National Chronic Obstructive Pulmonary Disease Research Articles

UK National COPD Resources and Outcomes Project 2008: Patients with Chronic Obstructive Pulmonary Disease Exacerbations Who Present with Radiological Pneumonia Have Worse Outcome Compared to Those with Non-Pneumonic Chronic Obstructive Pulmonary Disease Exacerbations

Background: Limited comparative data exist on the outcomes of patients presenting with chronic obstructive pulmonary disease (COPD) exacerbations with or without radiological pneumonia. Objective: To examine the outcome differences amongst these patients. Methods: We analysed 2008 UK National COPD audit data to examine the characteristics, management and outcomes, inpatient- and 90-day mortality and length of stay of patients admitted with COPD exacerbations. Results: Of 9,338 admissions, 16% (1,505) had changes consistent with pneumonia indicated on the admission chest X-ray. They tended to be older (mean ages 75 vs. 72 years), male (53 vs. 50%), more likely to come from care homes, with more disability, higher BMI and co-morbidity, lower albumin but higher urea levels, and less likely to be current smokers. COPD exacerbations with pneumonia were associated with worse outcomes: inpatient mortality was 11 and 7% and 90-day mortality was 17 and 13% for pneumonia and non-pneumonia patients, respectively (p < 0.001). After adjusting for factors that are significantly different between the 2 groups, including age, sex, place of residence, level of disability, co-morbidity, albumin and urea levels, estimated risk ratios for inpatient and 90-day mortality for pneumonia compared to non-pneumonia cases in this series were 1.19 (1.01,1.42) and 1.09 (0.96,1.23), respectively. The adjusted risk ratio of a prolonged acute hospital stay of more than 7 days was 1.15 (1.07, 1.23). Conclusions: Patients who present with radiological pneumonia have worse outcomes compared to those admitted without pneumonia in exacerbation of COPD.

A randomized trial of peer review: the UK National Chronic Obstructive Pulmonary Disease Resources and Outcomes Project: three‐year evaluation

Peer review has been widely used within the National Health Service to facilitate health quality improvement but evaluation has been limited particularly over the longer-term. Change within the National Health Service (NHS) can take a prolonged period--1-2 years--to occur. We report here a 3-year evaluation of the largest randomized trial of peer review ever conducted in the UK. To evaluate whether targeted mutual peer review of respiratory units brings about improvements in services for chronic obstructive pulmonary disease (COPD) over 3 years. The peer review intervention was a reciprocal supportive exercise that included clinicians, hospital management, commissioners and patients, which focused on the quality of the provision of four specific evidence-based aspects of COPD care. Follow-up at 36 months demonstrated limited significant quantitative differences in the quality of services offered in the two groups but a strong trend in favour of intervention sites. Qualitative data suggested many benefits of peer review in most but not all intervention units and some control teams. The data identify factors that promote and obstruct change. The findings demonstrate significant change in service provision over 3 years in both control and intervention sites with great variability in both groups. The combined quantitative and qualitative findings indicate that targeted mutual peer review is associated with improved quality of care, improvements in service delivery and with changes within departments that promote and are precursors to quality improvement. The generic findings of this study have potential implications for the application of peer review throughout the NHS.

Collaborative working within UK NHS secondary care and across sectors for COPD and the impact of peer review: qualitative findings from the UK National COPD Resources and Outcomes Project

WE INVESTIGATED THE EFFECTS ON COLLABORATIVE WORK WITHIN THE UK NATIONAL HEALTH SERVICE (NHS) OF AN INTERVENTION FOR SERVICE QUALITY IMPROVEMENT: informal, structured, reciprocated, multidisciplinary peer review with feedback and action plans. The setting was care for chronic obstructive pulmonary disease (COPD). We analysed semi-structured interviews with 43 hospital respiratory consultants, nurses and general managers at 24 intervention and 11 control sites, as part of a UK randomised controlled study, the National COPD Resources and Outcomes Project (NCROP), using Scott's conceptual framework for action (inter-organisational, intra-organisational, inter-professional and inter-individual). Three areas of care targeted by NCROP involved collaboration across primary and secondary care. Hospital respiratory department collaborations with commissioners and hospital managers varied. Analysis suggested that this is related to team responses to barriers. Clinicians in unsuccessful collaborations told 'atrocity stories' of organisational, structural and professional barriers to service improvement. The others removed barriers by working with government and commissioner agendas to ensure continued involvement in patients' care. Multidisciplinary peer review facilitated collaboration between participants, enabling them to meet, reconcile differences and exchange ideas across boundaries. The data come from the first randomised controlled trial of organisational peer review, adding to research into UK health service collaborative work, which has had a more restricted focus on inter-professional relations. NCROP peer review may only modestly improve collaboration but these data suggest it might be more effective than top-down exhortations to change when collaboration both across and within organisations is required.

Prevalence of major comorbidities in subjects with COPD and incidence of myocardial infarction and stroke: a comprehensive analysis using data from primary care

BackgroundComorbidities associated with systemic inflammation including cardiovascular disease (CVD), stroke and diabetes mellitus (DM) are common among individuals with chronic obstructive pulmonary disease (COPD). A study was undertaken to quantify...

UK National COPD Resources and Outcomes Project (NCROP): 2008 National Audit Data Presents An Opportunity to Highlight the Areas for Improvement in COPD Care in the Ageing Population

Chronic Obstructive Pulmonary Disease (COPD) is a disease of older people and a common cause of chronic disability and death, there being approximately 25,000 deaths annually in the UK (1). It is t...

The UK National Chronic Obstructive Pulmonary Disease Resources and Outcomes Project – a feasibility study of large‐scale clinical service peer review

Service provision and clinical outcomes for patients admitted with chronic obstructive pulmonary disease remain unacceptably variable despite guidelines and performance feedback of national audit, data. This study aims to assess the impact of mutual peer review on service improvement. The initial phase of this study was to assess the feasibility and determine the practicalities of delivering such a peer review programme on a large scale. All UK acute hospitals were invited to participate in a reciprocal peer review programme administered by a central team from three UK health organizations. Hospitals with the most resources were paired with those with the least (as defined in a baseline survey) and pairs randomized on a 3:2 basis into intervention or control groups. A number of key quality indicators were derived to measure service levels at the beginning and end of the study. Peer review teams included clinicians and managers from acute and primary care organizations and when possible a patient representative. Visits were focussed on four key areas of chronic obstructive pulmonary disease service. Teams were to agree service improvements and submit plans signed off by participants. Monthly change diaries were to be used to record progress towards agreed goals. A total of 100 hospitals participated in the programme. Overall, 52 of 54 peer review visits took place within a 4-week time frame and all units submitted service improvement plans within an agreed time frame. Secondary care representatives participated in all visits, primary care in 30 but patients in only 17. The mean number of diaries returned was 2, but 94% of units returned initial and final versions. It is possible to deliver successful large-scale mutual peer review using a limited but focussed programme. Participation of patients and use of change diaries requires further evaluation.

A randomised trial of peer review: the UK National Chronic Obstructive Pulmonary Disease Resources and Outcomes Project

Peer review has been widely employed within the NHS to facilitate health quality improvement but has not been rigorously evaluated. This article reports the largest randomised trial of peer review ever conducted in the UK. The peer review intervention was a reciprocal supportive exercise that included clinicians, hospital management, commissioners and patients which focused on the quality of the provision of four specific evidence-based aspects of chronic obstructive pulmonary disease care. Follow up at 12 months demonstrated few quantitative differences in the number or quality of services offered in the two groups. Qualitative data in contrast suggested many benefits of peer review in most but not all intervention units and some control teams. Findings suggest peer review in this format is a positive experience for most participants but is ineffective in some situations. Its longer term benefits and cost effectiveness require further study. The generic findings of this study have potential implications for the application of peer review throughout the NHS.

Does the Introduction of a COPD Pro-Forma Improve the Standards of Care Delivered by Junior Doctors in the Emergency Department

ABSTRACTAim: To determine if pro-forma based management improves standards of care delivered by junior doctors in chronic obstructive pulmonary disease (COPD) patients in the Emergency Department (ED). Introduction: National COPD audits have found large variations in ED standards of care compared to guidelines. They concluded that the publication of guidelines itself does not translate to an improvement in care. Method: A pro-forma based on the British Thoracic Society Guidelines on COPD, 1997, NICE Guidelines CG12, 2004 and Non Invasive Ventilation (NIV), 2002 was devised and implemented following targeted education. Data were collected pre and post pro-forma implementation and analysed. The primary end point was categorisation of respiratory failure as it was felt that this concept was fundamental in COPD management. Secondary endpoints included the administration of controlled oxygen, repeat blood gases and appropriate referral for NIV. Results: There were a total of 55 patients in each group. The correct categorisation of respiratory failure improved significantly from 4% in the pre- compared to 89% (p < 0.0001) in the post-intervention group. Similarly the administration of controlled oxygen (47% compared to 92%, p < 0.0001), repeat arterial blood gases (50% compared to 83%, p = 0.0098), and appropriate referral for NIV (33% compared to 100%, p = 0.0023) showed significant improvement after the pro-forma was introduced. Conclusion: Pro-forma aided management significantly improves the standards of care in COPD patients in the ED.

Bridging the Gap: The Patient-Doctor Relationship

In January 2007 the National Heart, Lung, and Blood Institute (NHLBI) launched a national chronic obstructive pulmonary disease (COPD) awareness and education campaign: ‘Learn More Breathe Better’ [...]

Spirometry in primary care

An evaluation of lung function is an essential part of the diagnosis and management of respiratory disease but spirometry was, until recently, rarely available in primary care. The emphasis in national chronic obstructive pulmonary disease (COPD) and asthma guidelines on spirometry for diagnosis and monitoring, together with its inclusion in the quality and outcomes framework (QOF) for COPD in the General Medical Services contract, has led to its wider availability in this setting. Spirometry is a relatively easy test, but is unreliable and confusing if not performed and interpreted correctly.

Épidémiologie de la bronchopneumopathie chronique obstructive en France

Chronic obstructive pulmonary disease (COPD) is a frequent and disabling disease but epidemiologic data remain fragmentary. The objective of this work was to bring together and describe the French epidemiologic data about COPD. This review of the literature was performed by querying the NLM PubMed database in French and in English with the key words "chronic obstructive pulmonary disease", "epidemiology", "mortality", and "France". The studies including French data were selected. Four prevalence studies and one mortality study were identified. Prevalence was estimated between 1.0 and 11.1% in the general population. The mean mortality rate between 2000 and 2002 was 84.3/100,000 in men and 19.1/100,000 in women. Smoking is the best documented risk factor and a dose-response relationship has been established. The attributable risk fraction for occupational exposure is assessed at 15 to 20%. Prevalence studies are rare and do not always include objective measures of respiratory function. There are no specific French data in populations of smokers. COPD is a major public health issue. The main risk factor is smoking but the risk fraction attributable to occupational exposure is substantial. Epidemiologic knowledge of COPD should advance as the results of studies and screening program for at-risk subjects currently underway as part of the national COPD plan become available.

Chronic obstructive pulmonary disease: Diagnosis and management

The purpose of this article is to provide a comprehensive review of the current modalities employed in diagnosing and treating chronic obstructive pulmonary disease (COPD). Special emphasis is placed on current guidelines, as defined by the Global Initiative for Chronic Obstructive Lung Disease. A comprehensive literature review for COPD serves as the basis for this article. According to the National COPD Coalition (2004), there are nearly 24 million Americans who suffer from COPD. The incidence of COPD is rising globally and is associated with increased morbidity and mortality. COPD is characterized by progressive decline in function, resulting in concomitant diseases, which increase healthcare dollar expenditures, thus making COPD a concern for healthcare providers in the United States and abroad. Once a diagnosis of COPD is made, healthcare providers should explore multiple treatment options in an effort to find the most beneficial regimen. It is only when the treatments are individualized, including physiological therapies and cognitive approaches to lessen risks as well as to reduce exacerbations, that the patient with COPD is able to potentially experience a reasonable quality of life.

Systematic assessment of clinical practice guidelines for the management of chronic obstructive pulmonary disease

Objective: To systematically evaluate the quality of the development of guidelines for the management of chronic obstructive pulmonary disease (COPD). Methodology: MEDLINE and Excerpta Medica search for published guidelines, followed by independent evaluation by two reviewers, according to previously reported guideline development quality criteria, on a three-point scale. Results: Five national COPD guidelines and two international COPD guidelines were retrieved. Reviewers demonstrated good inter-observer agreement in assessing the 10 combined guideline development criteria for the seven guidelines [κ=0.66]. Guidelines were only partly multi-disciplinary, with little or no consumer input, were up to 48 pages in length, and often lacked practical summaries or management flow charts which could have facilitated retrieval of key management recommendations. Almost all the papers were based upon a consensus approach, rather than evidence based, and methods of resolution of differences of opinion were not stated. Patient outcomes, ethical and medico-legal implications were not addressed and six of the guidelines were sponsored directly or indirectly by a single drug company. Conclusions: In spite of COPD guidelines being reported by major national bodies for over a decade now, most fail to meet important criteria for high-quality guideline development, and evaluation of clinical impact remains undetermined.

The quality of spirometric examinations in Finland: results from a national questionnaire survey.

National treatment programmes for asthma and chronic obstructive pulmonary disease (COPD) have in the past few years increased the need for spirometry in Finland. The purpose of this study was to determine, by means of a national questionnaire survey, the quality and number of spirometric examinations performed in Finland in 1998, the year when the national COPD programme was initiated. We estimated that 395 000-425 000 spirometric examinations were performed in Finland in 1998. The mean quality of spirometry was evaluated as moderate, and the quality index developed for this study indicated an average of scores of 67 (max 100), ranging between 43 and 88 in the whole country. The most common qualitative insufficiencies in spirometric examinations were found in preparation of the subject for the examination, performance of the examination, recognition of a successful spirometric curve and evaluation of reproducibility of the examination. Furthermore, the time reserved in the reports for performing the examination was often very short. However, in comparison with the previous questionnaire survey in Finland (in 1990), the quality of spirometry had markedly improved.