Development and evaluation of a tool to optimise inhaler selection prior to hospital discharge following an exacerbation of COPD

Introduction

Rates of mortality and re-admission after a hospitalised exacerbation of COPD are high and resistant to change. COPD guidelines do not give practical advice about the optimal selection of inhaled drugs and device in this situation. We hypothesised that a failure to optimise inhaled drug and drug delivery prior to discharge from hospital after an exacerbation would be associated with a modifiable increased risk of re-admission and death. We designed a study to 1) develop a practical inhaler selection tool to use at the point of hospital discharge and 2) implement this tool to understand the potential impact on modifying inhaler prescriptions, clinical outcomes, acceptability to clinicians and patients, and the feasibility of delivering a definitive trial to demonstrate potential benefit.

Methods

We iteratively developed an inhaler selection tool for use prior to discharge following a hospitalised exacerbation of COPD using surveys with multiprofessional clinicians and a focus group of people living with COPD. We surveyed clinicians to understand their views on the minimum clinically important difference (MCID) for death and re-admission following a hospitalised exacerbation of COPD. We conducted a mixed-methods implementation feasibility study using the tool at discharge, and collated 30- and 90-day follow-up data including death and re-admissions. Additionally, we observed the tool being used and interviewed clinicians and patients about use of the tool in this setting.

Results

We completed the design of an inhaler selection tool through two rounds of consultations with 94 multiprofessional clinicians, and a focus group of four expert patients. Regarding MCIDs, there was majority consensus for the following reductions from baseline being the MCID: 30-day readmissions 5-10%, 90-day readmissions 10-20%, 30-day mortality 5-10% and 90-day mortality 5-10%. 118 patients were assessed for eligibility and 26 had the tool applied. A change in inhaled medication was recommended in nine (35%) out of 26. Re-admission or death at 30 days was seen in 33% of the switch group and 35% of the no-switch group. Re-admission or death at 90 days was seen in 56% of the switch group and 41% of the no-switch group. Satisfaction with inhalers was generally high, and switching was associated with a small increase in the Feeling of Satisfaction with Inhaler questionnaire of 3 out of 50 points. Delivery of a definitive study would be challenging.

Conclusion

We completed a mixed-methods study to design and implement a tool to aid optimisation of inhaled pharmacotherapy prior to discharge following a hospitalised exacerbation of COPD. This was not associated with fewer re-admissions, but was well received and one-third of people were eligible for a change in inhalers.

Comparison of the overall quality of life in 50 long-term survivors of autologous and allogeneic bone marrow transplantation

Fifty long-term survivors of bone marrow transplant (mean post-transplant time = 42.4 months) participated in a study examining their psychosocial adjustment and quality of life. Differences between patients who received an autologous marrow transplant and those who received an allogeneic marrow transplant were identified. Patients with an autologous transplant had mainly psychological difficulties in their post-transplant adaptation, whereas patients with allogeneic transplant developed more physical problems. Overall, their psychosocial adjustment was similar and comparable with other medical groups of patients. A quarter of both groups had failed to return to work/education and up to 9.5% had difficulty in carrying out daily tasks. Twenty per cent of the patients with autologous transplant had clinical signs of anxiety and 10% clinical signs of depression, whereas there was an incidence of 10% of patients with allogeneic transplant with anxiety, but no cases with clinical depression. Family relationships were found to be more integrated and lower in conflict compared with normal families. Quality of life has been described as good to excellent in most of the patients. Multiple regression analysis showed that physical symptomatology, vocational adjustment and depression are predictors of the degree of the patients' quality of life.

Doh keep committees strictly ethical

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