All-cause admissions following a first ever exacerbation-related hospitalisation in COPD

Cluster randomised controlled trial on the effects of long-term home-based exercise for patients with chronic obstructive pulmonary disease with recent exacerbation: research protocol of the COPDtoParis Project

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a highly prevalent respiratory disease associated with significant health decline and economic burdens. Pulmonary rehabilitation is an effective intervention, but securing adherence to exercise is difficult, particularly for frail and disabled patients, challenged by leaving their home. Home-based exercise is an emerging alternative for persons with COPD, but long-term adherence is unclear. This study aims to investigate the effects, experiences and acceptability of long-term home-based cycling for patients with COPD post exacerbation.

METHODS AND ANALYSES

This cluster randomised controlled trial will recruit hospitalised patients with COPD following hospitalisation following exacerbation of COPD. Participants will be referred to acute rehabilitation for 8 weeks at discharge. After rehabilitation, participants are randomised in clusters of five into 1 year of home-based cycling with the goal of cycling from Aalborg to Paris, or into the control group, who will receive standard care. Data will be collected at baseline, postrehabilitation/intervention initiation, at 6 and 12 months. Primary outcome is physical performance, while secondary outcomes include daily activity levels, lung function, mobility, frailty, symptom severity, health-related quality of life, survival rates and readmissions. A qualitative substudy will uncover experiences from participants. Daily activity levels will be measured using leg-mounted triaxial accelerometers. Other parameters will be tested with physical tests, questionnaires and interviews. The study aims to include 50 patients, with 25 participants in each group. A cost-effectiveness analysis will assess the impact on disease prevention and hospitalisation.

ETHICS AND DISSEMINATION

This study, approved by The North Denmark Region Committee on Health Research Ethics (N-20230008) and compliant with the Helsinki Declaration, includes annual safety and progress reporting of potential adverse events. Results will be disseminated through peer-reviewed publications, conference presentations and community outreach to ensure accessibility to participants, healthcare professionals and the public.

TRIAL REGISTRATION NUMBER

NCT06235502 and Northern Jutland trial register (F2023-066).

A 7-point evidence-based care discharge protocol for patients hospitalized for exacerbation of COPD: consensus strategy and expert recommendation

Acute exacerbations of COPD (ECOPD) are an important event in the life of a COPD patient as it causes significant deterioration of physical, mental, and social health, hastens disease progression, increases the risk of dying and causes a huge economic loss. Preventing ECOPD is therefore one of the most important goals in the management of COPD. Before the patient is discharged after hospitalization for ECOPD, it is crucial to offer an evidence-based care bundle protocol that will help minimize the future risk of readmissions and death. To develop the content of this quality care bundle, an Expert Working Group was formed, which performed a systematic review of literature, brainstormed, and debated on key clinical issues before arriving at a consensus strategy that could help physicians achieve this goal. A 7-point consensus strategy was prepared, which included: (1) enhancing awareness and seriousness of ECOPD, (2) identifying patients at risk for future exacerbations, (3) optimizing pharmacologic treatment of COPD, (4) identifying and treating comorbidities, (5) preventing bacterial and viral infections, (6) pulmonary rehabilitation, and (7) palliative care. Physicians may find this 7-point care bundle useful to minimize the risk of future exacerbations and reduce morbidity and mortality.

GOLD COPD Exacerbation History Categories and Disease Outcomes

Importance

Previous exacerbations of chronic obstructive pulmonary disease (ECOPD) are associated with future events. For more than a decade, patients at high risk have been defined as individuals with a history of 2 or more moderate ECOPD, 1 or more severe ECOPD, or both within 12 months, and treatments have been allocated accordingly, but these cutoffs lack validation.

Objectives

To validate ECOPD history categories by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) and explore alternative cutoffs to estimate moderate and severe ECOPD and all-cause mortality in COPD.

Design, Setting, and Participants

This cohort study analyzed data from patients with COPD in the German COPD and Systemic Consequences-Comorbidities Network (COSYCONET) study. Patients were recruited from September 2010 to December 2013. Analyses were conducted in September 2023 to August 2024.

Main Outcomes and Measures

Risk of moderate and severe (ie, with hospitalization) ECOPD and all-cause mortality over a 4.5-year follow-up period were assessed using binomial logistic regressions and area under the receiver operating characteristic curves (AUROCs) with 95% CIs.

Results

Among 2291 patients with COPD GOLD categories 1 to 4 (mean [SD] age, 65 [8] years; 1396 male [60.9%]), the mean (SD) estimated forced expiratory volume in the first second of expiration was 52.5% (18.6%). ECOPD history categories by GOLD had an AUROC of 0.63 (95% CI, 0.60-0.65) and 0.62 (95% CI, 0.58-0.66) to estimate moderate and severe ECOPD, respectively. A single previous moderate ECOPD within 12 months more accurately estimated future moderate and severe ECOPD (AUROC, 0.66; 95% CI, 0.64-0.69), and in line with GOLD, 1 previous severe ECOPD within 12 months estimated moderate and severe ECOPD (AUROC, 0.63; 95% CI, 0.60-0.67). The 4-year mortality rate was 219 patients (9.6%). Patients with 3 or more previous moderate ECOPD (odds ratio, 2.18; 95% CI, 1.27-3.72) or 1 or more previous severe ECOPD (odds ratio, 1.57; 95% CI, 1.29-1.91) within 12 months were more likely to die compared with patients without prior ECOPD.

Conclusions and Relevance

This study's findings suggest a limited estimative performance of ECOPD history categories by GOLD. Novel cutoffs were suggested, categorizing patients as without exacerbations or with high-risk exacerbations based on a history of 1 or more moderate ECOPD, 1 or more severe ECOPD, or both within 12 months.

Patient characteristics and mortality across diagnostic settings in COPD

BACKGROUND

Many patients with chronic obstructive pulmonary disease (COPD) are diagnosed late, e.g., at first acute exacerbation of COPD (AECOPD). AECOPD increases the risk of death. We aim to investigate patient characteristics and mortality across diagnostic settings among patients with COPD.

METHODS

This nationwide Danish study allocated 107,023 patients with a first-time registered COPD-related hospital contact between 2010 and 2018 based on diagnostic setting: primary care (prior inhalation medication use), hospital outpatient clinic or hospital admission. Multivariable logistic regression was employed to investigate patient characteristics and mortality across these diagnostic settings.

RESULTS

In total, 81,035 (75.7 %) patients were diagnosed in primary care, median age 63 years (interquartile range (IQR) 53-71); 11,302 (10.6 %) at an outpatient clinic, median age 68 years (IQR 60-76), and 14,686 (13.7 %) during hospital admission, median age 73 years (IQR 65-81). Patient characteristics associated with diagnosis during hospital admission encompassed age (odds ratio (OR) 1.05, 95 % confidence interval (CI) 1.05-1.05, p < 0.001), male sex (OR 1.14, CI 1.10-1.19, p < 0.001), and number of comorbidities, which increased from one comorbidity (OR 2.64, CI 2.50-2.79, p < 0.001) to six or more comorbidities (OR 12.37, CI 11.26-13.60, p < 0.001). Diagnosis during hospital admission due to AECOPD was associated with increased one-year mortality (OR 1.24, CI 1.16-1.33, p < 0.001) compared to diagnosis in primary care.

CONCLUSION

Patients diagnosed with COPD in hospital settings were generally older, predominantly male, and had more comorbidities. Patients diagnosed in primary care prior to their first AECOPD admission had higher one-year survival.

Application of the Clinical Outcomes, Healthcare Resource Utilization, and Related Costs Model in Chronic Obstructive Pulmonary Disease Patients

INTRODUCTION

The change in prevalence and management of chronic obstructive pulmonary disease (COPD) led to changes in outcomes and costs. We aimed to assess current clinical outcomes, resource utilisation, and costs in COPD.

METHODS

Retrospective, observational study of a cohort of consecutive COPD patients who visited the emergency department (ED) of a large tertiary hospital in 2018. The study measured baseline characteristics, 30-day and 1-year mortality, readmission, re-ED visit rates, and costs using the Clinical Outcomes, HEalthcare REsource utilisatioN, and relaTed costs (COHERENT) model, validated for heart failure. This model, featuring a colour graphic system, tracks time spent in different clinical situations (home, ED, hospital), considering vital status, healthcare resource use, and related costs.

RESULTS

In 2018, 2,384 patients with a primary COPD diagnosis visited the ED. The average age was 76 years, with 40% women. Observed mortality rates were 7.6% in-hospital, 8.5% at 30 days, and 23.4% at 1 year. The readmission rates were 9.9% and 36.1%, respectively. The cohort's 1-year cost was approximately EUR 14.6 million (USD 15.95 million), with a median cost per patient of EUR 3,298 (USD 3,603.96). Hospitalisation incurred the highest costs, with initial hospitalisation and readmissions accounting for 44.7% and 42.6% of expenditures, respectively.

CONCLUSION

One-year mortality and readmission rates for patients with COPD visiting the ED remain high with a significant economic impact on the health system. This burden justifies special programs to improve their care.

Non-invasive respiratory support in elderly hospitalized patients

INTRODUCTION

The proportion of elderly people among hospitalized patients is rapidly growing. Between 7% to 25% of ICU patients are aged 85 and over and noninvasive respiratory support is often offered to avoid the risks of invasive mechanical ventilation or in patients with a 'do-not-intubate' order. However, while noninvasive respiratory support has been extensively studied in the general population, there is limited data available on its efficacy in elderly patients with ARF.

AREAS COVERED

PubMed/Medline, Web of Science, Scopus and Embase online databases were searched for studies that assessed clinical efficacy of high flow nasal cannula, continuous positive airway pressure and noninvasive ventilation in patients ≥ 65 years old with acute de novo ARF, showing that short to mid-term benefits provided by noninvasive respiratory support in elderly patients in terms of reduction of mechanical ventilation risk and mortality are similar to younger patients, if adjusted for the severity of comorbidities and respiratory failure.

EXPERT OPINION

Noninvasive support strategies can represent an effective opportunity in elderly patients with ARF, especially in patients too frail to undergo endotracheal intubation and in whom received or decided for a 'do not intubate' order. Indeed, noninvasive support has a different impact, depending on the setting.

Association of inadequate social support and clinical outcomes in patients with chronic obstructive pulmonary disease - A cross-sectional study

INTRODUCTION

In patients with chronic obstructive pulmonary disease (COPD), loneliness and social isolation are associated with increased morbidity and decreased mobility, self-reliance, and health-related quality of life. Social support has been shown to improve these outcomes.

AIMS

This cross-sectional study aimed to investigate the level of experienced social support and the clinical outcomes associated with inadequate social support among patients with COPD with a resident loved one.

METHODS

Level of social support was assessed with the Medical Outcomes Study - Social Support Survey (MOS-SSS) in patients with COPD with a resident loved one. Patients were sub-grouped into adequate or inadequate social support. Multiple clinical outcomes were assessed, including lung function, degree of dyspnoea, health status, symptoms of anxiety and depression, the degree of care dependency, functional status, and mobility.

RESULTS

The study included 191 Dutch patients with COPD (53.4% men, age: 65.6 ± 8.9 years, FEV1: 47.3 ± 17.7% predicted). Eighteen percent of the patients reported inadequate social support. Patients with inadequate social support reported a significantly symptom severity of COPD (p = 0.004), a higher care dependency level (p = 0.04) and a higher level of depression (p = 0.004) compared to patients with adequate social support. Other traits were comparable for both groups.

CONCLUSION

Patients with COPD with a resident loved one who perceive an inadequate level of social support are more likely to report a higher impact of COPD, a higher care dependency and symptoms of depression. Other characteristics are comparable with patients who perceive adequate social support.

Implementing an Evidence-Based COPD Hospital Discharge Protocol: A Narrative Review and Expert Recommendations

Discharge bundles, comprising evidence-based practices to be implemented prior to discharge, aim to optimise patient outcomes. They have been recommended to address high readmission rates in patients who have been hospitalised for an exacerbation of chronic obstructive pulmonary disease (COPD). Hospital readmission is associated with increased morbidity and healthcare resource utilisation, contributing substantially to the economic burden of COPD. Previous studies suggest that COPD discharge bundles may result in fewer hospital readmissions, lower risk of mortality and improvement of patient quality of life. However, evidence for their effectiveness is inconsistent, likely owing to variable content and implementation of these bundles. To ensure consistent provision of high-quality care for patients hospitalised with an exacerbation of COPD and reduce readmission rates following discharge, we propose a comprehensive discharge protocol, and provide evidence highlighting the importance of each element of the protocol. We then review care bundles used in COPD and other disease areas to understand how they affect patient outcomes, the barriers to implementing these bundles and what strategies have been used in other disease areas to overcome these barriers. We identified four evidence-based care bundle items for review prior to a patient's discharge from hospital, including (1) smoking cessation and assessment of environmental exposures, (2) treatment optimisation, (3) pulmonary rehabilitation, and (4) continuity of care. Resource constraints, lack of staff engagement and knowledge, and complexity of the COPD population were some of the key barriers inhibiting effective bundle implementation. These barriers can be addressed by applying learnings on successful bundle implementation from other disease areas, such as healthcare practitioner education and audit and feedback. By utilising the relevant implementation strategies, discharge bundles can be more (cost-)effectively delivered to improve patient outcomes, reduce readmission rates and ensure continuity of care for patients who have been discharged from hospital following a COPD exacerbation.