingham VA Medical Center, Birmingham, AL, USA,
| | - James Michael Wells
- Department of Medicine, University of Alabama at Birmingham (UAB), Birmingham, AL, USA, .,Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham (UAB), Birmingham, AL, USA, .,UAB Lung Health Center, Birmingham, AL, USA, .,Birmingham VA Medical Center, Birmingham, AL, USA,
| |
Collapse
|
32
|
Pearce JA, Shiltz DL, Ding Q. Effectiveness and Safety Comparison for Systemic Corticosteroid Therapy With and Without Inhaled Corticosteroids for COPD Exacerbation Management. Ann Pharmacother 2018; 52:1070-1077. [DOI: 10.1177/1060028018777769] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Only 1 small, single-center study has evaluated the combination of systemic plus inhaled corticosteroid (ICS) routes for chronic obstructive pulmonary disease (COPD) exacerbation management. This study aims to further improve the existing quantity and quality of evidence regarding the utility for combination therapy in the management of COPD exacerbation. Objectives: To evaluate length of hospital stay, readmission rate, incidence of infection, and mortality in hospitalized patients who experience a COPD exacerbation and receive systemic corticosteroid therapy with or without concurrent ICS. Methods: Design: retrospective cohort study. Participants and setting: patients at least 18 years old admitted between May 31, 2015, and May 31, 2016, for an acute COPD exacerbation at any of 7 Indiana University Health system hospitals. Interventions: patients who received an oral or intravenous systemic corticosteroid either with or without concurrent ICS therapy. Results: This study included 241 patients. No significant difference was found between rates of 30-day readmission or inpatient mortality. Patients receiving concurrent therapy had longer lengths of stay versus those who only received systemic corticosteroid therapy (6.35 ± 3.98 vs 4.99 ± 2.89 days, P = 0.0039). Differences in the rates of antifungal use and mechanical ventilation did not statistically differ. Conclusion and Relevance: There was no significant benefit demonstrated when adding ICS to systemic corticosteroid therapy for COPD exacerbation management. These preliminary findings build on the limited evidence on how best to manage corticosteroid therapy in the inpatient setting, but a large, prospective trial remains warranted to confirm these findings given the design, size, and concern for selection bias limitations in the present study.
Collapse
Affiliation(s)
| | - Dane L. Shiltz
- Ferris State University College of Pharmacy, Grand Rapids, MI, USA
| | - Qian Ding
- Ferris State University College of Pharmacy, Big Rapids, MI, USA
| |
Collapse
|
33
|
Post hospitalization management of patients with COPD. Nurs Manag (Harrow) 2017; 49:14-21. [PMID: 29287045 DOI: 10.1097/01.numa.0000527713.06404.d1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
34
|
Hakim MA, Garden FL, Jennings MD, Dobler CC. Performance of the LACE index to predict 30-day hospital readmissions in patients with chronic obstructive pulmonary disease. Clin Epidemiol 2017; 10:51-59. [PMID: 29343987 PMCID: PMC5751805 DOI: 10.2147/clep.s149574] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background and objective Patients hospitalized for acute exacerbation of chronic obstructive pulmonary disease (COPD) have a high 30-day hospital readmission rate, which has a large impact on the health care system and patients’ quality of life. The use of a prediction model to quantify a patient’s risk of readmission may assist in directing interventions to patients who will benefit most. The objective of this study was to calculate the rate of 30-day readmissions and evaluate the accuracy of the LACE index (length of stay, acuity of admission, co-morbidities, and emergency department visits within the last 6 months) for 30-day readmissions in a general hospital population of COPD patients. Methods All patients admitted with a principal diagnosis of COPD to Liverpool Hospital, a tertiary hospital in Sydney, Australia, between 2006 and 2016 were included in the study. A LACE index score was calculated for each patient and assessed using receiver operator characteristic curves. Results During the study period, 2,662 patients had 5,979 hospitalizations for COPD. Four percent of patients died in hospital and 25% were readmitted within 30 days; 56% of all 30-day readmissions were again due to COPD. The most common reasons for readmission, following COPD, were heart failure, pneumonia, and chest pain. The LACE index had moderate discriminative ability to predict 30-day readmission (C-statistic =0.63). Conclusion The 30-day hospital readmission rate was 25% following hospitalization for COPD in an Australian tertiary hospital and as such comparable to international published rates. The LACE index only had moderate discriminative ability to predict 30-day readmission in patients hospitalized for COPD.
Collapse
Affiliation(s)
- Maryam A Hakim
- Department of Respiratory Medicine, Liverpool Hospital.,South Western Sydney Clinical School, University of New South Wales
| | - Frances L Garden
- South Western Sydney Clinical School, University of New South Wales.,Ingham Institute for Applied Medical Research
| | | | - Claudia C Dobler
- Department of Respiratory Medicine, Liverpool Hospital.,South Western Sydney Clinical School, University of New South Wales.,Ingham Institute for Applied Medical Research.,Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
35
|
Wong J, Magun BE, Wood LJ. Lung inflammation caused by inhaled toxicants: a review. Int J Chron Obstruct Pulmon Dis 2016; 11:1391-401. [PMID: 27382275 PMCID: PMC4922809 DOI: 10.2147/copd.s106009] [Citation(s) in RCA: 120] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Exposure of the lungs to airborne toxicants from different sources in the environment may lead to acute and chronic pulmonary or even systemic inflammation. Cigarette smoke is the leading cause of chronic obstructive pulmonary disease, although wood smoke in urban areas of underdeveloped countries is now recognized as a leading cause of respiratory disease. Mycotoxins from fungal spores pose an occupational risk for respiratory illness and also present a health hazard to those living in damp buildings. Microscopic airborne particulates of asbestos and silica (from building materials) and those of heavy metals (from paint) are additional sources of indoor air pollution that contributes to respiratory illness and is known to cause respiratory illness in experimental animals. Ricin in aerosolized form is a potential bioweapon that is extremely toxic yet relatively easy to produce. Although the aforementioned agents belong to different classes of toxic chemicals, their pathogenicity is similar. They induce the recruitment and activation of macrophages, activation of mitogen-activated protein kinases, inhibition of protein synthesis, and production of interleukin-1 beta. Targeting either macrophages (using nanoparticles) or the production of interleukin-1 beta (using inhibitors against protein kinases, NOD-like receptor protein-3, or P2X7) may potentially be employed to treat these types of lung inflammation without affecting the natural immune response to bacterial infections.
Collapse
Affiliation(s)
- John Wong
- School of Nursing, MGH Institute of Health Professions, Boston, MA, USA
| | - Bruce E Magun
- School of Nursing, MGH Institute of Health Professions, Boston, MA, USA
| | - Lisa J Wood
- School of Nursing, MGH Institute of Health Professions, Boston, MA, USA
| |
Collapse
|