Factors Influencing the Treatment of COPD
Lindenauer PK, Pekow P, Gao S, et al. Quality of care for patients hospitalized for acute exacerbations of chronic obstructive pulmonary disease. Ann Intern Med. 2006;144:894-903.
Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death in the United States, resulting in more than $18 billion in annual health costs. Acute exacerbations of COPD can lead to respiratory compromise and are one of the 10 leading causes of hospitalization in the United States.
Hospitalists currently have evidence-based guidelines available that recommend therapies for patients with acute exacerbations of COPD. This study was designed to evaluate the practice patterns in the United States and to evaluate the quality of care provided to hospitalized patients based on comparisons with these published guidelines. The authors did not report any conflicts of interest, and this work was performed without external grant support.
Using administrative data from the 360 hospitals that participate in Perspective, a database developed for measuring healthcare quality and utilization, the authors performed a retrospective cohort study. Patients hospitalized for a primary diagnosis of acute exacerbation of COPD were chosen. Patients with pneumonia were specifically excluded. The outcomes of interest included adherence to the diagnostic and therapeutic recommendations of the joint American College of Physicians and American College of Chest Physicians evidence-based COPD guideline, published in 2001.
Of the 69,820 patients included in the analysis, 33% received “ideal care,” defined as all of the recommended care and none of the non-beneficial interventions. Specific results included varied utilization of recommended care: 95% had chest radiography, 91% received supplemental oxygen, 97% had bronchodilators, 85% were given systemic steroids, and 85% received antibiotics.
Overall, 45% of patients received at least one non-beneficial intervention specified in the guidelines: 24% were treated with methylxanthines, 14% underwent sputum testing, 12% had acute spirometry, 6% received chest physiotherapy, and 2% were given mucolytics.
Older patients and women were more likely to receive ideal care as defined, but hospitals with a higher annual volume of COPD cases were not associated with improved performance in this analysis.
Given a widely accepted evidence-based practice guideline as a benchmark, significant variation exists across hospitals in the quality of care for acute exacerbations of COPD. Opportunities exist to improve the quality of care, in particular by increasing the use of systemic corticosteroids and antibiotic therapy and reducing the utilization of many diagnostic and therapeutic interventions that are not only not recommended but are also potentially harmful.
COPD management in the acute inpatient setting is on the horizon as a focus of policymakers, and this study suggests that significant opportunities exist for inpatient physicians to reduce variation in practice and utilize an evidence-based approach to the treatment of acute exacerbations of COPD. This study is limited by its use of administrative data, its inability to use clinical data to best determine appropriate care processes for individual patients, and its retrospective design.
As we move toward external quality metrics for the care of patients with acute exacerbations of COPD, further prospective studies evaluating clinical outcomes of interest, including mortality and readmission rates, are needed to determine the effects of adherence to ideal or recommended care for acute exacerbations of COPD.1-3
- Snow V, Lascher S, Mottur-Pilson C, et al. Evidence base for management of acute exacerbations of chronic obstructive pulmonary disease. Ann Intern Med. 2001 Apr 3;134(7):595-599.
- American Thoracic Society. Standards for the diagnosis and care of patients with chronic obstructive pulmonary disease (COPD) and asthma. This official statement of the American Thoracic Society was adopted by the ATS Board of Directors, November 1986. Am Rev Respir Dis. 1987 Jul;136(1):225-244.
- Agency for Healthcare Research and Quality. Management of Acute Exacerbations of Chronic Obstructive Pulmonary Disease. Rockville, Md.: Agency for Healthcare Research and Quality; 2000.