Primary Care Management of Chronic Obstructive Pulmonary Disease to Reduce Exacerbations and Their Consequences

Chronic Rhinitis Is a High-Risk Comorbidity for 30-Day Hospital Readmission of Patients with Asthma and Chronic Obstructive Pulmonary Disease

BACKGROUND

Early hospital readmissions for asthma and chronic obstructive pulmonary disease (COPD), measured as hospital readmission within 30 days from the last discharge, is a major economic burden to our health care system. The association of this measure with comorbid chronic rhinitis (CR) has not been investigated before despite significant clinical association between CR and asthma or COPD.

OBJECTIVE

To investigate the association of CR with the risk of asthma or COPD-related early hospital readmission rates.

METHODS

This retrospective cohort study was performed using the asthma- and COPD-related hospital encounter and patient comorbidity data between June 15, 2012, and July 19, 2017, from a large hospital care system in Cincinnati, Ohio. Patients (any sex, race or socioeconomic status, and of all ages) with a primary discharge diagnosis of asthma (n = 4754 patients, 10,111 encounters) and COPD (n = 2176 patients, 4748 encounters) based on International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes were included. Relevant comorbidities, including comorbid allergic rhinitis (AR) or nonallergic rhinitis (NAR), in such patients were identified using ICD-10-CM codes. The association between 30-day asthma or COPD-related hospital readmission (1670 such encounters for asthma and 736 for COPD) and comorbid CR in the affected patients were determined using Cox proportional hazards models. Multivariate-adjusted hazard ratios (HRs), adjusted for relevant patient comorbidities, compared 30-day asthma- and COPD-related readmissions of patients with CR with those patients without a CR diagnosis.

RESULTS

Analysis was performed on 4754 patients with asthma and 2176 patients with COPD. The median follow-up period (+interquartile range) for asthma was 980 (+760) days and for COPD was 553 (+827) days. The HRs for 30-day asthma- or COPD-related readmission rates were significantly higher in patients with AR (HR = 4.4 [3.9, 5.0] and 2.4 [1.7, 3.2], respectively) or NAR (HR = 3.7 [2.9, 4.9] and 2.6 [1.8, 3.7], respectively) compared with patients without rhinitis. For asthma, both AR and NAR had higher HRs compared with all other comorbidities analyzed. For COPD, both AR and NAR had HRs to the magnitude as obesity and hypertension.

CONCLUSIONS

Comorbid CR is significantly associated with 30-day asthma- and COPD-related readmissions. These findings are useful for guiding health care professionals to focus on outpatient management of both the upper and lower respiratory tracts to reduce early readmission of patients with asthma and COPD.

[Effects of Geriatric COPD rehabilitation on hospital admissions and exercise tolerance: a retrospective observational study]

INTRODUCTION

Frail COPD patients are frequently not accepted for regular pulmonary rehabilitation programs due to low physical condition and functional limitations. Rehabilitation programs in nursing homes for geriatric patients with COPD have been developed. The effects of such programs are largely unknown.

AIMS

To assess the course of COPD-related hospital admissions and exercise tolerance in a cohort of frail COPD patients participating in geriatric COPD rehabilitation.

METHODS

Retrospective observational study with a follow up of 12 months after discharge from rehabilitation. COPD related hospital admission days were measured in the year before and after participating rehabilitation. Exercise tolerance was measured by the six minute walk test (6MWT) at admission and at discharge from rehabilitation.

RESULTS

Fifty-eight participants accomplished the rehabilitation program. Twelve patients died in the first year after discharge. The median number of hospital admission days in the year before participating rehabilitation was 21 (IQR 10-33). The first year after discharge this was decreased to a median of 6 (IQR 0-12). The 6MWT increased from 194 (SD 85) meters at admission to 274 (SD 95) meters at discharge (mean difference 80 m, SD 72; p < 0.05).

CONCLUSIONS

Geriatric COPD rehabilitation in a nursing home setting seems to reduce hospital admissions in frail COPD patients and to increase exercise tolerance.

Implementation of a novel population panel management curriculum among interprofessional health care trainees

BACKGROUND

Gaps in chronic disease management have led to calls for novel methods of interprofessional, team-based care. Population panel management (PPM), the process of continuous quality improvement across groups of patients, is rarely included in health professions training for physicians, nurses, or pharmacists. The feasibility and acceptance of such training across different healthcare professions is unknown. We developed and implemented a novel, interprofessional PPM curriculum targeted to diverse health professions trainees.

METHODS

The curriculum was implemented annually among internal medicine residents, nurse practitioner students and residents, and pharmacy residents co-located in a large, academic primary care site. Small groups of interprofessional trainees participated in supervised quarterly seminars focusing on chronic disease management (e.g., diabetes mellitus, hypertension, or chronic obstructive pulmonary disease) or processes of care (e.g., emergency department utilization for nonacute conditions or chronic opioid management). Following brief didactic presentations, trainees self-assessed their clinic performance using patient-level chart review, presented individual cases to interprofessional staff and faculty, and implemented subsequent feedback with their clinic team. We report data from 2011 to 2015. Program evaluation included post-session participant surveys regarding attitudes, knowledge and confidence towards PPM, ability to identify patients for referral to interprofessional team members, and major learning points from the session. Directed content analysis was performed on an open-ended survey question.

RESULTS

Trainees (n = 168) completed 122 evaluation assessments. Trainees overwhelmingly reported increased confidence in using PPM and increased knowledge about managing their patient panel. Trainees reported improved ability to identify patients who would benefit from multidisciplinary care or referral to another team member. Directed content analysis revealed that trainees viewed team members as important system resources (n = 82).

CONCLUSIONS

Structured interprofessional training in PPM is both feasible and acceptable to trainees across multiple professions. Curriculum participants reported improved panel management skills, increased confidence in using PPM, and increased confidence in identifying candidates for interprofessional care. The curriculum could be readily exported to other programs and contexts.

Chronic disease burden among cancer survivors in the California Behavioral Risk Factor Surveillance System, 2009-2010

PURPOSE

The California Behavioral Risk Factor Surveillance System estimates that 56.6 % of cancer survivors report ever being diagnosed with a chronic disease. Few studies have assessed potential variability in comorbidity by cancer type.

METHODS

We used data collected from a representative sample of adult participants in the 2009 and 2010 California Behavioral Risk Factor Surveillance System (n = 18,807). Chronic diseases were examined with cancer survivorship in case/non-case and case/case analyses. Prevalence ratios (PR) and corresponding 95 % confidence intervals (95 % CI) were estimated using Cox proportional hazards models, with adjustment on race, sex, age, education, smoking, and drinking.

RESULTS

Obesity was associated with gynecological cancers (PR 1.74; 95 % CI 1.26-2.41), and being overweight was associated with gynecological (PR 1.40; 95 % CI 1.05-1.86) and urinary (PR 2.19; 95 % CI 1.21-3.95) cancers. Arthritis was associated with infection-related (PR 1.78; 95 % CI 1.12-2.83) and hormone-related (PR 1.20; 95 % CI 1.01-1.42) cancers. Asthma was associated with infection- (PR 2.26; 95 % CI 1.49-3.43), hormone- (PR 1.46; 95 % CI 1.21-1.77), and tobacco- (PR 1.86; 95 % CI 1.25-2.77) related cancers. Chronic obstructive pulmonary disease (COPD) was associated with infection- (PR 2.16; 95 % CI 1.22-3.83) and tobacco-related (PR 2.24; 95 % CI 1.37-3.66) cancers and with gynecological cancers (PR 1.60; 95 % 1.00-2.56).

CONCLUSIONS

This is the first study to examine chronic disease burden among cancer survivors in California. Our findings suggest that the chronic disease burden varies by cancer etiology.

IMPLICATIONS FOR CANCER SURVIVORS

A clear need has emerged for future biological and epidemiological studies of the interaction between chronic disease and cancer etiology in survivors.

The complexity of managing COPD exacerbations: a grounded theory study of European general practice

OBJECTIVES

To understand the concerns and challenges faced by general practitioners (GPs) and respiratory physicians about primary care management of acute exacerbations in patients with chronic obstructive pulmonary disease (COPD).

DESIGN

21 focus group discussions (FGDs) were performed in seven countries with a Grounded Theory approach. Each country performed three rounds of FGDs.

SETTING

Primary and secondary care in Norway, Germany, Wales, Poland, Russia, The Netherlands, China (Hong Kong).

PARTICIPANTS

142 GPs and respiratory physicians were chosen to include urban and rural GPs as well as hospital-based and out patient-clinic respiratory physicians.

RESULTS

Management of acute COPD exacerbations is dealt with within a scope of concerns. These concerns range from 'dealing with comorbidity' through 'having difficult patients' to 'confronting a hopeless disease'. The first concern displays medical uncertainty regarding diagnosis, medication and hospitalisation. These clinical processes become blurred by comorbidity and the social context of the patient. The second concern shows how patients receive the label 'difficult' exactly because they need complex attention, but even more because they are time consuming, do not take responsibility and are non-compliant. The third concern relates to the emotional reactions by the physicians when confronted with 'a hopeless disease' due to the fact that most of the patients do not improve and the treatment slows down the process at best. GPs and respiratory physicians balance these concerns with medical knowledge and practical, situational knowledge, trying to encompass the complexity of a medical condition.

CONCLUSIONS

Knowing the patient is essential when dealing with comorbidities as well as with difficult relations in the consultations on exacerbations. This study suggests that it is crucial to improve the collaboration between primary and secondary care, in terms of, for example, shared consultations and defined work tasks, which may enhance shared knowledge of patients, medical decision-making and improved management planning.

Predictors of exacerbations of asthma and COPD during one year in primary care

AIMS

To investigate the incidence of asthma and chronic obstructive pulmonary disease (COPD) exacerbations in primary care during one year and to identify risk factors for such events.

METHODS

The study was carried out at seven general practice offices in Norway. Patients aged 40 years or more registered with a diagnosis of asthma and/or COPD the previous 5 years were included. After a baseline examination, the participants consulted their GP during exacerbations for the following 12 months. A questionnaire on exacerbations during the follow-up year was distributed to all. Univariable and multivariable logistic regression was performed to determine predictors of future exacerbations.

RESULTS

Three hundred and eighty patients attended the baseline examination and complete follow-up data were retrieved from 340 patients. COPD as defined by forced expiratory volume in the first second of expiration/forced vital capacity (FEV1/FVC) < 0.7, was found in 132 (38.8%) patients. One hundred and fifty-nine patients (46.8%) experienced one exacerbation or more and 101 (29.7%) two exacerbations or more. Patients who had an exacerbation treated with antibiotics or systemic corticosteroids or leading to hospitalization the year before baseline (N = 88) had the highest risk of getting an exacerbation during the subsequent year (odds ratio 9.2), whether the FEV1/FVC was below 0.7 or not. Increased risk of future exacerbations was also related to age ≥ 65 years and limitations in social activities, but not to the FEV1.

CONCLUSIONS

The study confirms that previous exacerbations strongly predict future exacerbations in patients with COPD or asthma. Identification and a closer follow-up of patients at risk of such events could promote earlier treatment when necessary and prevent a rapid deterioration of their condition.

The impact of aerosolized mucolytic agents on the airflow resistance of bacterial filters used in mechanical ventilation

BACKGROUND/PURPOSE

In order to reduce the contamination in the ventilator, bacterial filters were placed on the expiratory limb of a ventilator circuit. Aerosolized mucolytic agents may increase the resistance of the ventilator. The goal of this study is to determine the impact of aerosolized mucolytic agents on the pressure change during mechanical ventilation.

METHODS

A lung model was investigated with mucolytic inhaled agents of 10% acetylcysteine and 2% hypertonic saline. The agents were administered using a jet nebulizer every 45 minutes for 15 minutes. The pressure drop was measured after nebulization. The end point was referred to the 45(th) dose or obstruction of the filter. Furthermore, the pressure drop after steam autoclaving was also measured.

RESULTS

The maximum pressure was significantly higher with 10% acetylcysteine than with 2% sodium chloride (39.32 ± 7.22 cmH2O vs. 3.53 ± 0.90 cmH2O, p < 0.001). With acetylcysteine filters, the pressure drop over 4 cmH2O occurred earlier and had a good relationship between the degree of pressure drop and doses. The acetylcysteine group yielded a significant difference in the pressure drop compared to the newly autoclaved and the end point of inhalation (p = 0.043).

CONCLUSION

This study demonstrated the aerosolized mucolytic agents could increase the pressure drop of the bacterial filters during mechanical ventilation. The pressure drop of the bacterial filters was higher with 10% acetylcysteine. It is critical to continuously monitor the expiration resistance, auto-positive end-expiratory pressure, and ventilator output waveform when aerosolized 10% acetylcysteine was used in mechanical ventilation patients.

Long-term efficacy of pulmonary rehabilitation: a state-of-the-art review

PURPOSE

While the short-term efficacy of pulmonary rehabilitation in chronic obstructive pulmonary disease (COPD) is well documented, less is known about its sustainability and long-term effects in non-COPD patients, as well as secondary effects on exacerbation rates and the use of health care resources.

METHODS

We conducted a MEDLINE literature search on studies of pulmonary rehabilitation from the years 2000 to 2010. For each study, design, modalities, and outcomes were tabulated.

RESULTS

Design, group size, and duration of followup varied considerably between studies. Fifteen studies assessed physical performance, quality of life, or dyspnea in patients with COPD up to 24 months after rehabilitation. Six studies conducted followup evaluations in patients with interstitial lung disease, and 1 study considered asthma. Exacerbation rates and the use of health care resources were assessed in 20 studies in COPD and in 1 study in asthma. Results indicated the maintenance of the primary effects up to 1 year after pulmonary rehabilitation in COPD, while such effects were less pronounced in patients with interstitial lung disease. Secondary improvements regarding exacerbation rates and the use of health care resources were not consistent throughout studies and diseases.

CONCLUSIONS

Pulmonary rehabilitation has positive short- and long-term functional effects in COPD and more recent research supports improvements of exacerbation rates and the use of health care resources as secondary outcomes of pulmonary rehabilitation. Additional research on long-term efficacy regarding secondary effects and non-COPD patients is essential.

Early Identification of Exacerbations in Patients With Chronic Obstructive Pulmonary Disease

Frequent exacerbations of chronic obstructive pulmonary disease (COPD) place a considerable burden on the health care system and are a major cause of decreased health-related quality of life, accelerated pulmonary decline, and mortality in individual patients. Primary care physicians are usually the first point of contact for patients experiencing an exacerbation and are therefore best placed to prevent, identify, and treat these events in a timely manner. This review addresses the triggers and risk factors for COPD exacerbations, including the exacerbation-prone phenotype. The prevention, prompt diagnosis, and early appropriate pharmacological/nonpharmacological treatment of COPD exacerbations is important, as early recognition of symptoms (as supported by tools for measuring the illness/wellness experience of COPD patients in primary care) and treatment lead to optimal recovery in these patients. The review also highlights the importance of the urgency in identifying exacerbations and the important role played by primary care physicians in the prevention and postexacerbation management of patients with COPD.

Implementing chronic care for COPD: planned visits, care coordination, and patient empowerment for improved outcomes

Current primary care patterns for chronic obstructive pulmonary disease (COPD) focus on reactive care for acute exacerbations, often neglecting ongoing COPD management to the detriment of patient experience and outcomes. Proactive diagnosis and ongoing multifactorial COPD management, comprising smoking cessation, influenza and pneumonia vaccinations, pulmonary rehabilitation, and symptomatic and maintenance pharmacotherapy according to severity, can significantly improve a patient's health-related quality of life, reduce exacerbations and their consequences, and alleviate the functional, utilization, and financial burden of COPD. Redesign of primary care according to principles of the chronic care model, which is implemented in the patient-centered medical home, can shift COPD management from acute rescue to proactive maintenance. The chronic care model and patient-centered medical home combine delivery system redesign, clinical information systems, decision support, and self-management support within a practice, linked with health care organization and community resources beyond the practice. COPD care programs implementing two or more chronic care model components effectively reduce emergency room and inpatient utilization. This review guides primary care practices in improving COPD care workflows, highlighting the contributions of multidisciplinary collaborative team care, care coordination, and patient engagement. Each primary care practice can devise a COPD care workflow addressing risk awareness, spirometric diagnosis, guideline-based treatment and rehabilitation, and self-management support, to improve patient outcomes in COPD.

Diagnosing and treating COPD: understanding the challenges and finding solutions

Chronic obstructive pulmonary disease (COPD) is characterized by airflow obstruction that is not fully reversible; symptoms include chronic cough, sputum production, and dyspnea with exertion. An estimated 50% of the 24 million adults in the USA who have COPD are thought to be misdiagnosed or undiagnosed. Factors contributing to this include a low awareness of COPD and the initial symptoms of the disease among the general population, acceptance of these symptoms as a consequence of aging or smoking, some symptomatic similarity to asthma, and failure of health care personnel to use spirometry for diagnosis. Increased familiarization with COPD diagnosis and treatment guidelines, and proactive identification of patients with increased risk of developing COPD through occupational, environmental, or lifestyle exposures, will assist in a timely, accurate diagnosis and effective treatment, which will consequently improve patient outcomes. This review addresses the issues surrounding the diagnosis and misdiagnosis of COPD, their consequences, and how COPD can be better managed within primary care, including consideration of COPD care in patient-centered medical home and chronic care models.