Admissions to hospital with exacerbations of chronic obstructive pulmonary disease: Effect of age related factors and service organisation.

BACKGROUND: Exacerbations of chronic obstructive pulmonary disease (COPD) have a high rate of mortality which gets worse with advancing age. It is unknown whether this is due to age related deficiencies in process of care. A study was undertaken in patients with COPD exacerbations admitted to UK hospitals to assess whether there were age related differences in the process of care that might affect outcome, and whether different models of care affected process and outcome. METHODS: 247 hospital units audited activity and outcomes (inpatient death, death within 90 days, length of stay (LOS), readmission within 90 days) for 40 consecutive COPD exacerbation admissions in autumn 2003. Logistic regression methods were used to assess relationships between process and outcome at p < 0.001. RESULTS: 7514 patients (36% aged > or = 75 years) were included. Patients aged > or = 75 years were less likely to have blood gases documented, to have FEV1 recorded, or to be given systemic corticosteroids. Those admitted under care of the elderly (CoE) physicians were less likely to enter early discharge schemes or to receive non-invasive ventilation when acidotic. Overall inpatient and 90 day mortality was 7.4% and 15.3%, respectively. Inpatient and 90 day adjusted odds mortality rates for those aged > or = 85 years (versus < or = 65 years) were 3.25 and 2.54, respectively. Mortality was unaffected by admitting physician (CoE v general v respiratory). Age predicted LOS but not readmission. Age related deficiencies in process of care did not predict inpatient or 90 day mortality, readmission, or LOS. CONCLUSIONS: Management of COPD exacerbations varies with age in UK hospitals. Inpatient and 90 day mortality is approximately three times higher in very elderly patients with a COPD exacerbation than in younger patients. Age related deficiencies in the process of care were not associated with mortality, but it is likely that they represent poorer quality of care and patient experience. Recommended standards of care should be applied equally to elderly patients with an exacerbation of COPD.

UK National COPD Audit 2003: Impact of hospital resources and organisation of care on patient outcome following admission for acute COPD exacerbation.

BACKGROUND: Acute chronic obstructive pulmonary disease (COPD) exacerbations use many hospital bed days and have a high rate of mortality. Previous audits have shown wide variability in the length of stay and mortality between units not explained by patient factors. This study aimed to explore associations between resources and organisation of care and patient outcomes. METHODS: 234 UK acute hospitals each prospectively identified 40 consecutive acute COPD admissions, documenting process of care and outcomes from a retrospective case note audit. Units also completed a resources and organisation of care proforma. RESULTS: Data for 7529 patients were received. Inpatient mortality was 7.4% and mortality at 90 days was 15.3%; the readmission rate was 31.4%. Mean length of stay for discharged patients was 8.7 days (median 6 days). Wide variation was observed in all outcomes between hospitals. Both inpatient mortality (odds ratio (OR) 0.67, CI 0.50 to 0.90) and 90 day mortality (OR 0.75, CI 0.60 to 0.94) were associated with a staff ratio of four or more respiratory consultants per 1000 hospital beds. The length of stay was reduced in units with more respiratory consultants, better organisation of care scores, an early discharge scheme, and local COPD management guidelines. CONCLUSIONS: Units with more respiratory consultants and better quality organised care have lower mortality and reduced length of hospital stay. This may reflect unit resource richness. Dissemination of good organisational practice and recruitment of more respiratory specialists offers the potential for improved outcomes for hospitalised COPD patients.

The relationship between the quality of prescribing and practice appointment rates with asthma management data in those admitted to hospital due to an acute exacerbation.

Specific targeting of patients with a previous asthma hospitalisation could be more focused if predictors could be identified. This study was an observational retrospective analysis using ridge and linear multivariate regression analysis. Patient asthma management data were extracted from the hospital and general practice notes of those that had been admitted with an acute exacerbation of their asthma over a 5-year period. From the prescribing data, the annual doses of preventer (P) and reliever (R) medication were converted to defined daily doses then divided to give a P:R ratio. Preliminary statistical analysis was used to identify any association between either the P:R ratio or for the number of general practitioner (GP) practice appointments (PA) and their asthma management data. Multivariate regression analysis was applied to the P:R ratio and to PA to determine a model between each of these and asthma management data/events. GPs gave consent to access the data of 115 (out of 440) asthmatics, age >5 years, admitted to a district general hospital for asthma exacerbations between 1994 and 1998. The multivariate analysis revealed that PA was associated with oral prednisolone rescue courses (PRCs) and age whilst the P:R ratio was associated to PRCs and more reliever usage but not preventers. Patients with low preventer usage with respect to their reliever medication should be targeted for medication review as these were the patients prescribed more prednisolone courses and their increased PAs reflect this. This could decrease visits to the doctor and acute exacerbations.

A Cox regression analysis of covariates for asthma hospital readmissions.

BACKGROUND: Asthma hospital admissions and readmissions are unacceptably high, thus, a method to identify those at greatest risk could be helpful. METHODS: An observational retrospective study using a Cox regression to determine the relationship between the time interval between admissions and possible covariates of a readmission. The covariates were age, sex, ethnicity, smoking habit, history of allergy or eczema/hay fever, age of onset, Townsend index (TI), Jarman score (JS), and drugs on discharge. Those with p < 0.2, together with interacting covariates, from the preliminary analysis were eligible for the multivariate Cox regression analysis. RESULTS: Of the 523 patients admitted between 1994 and 1998 because of their asthma, complete data were available for 440. Of these, 112 were readmitted. Eligible covariates for the multivariate Cox regression analysis were sex, allergy status, history of eczema/hay fever, the JS and TI together with interactions between JS and TI, JS and allergy, and allergy with eczema/hay fever. There were 278 subjects (71 with a readmission) with complete data for these eligible covariates. The multivariate analysis revealed that female sex (odds ratio [OR] = 2.65, 95% confidence interval [CI] 1.42, 4.92), high JS (OR = 2.03, 95% CI 1.13-3.65), and history of allergy (OR = 1.88, 95% CI 1.06-3.32) formed the final model as significant predictors of readmission. CONCLUSION: Females with a history of allergy that were registered at a practice with a high workload (JS) had a higher risk of readmission. The analysis method used highlights how those at risk of readmission can be identified so that they can be targeted post discharge.

Choice of add-on therapy in asthma - another inhaler or a tablet/syrup? A survey of 1415 UK asthmatics.

OBJECTIVES: To determine preferences for asthma treatment given as inhaled therapy or as a tablet / syrup, to identify factors that influence this choice, and to assess how many patients would sacrifice greater efficacy of therapy in order to use the delivery route of their choice. DESIGN: Postal Questionnaire to patients with an active diagnosis of asthma aged less than 60 years under the care of general practitioners, paediatricians or adult respiratory physicians. MAIN OUTCOME MEASURE: Patient preference for inhaled therapy or tablet/syrup. RESULTS: 715 replies were analysed (93% Caucasian). 58% (417) preferred tablets (p<0.01) based on an equal chance of symptom improvement. There was no sex difference, but more children aged 6-10 and parents of under 6 year olds preferred tablets or syrup than adults (65% vs. 54%, p=0.03). Preference for tablets increased with number of current inhalers (p<0.05) but there was no correlation with total number of puffs per day or numbers of existing tablets taken. 238 (36%) opted for their preferred route of delivery in preference to greater efficacy. CONCLUSION: More asthmatics would choose a tablet or syrup than another inhaler as add-on therapy for their asthma. This preference was more marked in children and in patients already taking several inhalers. 36% of patients are prepared to sacrifice greater efficacy in favour of their choice of route of delivery.

Primary pulmonary botryomycosis: a late complication of foreign body aspiration.

Primary pulmonary botryomycosis is a rare cause of haemoptysis and can enter the differential diagnosis of a mass on the plain chest radiograph. The case history is presented of a 63 year old man with botryomycosis which was initially thought to be a bronchial carcinoma. When the diagnosis was made several years later it was found to be secondary to persisting vegetable material in the bronchial tree following previous aspiration.

Churg-Strauss syndrome associated with montelukast therapy.

Churg-Strauss syndrome is a rare form of eosinophilic vasculitis associated with asthma. There have been several recent case reports of the condition in association with leukotriene antagonists and it has been speculated that the Churg-Strauss syndrome was unmasked when oral corticosteroids were withdrawn. We report a case of Churg-Strauss syndrome associated with montelukast therapy in an asthmatic patient in whom there had been no recent oral corticosteroid use. We believe that this is the first such reported case and would suggest that clinicians need to be vigilant in all patients who develop systemic symptoms when starting treatment with leukotriene antagonists.

Modified ice study: a phase II study of an intensive, modified ICE regimen (ifosfamide, carboplatin and etoposide) in patients with better prognosis, small cell lung cancer.

A total of 30 with good prognosis small cell lung cancer were treated with a modified 'ICE' (ifosfamide, carboplatin and etoposide) chemotherapy regimen in an attempt to achieve a high response rate with less toxicity than is seen with the full 'ICE' regimen. This was given every 4 weeks for a maximum of six cycles. In total 25 patients (83%, 95% CI (70-97%)) experienced a partial or complete response at some stage of their treatment. Of these patients, 12 (40%, 95% CI (22-58%)) showed a complete response. A total of 19 patients (63%) had to have their dose reduced and/or delayed at some point due to toxicity. Nadir blood counts showed that 19 patients (63%, 95% CI (46-81%)) had WHO grade 3 or 4 thrombocytopenia, and 24 (86%, 95% CI (73-99%)) had grade 3 or 4 neutropenia. A total of 17 patients (53%) completed six cycles of chemotherapy. In total 3 patients died during treatment all due to treatment-related complications. Median survival was 12.6 months (95% CI (11.6, 14.7 months)). Nausea, vomiting, dysphagia, activity, mood and overall condition, as recorded using daily diary cards, were worse at the beginning of each chemotherapy cycle. Both response rates and survival were clinically acceptable. However, neutropenia and thrombocytopenia, although reduced from rates reported with the full ICE regimen, were still high. A prospective randomised controlled trial is now needed to assess this regimen in more detail.

Slowing the rate of acute medical admissions.

We studied the effectiveness of a dedicated medical receiving room (MRR) with senior registrar (SR) assessment of GP requests for medical admission. In the first of three 16-week study periods, patients were assessed by senior house officers or registrars. In the second period, patients were assessed by a single SR. In the third period, nine SRs manned the MRR on a rota. Outcome measures included same-day discharge rate, use of specialist beds and 28-day readmission rate. A questionnaire was sent to general practitioners (GPs) of patients discharged in period three to assess their satisfaction with the service. The same-day discharge rate increased from 3.6% in period one to 29% in period two (p < 0.001) and 15% in period three (p < 0.001). The use of specialist and off-site beds also increased from 1.2 per week in period one to 2.9 in period two and 3.1 in period three. The 28-day readmission rate was 13.3% in period one, 6.9% in period two and 6% in period three. The GPs were satisfied with the service provided by the MRR and all felt that the discharge was appropriate. Assessment of GP referrals for acute medical admission by SRs in a MRR allows more patients to be safely discharged on the same day than if the assessment is carried out by a more junior doctor. SRs also direct more patients to the relevant specialty, so improving patient care and effective use of available beds.

The prevalence and clinical significance of pulmonary infection due to non-tuberculous mycobacteria in Hong Kong.

An unexpected increase in positive sputum cultures of non-tuberculous mycobacteria (NTM) was noted in Hong Kong in 1990 compared to previous years, in contrast to a steady decline in the number of positive cultures of Mycobacterium tuberculosis. A retrospective case note study was therefore undertaken to ascertain the clinical importance of the rise in NTM isolates. A representative sample of 183 of the 675 patients with NTM isolates from sputum during 1990 was identified. Cases were assigned to groups according to whether there was evidence of progressive pulmonary disease due to NTM (group 1), persisting colonization without evidence of progressive disease (group 2) or transient isolation of NTM without evidence of progressive disease (group 3). Of 168 cases with adequate clinical and radiological records, 28 (16.7%) represented progressive disease due to NTM and 6 (3.6%) represented persisting colonization. The remainder were both transient and clinically insignificant. Most patients (71%) with progressive pulmonary disease due to NTM had pre-existing lung damage, and 50% had received anti-tuberculous therapy for documented M. tuberculosis previously. The commonest organism involved was the M avium complex. Eighty-six percent of patients with progressive disease and 83% of those with persisting colonization had at least one smear positive sputum specimen, whereas only 2% of patients with sputum contamination had a smear positive sputum sample (P < 0.0001). M. malmoense, M. xenopi and M. fortuitum all appear to be rare causes of significant NTM disease in Hong Kong. However, M. chelonei caused four cases of progressive disease within the study population, two of which were fatal.(ABSTRACT TRUNCATED AT 250 WORDS)

Assessment and provision of home nebulizers for chronic obstructive pulmonary disease (COPD) in the Yorkshire region of the U.K.

A survey was undertaken to determine the current practice in the Yorkshire Health Region for the assessment and provision of home nebulizers for adults with chronic obstructive pulmonary disease (COPD). A detailed postal questionnaire on assessment methods was sent to each of the 22 consultant physicians in respiratory medicine. The 17 consultants who also organized the adult home nebulizer service for their health district were asked about the services offered and funding for the service. Replies were received from all consultants. All physicians use objective measurement for assessing patients for home nebulizer therapy, but there is a variable emphasis on laboratory studies, walking distance and home trials with peak flow measurements. The majority (86%) incorporate a home trial into their assessment. Many physicians also take into account subjective response to nebulized bronchodilators. There is considerable variation in the provision and funding of home nebulizer services. Those districts with a coordinated service appear to offer a more comprehensive service. A consensus on nebulizer provision, with recommendations for minimum levels of provision in each health district, should result in a more uniform delivery of service.

Mycoplasma pneumoniae infection in Hong Kong--clinical and epidemiological features during an epidemic.

An epidemic of infection due to Mycoplasma pneumoniae occurred in Hong Kong in 1986-1988. One hundred and seventy-nine cases were identified at the Prince of Wales Hospital over this period. Clinically significant infection predominantly affected children under 12 years, with 32% of all infections occurring in children aged between 6 and 11 years, and 39% in children between 1 and 5 years. Ninety-seven percent of childhood infections were respiratory in nature, the other 4 presentations were neuropsychiatric. Adequate information was available on 36 of the 43 subjects over 12 years. One teenager presented with acute psychosis; all other cases (35) were respiratory. In these cases cough was universal, and fever was present in 34 (97%). A variety of non-specific symptoms (rigors/chills, malaise, headache, sore throat, sweating) were frequently noted. Sputum production was documented in 75% of cases, and was frequently purulent. Radiological consolidation was very common (95% of cases), but resolved fully after 4 weeks. Complications were rare and included acute pericarditis in 1 patient and haemolysis in another, and both patients recovered subsequently. Clinical recovery was otherwise rapid and complete in all other patients. Persisting dry cough was the only symptom documented at follow-up. Although infection due to M. pneumoniae in an ethnic Chinese population appears similar to that described in other populations, a higher incidence in younger children was recorded in this study.

Prognostic significance of paraproteinaemia in rheumatoid arthritis.

The incidence of lymphoma and myeloma is increased in rheumatoid arthritis (RA), though the reasons for this are incompletely understood. The predictive value of monoclonal gammopathy in RA for the later development of lymphoproliferative malignancy was assessed. A serum paraprotein was discovered in 23 patients (14 female) with a median age of 58 years and a median duration of RA of six years. The paraprotein was quantified and further investigations, including a bone marrow examination and skeletal survey, were undertaken to study the possible development of a lymphoproliferative disorder. Secondary Sjögren's syndrome was noted in 12 patients. The paraprotein was monoclonal in 21 patients and was classed as IgG (12 cases), IgA (six cases), or IgM (three cases). Biclonal paraproteins were seen in two patients. Free light chains were found in the urine of eight patients. Bone marrow abnormalities were found in 13 subjects. The bone marrow was abnormal in four of six patients with an IgA paraprotein, in two of three with an IgM paraprotein but in only five of 12 patients with an IgG paraprotein. Patients were followed up for a median of four years, and five patients with an abnormal bone marrow developed myeloma, of whom three had an IgA lambda paraprotein. Two other patients developed non-Hodgkin's lymphoma. Extra-articular bone erosions were seen in four patients, three of whom developed myeloma, but the presence of urinary free light chains was not specific for the development of malignancy. Paraproteinaemia in RA indicates monoclonal B cell proliferation and carries a high risk of malignant transformation.