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.

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.

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.

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.