Medscape Medical News
European COPD Audit Finds Big National Differences!
September 30, 2011
Becky McCall
September 30, 2011 (Amsterdam, the Netherlands) — The initial results of the largest-ever prospective observational audit of chronic obstructive pulmonary disease (COPD) in 13 European countries were reported here at the European Respiratory Society (ERS) 2011 Annual Congress.
Mike Roberts, MD, consultant respiratory physician at Whipps Cross University Hospital, London, United Kingdom, and dean of students at Barts and the London School of Medicine and Dentistry, presented the results.
"The first-ever European audit of the standard of care of hospitalized COPD patients shows that nearly 50% of patients are either dead or back in hospital within 3 months of admission," Dr. Roberts told Medscape Medical News.
The findings showed that a high proportion of admissions are of women, disproportionate to smoking prevalence rates. Furthermore, both process of care and outcomes vary considerably, not only between countries, but also within them. On a more positive note, he said that the audit has identified areas of high-quality service delivery that need to be adopted across Europe.
The study was motivated by a need to reduce health inequalities on the European continent, Dr. Roberts explained.
"There are a number of reasons for these inequalities, and to us as individual physicians, some of these can seem so huge that we think we have no power to influence them at all; that these are issues for governments, the European Union, or even the World Health Organization to address," said Dr. Roberts.
He pointed out that all clinicians know their responsibility for delivering quality care to each patient, but that without measuring quality of care and comparing it to national and international standards, it is impossible to know how good each individual's quality of care is.
Dr. Roberts emphasized the importance of COPD in the European population. "It is estimated that there are a minimum of 300,000 deaths from the disease each year — that's the equivalent of 3 Hiroshima atomic bombs. Thirty billion euros are wasted through lost production due to COPD across Europe," he pointed out.
The ERS COPD audit was designed to compare care in different hospitals and in different countries in Europe. It consisted of a survey of organization of care and a prospective audit of clinical care. Investigators collected clinical-care data over a 60-day period, following up for 90 days to assess outcomes. The data were collected from October 2010 to June 2011. Thirteen countries, 421 hospitals, and more than 16,000 clinical cases were included in the study.
Of note, the audit showed that only half of the hospitals have a respiratory specialist on call every day. Dr. Roberts reported that "in half of the hospitals, a COPD patient might be admitted by somebody who is not a respiratory specialist. How would you feel if you were being admitted with a heart attack by somebody who is not a heart specialist? But with a lung attack, it doesn't seem to matter who looks after you, does it?"
The audit also showed that 32% of hospitals operated a triage system in which a patient admitted by a nonrespiratory clinician is rapidly referred to a respiratory clinician. Intensive care units (ICU) are available in 91% of hospitals, but only 79% of these ICUs actually admit COPD patients. "If your lungs are failing, it's tough; you won't survive," added Dr. Roberts.
One third of hospitals have an early discharge program with community nurses, and 50% have access to a pulmonary rehabilitation program. Only 60% of European hospitals have a palliative care facility for COPD patients.
Peter Sterk, MD, professor of the pathophysiology and phenotyping of asthma and COPD at the University of Amsterdam, the Netherlands, commented on the increase in women being admitted. "The problem is getting bigger because young female smokers are coming up. The COPD problem in women will be a problem for the next 20 years. Unfortunately, here in the Netherlands, while smoking rates have dropped from 32% to 28% in the past 4 years, smoking among 15-year-olds is rising, particularly in girls," he told Medscape Medical News.
Disease severity also showed variation among countries. The median percentage of expected forced expiratory volume in 1 second varied from 36% to 63%. The lowest values were in Turkey and the highest were in Slovakia.
The investigators found that length of stay varied from 6 to 15 days. Thirty-eight percent of patients were readmitted to the hospital within 90 days. "Altogether, admission, readmission, and death rates show that roughly 50% of these patients will either be dead or back in hospital within 90 days. Say that about heart attacks, gastrointestinal bleeds, or diabetes attacks and we'd all be having a heart attack! But with COPD this actually happens," Dr. Roberts said.
The researchers intend to determine the reasons behind the findings, to uncover good practice and share it, and to develop plans across Europe to reduce inequalities in COPD care. They will also monitor improvements in a couple of years.
The audit was funded by the ERS. Dr. Roberts and Dr. Sterk have disclosed no relevant financial relationships. No members of the steering group received any remuneration of any kind for this work, which was completed on a voluntary basis.
European Respiratory Society (ERS) 2011 Annual Congress: Abstract 400. Presented September 25, 2011.
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