What happens to COPD patients before an admission with exacerbation?

AIM: To obtain patient-generated data relating to the management of their chronic obstructive pulmonary disease (COPD) in Primary Care before hospitalisation with exacerbation. BACKGROUND: Previous audits of COPD have shown high rates of hospital admission and readmission. There is significant interest in understanding the reasons so that useful preventative strategies may be developed. As part of the 2008 UK COPD audit, which comprised 9716 cases of COPD admission across 97% of acute units, we obtained a sample of patient-generated data to assess understanding of COPD, use of healthcare resources, access to care and self-management in Primary Care prior to hospitalisation with exacerbation. We anticipated the data would provide useful insight for directing improvement strategies. METHOD: A paper-based, anonymised survey was completed by patients identified as having exacerbation by participating hospital teams. Response rate was an estimated 46%. FINDINGS: Understanding and awareness of COPD was very variable. Patients noticed symptoms of COPD exacerbation, particularly change in sputum, for some time prior to hospitalisation but tended not to react promptly to these changes. A minority had self-care plans, many bypassed Primary Care Services and there was variable access to a named health professional or advice. Patients using home oxygen and nebulisers were at particular risk of admission. CONCLUSION: We conclude these sick patients use a lot of resources and the data suggest a need to support and educate them in the proactive management of exacerbation. There needs to be better 'exacerbation planning' so patients know how to recognise and treat flare-up but also whom to contact in the event of decline. Targetted support should be considered for the most vulnerable, particularly those using home oxygen and nebulisers, who have very high rates of hospitalisation.

Managing patients with COPD exacerbation: does age matter?

INTRODUCTION: there is little information about the relationship between age and management of COPD exacerbation (AECOPD), although older persons are known to be at a greater risk of hospital admission. METHODS: we have investigated responses from the clinical and patient questionnaire elements of the 2008 UK COPD audit, splitting the data into age decile. RESULTS: age ranged from 27 to 102. Patient-reported data suggested older patients had inferior knowledge of COPD, undertook less self-care and were less likely to recognise symptoms of exacerbation prior to hospitalisation. Clinician-reported data showed that although older patients had severe disease and symptoms, greater co-morbidity at presentation and higher mortality, fewer were seen in hospital or followed up subsequently by respiratory specialists. Older patients were more likely to have a DNR order signed within 24 h of admission, irrespective of co-morbidities or performance status. The observations were particularly applicable to those aged 80 or above. CONCLUSIONS: clinicians should consider increasing age as a specific risk factor in the management of COPD. Acute units and community teams should review carefully their protocols and pathways for how they assess, manage, discharge and follow-up older patients with COPD exacerbation.

A randomized trial of peer review: the UK National Chronic Obstructive Pulmonary Disease Resources and Outcomes Project: three-year evaluation.

RATIONALE: Peer review has been widely used within the National Health Service to facilitate health quality improvement but evaluation has been limited particularly over the longer-term. Change within the National Health Service (NHS) can take a prolonged period--1-2 years--to occur. We report here a 3-year evaluation of the largest randomized trial of peer review ever conducted in the UK. AIM: To evaluate whether targeted mutual peer review of respiratory units brings about improvements in services for chronic obstructive pulmonary disease (COPD) over 3 years. METHODS: The peer review intervention was a reciprocal supportive exercise that included clinicians, hospital management, commissioners and patients, which focused on the quality of the provision of four specific evidence-based aspects of COPD care. RESULTS: Follow-up at 36 months demonstrated limited significant quantitative differences in the quality of services offered in the two groups but a strong trend in favour of intervention sites. Qualitative data suggested many benefits of peer review in most but not all intervention units and some control teams. The data identify factors that promote and obstruct change. CONCLUSION: The findings demonstrate significant change in service provision over 3 years in both control and intervention sites with great variability in both groups. The combined quantitative and qualitative findings indicate that targeted mutual peer review is associated with improved quality of care, improvements in service delivery and with changes within departments that promote and are precursors to quality improvement. The generic findings of this study have potential implications for the application of peer review throughout the NHS.

Co-morbidities and 90-day outcomes in hospitalized COPD exacerbations.

COPD exacerbations resulting in hospitalization are accompanied by high mortality and morbidity. The contribution of specific co-morbidities to acute outcomes is not known in detail: existing studies have used either administrative data or small clinical cohorts and have provided conflicting results. Identification of co-existent diseases that affect outcomes provides opportunities to address these conditions proactively and improve overall COPD care. Cases were identified prospectively on admission then underwent retrospective case note audit to collect data including co-morbidities on up to 60 unselected consecutive acute COPD admissions between March and May in each hospital participating in the 2008 UK National COPD audit. Outcomes recorded were death in hospital, length of stay, and death and readmission at 90 days after index admission. 232 hospitals collected data on 9716 patients, mean age 73, 50% male, mean FEV1 42% predicted. Prevalence of co-morbidities were associated with increased age but better FEV1 and ex-smoker status and with worse outcomes for all four measures. Hospital mortality risk was increased with cor pulmonale, left ventricular failure, neurological conditions and non-respiratory malignancies whilst 90 day death was also increased by lung cancer and arrhythmias. Ischaemic and other heart diseases were important factors in readmission. This study demonstrates that co-morbidities adversely affect a range of short-term patient outcomes related to acute admission to hospital with exacerbations of COPD. Recognition of relevant accompanying diseases at admission provides an opportunity for specific interventions that may improve short-term prognosis.

Current and planned palliative care service provision for chronic obstructive pulmonary disease patients in 239 UK hospital units: comparison with the gold standards framework.

Patients with chronic obstructive pulmonary disease report a symptom burden similar in magnitude to terminal cancer patients yet service provision and access has been reported as poor. In the absence of a specific national chronic obstructive pulmonary disease service framework the gold standards framework might support service developments. We surveyed 239 UK acute hospital units admitting chronic obstructive pulmonary disease patients, comprising 98% of all acute trusts, about their current and planned provision for palliative care services. Only 49% of units had a formal referral pathway for palliative care and only 13% had a policy of initiating end-of-life discussions with appropriate patients. Whilst 66% of units had plans to develop palliative care services, when mapped against the gold standards framework few were directly relevant and only three of the seven key standards were covered to any significant degree. We conclude that service provision remains poor and access is hindered by a lack of proactive initiation of discussion. Planned developments in chronic obstructive pulmonary disease palliative care services also lack a strategic framework that risks holistic design.

Exploring the outcomes and implications of the latest national COPD audit.

Publication of the clinical strategy for COPD is expected at the end of the year and it is anticipated that this will provide a structure to improve management of the condition. The latest national COPD audit has shown that although services have improved since the last audit in 2003, there are key areas in COPD management that need to be improved. This article analyses the results of this audit and the implications for practice.

Introducing the national COPD resources and outcomes project.

BACKGROUND: We report baseline data on the organisation of COPD care in UK NHS hospitals participating in the National COPD Resources and Outcomes Project (NCROP). METHODS: We undertook an initial survey of participating hospitals in 2007, looking at organisation and performance indicators in relation to general aspects of care, provision of non-invasive ventilation (NIV), pulmonary rehabilitation, early discharge schemes, and oxygen. We compare, where possible, against the national 2003 audit. RESULTS: 100 hospitals participated. These were typically larger sized Units. Many aspects of COPD care had improved since 2003. Areas for further improvement include organisation of acute care, staff training, end-of-life care, organisation of oxygen services and continuation of pulmonary rehabilitation. KEY POINTS: positive change occurs over time and repeated audit seems to deliver some improvement in services. It is necessary to assess interventions such as the Peer Review used in the NCROP to achieve more comprehensive and rapid change.