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Summary results of the ERS COPD Audit programme against GOLD standards Professor Mike Roberts (UK) and Professor Jose Luis Lopez-Campos (Spain)

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Presentation on theme: "Summary results of the ERS COPD Audit programme against GOLD standards Professor Mike Roberts (UK) and Professor Jose Luis Lopez-Campos (Spain)"— Presentation transcript:

1 Summary results of the ERS COPD Audit programme against GOLD standards Professor Mike Roberts (UK) and Professor Jose Luis Lopez-Campos (Spain)

2 Contents Methods Description of centres Guidelines adherence Conclusions Association with care

3 Methodology Lopez-Campos JL, et al. Eur Respir J 2013 Audit data collection Data analysis and reports Identify areas of improvement Consensus and prioritize the changes Implement changes

4 Methodology Lopez-Campos JL, et al. Eur Respir J 2013 Daily list of admitted patients Is COPD exacerbation the cause of admission? Excluded Provisional inclusion: Candidate case Discharge report COPD exacerbation? Definite inclusion: Record clinical variables Definite inclusion: Record clinical variables 90-day follow-up: Record outcomes NoYes No Yes

5 Methodology Lopez-Campos JL, et al. Eur Respir J variables – 42 variables with structure information 425 out of 432 centres that participated (98.3%) Hospital resources & organisation database: 127 variables – 117 variables with clinical information 16,018 cases out of 19,150 initially considered (83.6%) Clinical database: Provided resourcesTotal YesNo Provided cases Yes No480 Total

6 Methodology Lopez-Campos JL, et al. Eur Respir J 2013

7 Methodology Lopez-Campos JL, et al. Eur Respir J 2013 Ward: Clinical area in which patients are nursed in beds as admissions to hospital. Respiratory Department: An integrated clinical grouping of healthcare workers (clinicians and administrators) whose responsibility is to care for patients with respiratory conditions. This excludes healthcare workers whose responsibilities are purely research without a clinical role. A department may function within one hospital or across more than one hospital. Hospital: A healthcare facility located in a particular geographical site. It may compose of one or several buildings but these buildings are administered by a single executive board. Unit: A functional health care facility that is often identical to a hospital but may include more than one hospital and or more than one geographical location. The unit however functions as a single administrative and healthcare facility. Examples may include two, or even more, hospitals that previously were independent but have then merged clinical and administrative functions.

8 Contents Methods Description of centres Guidelines adherence Conclusions Association with care

9 Results: description of centres Lopez-Campos JL, et al. Submitted.

10 Results: description of centres Lopez-Campos JL, et al. Submitted. Global (n=425) Small hospitals (n=140) Medium hospitals (n=145) Large hospitals (n=140) p value* Number of beds per centre (n)562.2 ( ,099.0)220 ( ) ( )989 ( )<0.001 Catchment population (habitants) 442,415.7 (115, ,040,000) 279, (85, ,378,666.6) 406,630 (83, ,024,714.2) 6,414,052 (142, ,060,000) <0.001 University / teaching hospital (%)57.3 ( )36.4 (0-87.5)55.2 ( )80.6 (50-100)<0.001 Public hospital (%)92.9 ( )87.1 ( )94.5 ( )97.1 ( )0.003 Hospitals with ICU (%)91.3 ( )75.7 ( )98.6 (96-100)99.3 ( )<0.001 Number of beds in ICU (n)12.6 ( )8.43 (4.5-32)9.75 ( )18.7 (6-33)<0.001 Spirometry available (%)98.6 ( )97.9 ( )98.6 (96-100)99.3 ( )0.602 Hospitals with respiratory ward (%)81.4 (0-100)60.7 (25-100)87.6 ( )95.7 (0-100)<0.001 Hospitals with respiratory team (%)89.6 ( )81.4 (40-100)94 (40-100)96.4 ( )<0.001 Characteristics of the participant hospitals in the European COPD audit Data expressed as mean (inter-country range). *P value calculated by chi-square test or ANOVA as appropriate

11 Results: description of centres Lopez-Campos JL, et al. Submitted. Global (n=425) Small hospitals (n=140) Medium hospitals (n=145) Large hospitals (n=140) p value* Unit with respiratory outpatient clinic (%)90.0 ( )82.7 (30-100)91.7 ( )95.7 ( )0.001 Unit with COPD outpatient clinic (%)61.8 (0-82.1)50.4 (15-90)61.8 ( )73.4 (0-100)<0.001 Unit with respiratory ward (%)78.9 (0-100)60.4 (25-100)82.6 ( )93.5 (0-100)<0.001 Unit with admission ward for COPD (%)65.4 ( )51.1 ( )72.2 (0-100)72.7 (25-100)<0.001 Unit with system of specialty triage (%)32.0 (0-100)25.2 (0-100)32.6 (0-100)38.1 (0-100)0.067 Unit with emergency department (%)80.1 (50-100)68.3 ( )85.4 (60-100)86.3 (50-100)<0.001 Unit with high dependency unit (%)49.3 (10-100)45.3 (0-100)45.1 (0-100)57.6 (0-100)0.059 How many beds in the high dependency unit (n)7.1 ( )5.9 (2-9)6.8 (2-16.3)8.2 (3.3-19)0.061 Offer non-invasive ventilation for acidotic patients (%)89.6 (60-100)84.2 ( )87.5 ( )97.1 (75-100)0.001 Offer invasive ventilation for acidotic patients (%)75.8 ( )66.2 ( )81.2 ( )79.9 (0-100)0.005 The unit has access to respiratory rehabilitation programs (%)50.0 (0-90.9)41.7 ( )85.7 (0-100)60.4 (0-100)0.006 The unit has access to palliative care service (%)59.7 ( )52.5 (0-100)63.2 (0-91.8)63.3 (0-100)0.107 Resources of the participant units in the European COPD audit Data expressed as mean (inter-country range). *P value calculated by chi-square test or ANOVA as appropriate

12 Results: description of centres Lopez-Campos JL, et al. Submitted. Staffing of the respiratory units Data expressed as mean (inter-country range). *P value calculated by chi-square test or ANOVA as appropriate Global (n=425) Small hospitals (n=140) Medium hospitals (n=145) Large hospitals (n=140) p value* Number of respiratory specialists in unit (n)6.3 (2.9-15)4.1 ( )6.1 ( )8.8 ( )<0.001 Number of respiratory specialists in unit (n/1000 beds)14.7 ( )22.1 ( )12.8 ( )9.4 ( )<0.001 Number of respiratory trainees in unit (n)3.7 ( )2.04 ( )3.3 ( )5.9 (2.4-9)<0.001 Number of respiratory trainees in unit (n/1000 beds)7.7 ( )9.9 ( )6.8 ( )6.3 ( )0.074 Number of physiotherapist in unit (n)2.1 (0.6-6)1.6 ( )2.01 (0-13.2)2.5 ( )0.021 Number of physiotherapist in unit (n/1000 beds)5.05 ( )8.3 ( )4.1 (0-26.2)2.6 ( )<0.001 Number of nurse specialists in unit (n)7.9 (0-63.6)5.9 (0-69)11.4 (0-140)6.2 (0-31.5)0.245 Number of nurse specialists in unit (n/1000 beds)20.3 ( )31.5 ( )23.0 ( )6.5 ( )0.017 Number of lung function technicians in unit (n)2.5 ( )2.01 ( )2.1 (1.3-5)3.4 ( )<0.001 Number of lung function technicians in unit (n/1000 beds)6.3 ( )10.7 ( )4.5 ( )3.7 ( )<0.001

13 Contents Methods Description of centres Guidelines adherence Conclusions Association with care

14 Results: guideline adherence Roberts CM, et al. Thorax 2013 For patients that require hospitalization, measurement of arterial blood gases is important to assess the severity of an exacerbation 82.4% of cases had an ABG Median Hospital (%) IQR (%) Median Country (%) Range (%)

15 Results: guideline adherence Roberts CM, et al. Thorax ABG on admission by country

16 ABG by Hospital Austria

17 Results: guideline adherence Roberts CM, et al. Thorax 2013 Oxygen therapy is the cornerstone of hospital treatment of COPD exacerbations. 84.9% patients received controlled oxygen 9.7% high flow oxygen Median Hospital (%) IQR (%) Median Country (%) IQR (%) % of those not receiving oxygen of any kind had an admission PaO2 <8kpa

18 Results: guideline adherence Roberts CM, et al. Thorax 2013 Antibiotics should be given to: a) patients with the following three cardinal symptoms: increased dyspnea, increased sputum volume, and increased sputum purulence, b) Patients with two of the cardinal symptoms, if increased purulence of sputum is one of the two symptoms, c) patients that requires mechanical ventilation (invasive or noninvasive). 90.5% meeting these criteria received antibiotics Median HospitalIQRMedian CountryIQR But 79.7% patients who didnt meet these criteria also received antibiotics

19 % Cases Antibiotics correctly prescribed by Hospitals (Austria)

20 Results: guideline adherence Roberts CM, et al. Thorax 2013 Indications for Non Invasive Ventilation (NIV) include moderate to severe acidosis (pH 6.0kPa) without contraindications. 51% cases with these ABG received NIV Median HospitalIQRMedian CountryIQR % of patients who received NIV did not meet these criteria

21 Contents Methods Description of centres Guidelines adherence Conclusions Association with care

22 Results: association with care Lopez-Campos JL, et al. Submitted. Organisational performance of the respiratory units Data expressed as mean (inter-country range). *P value calculated by chi-square test or ANOVA as appropriate Global (n=425) Small hospitals (n=140) Medium hospitals (n=145) Large hospitals (n=140) p value* Admissions for any cause in the previous year (n) 22,547.6 ( ,438.4) 13,866.8 ( ,272.8) 22,107.1 (1, ,735.6) 31,895.3 ( ,645.8) Percentage of COPD admitted in the unit (%)60.6 ( )66.4 ( )57.8 ( )59.4 ( )0.134 ICU admits COPD patients (%)71.9 ( )59.3 ( )75.9 ( )80.6 ( )<0.001 Respiratory physician on call everyday (%)49.5 ( )45 ( )41.4 (0-100)62.6 (0-100)0.001 Number of ward rounds by admitting specialist (n)1.8 ( )1.6 ( )1.5 ( )1.8 (1-2.5)0.316 Percentage of patients seen by physiotherapist (%)53.2 ( )49.1 ( )51.1 ( )58.9 ( )0.147 Percentage of patients seen by respiratory specialist (%) 69.3 ( )64.7 (34-100)66.9 ( )76.4 (45-100)0.011

23 Results: association with care Lopez-Campos JL, et al. Submitted. Organisational performance of the respiratory units Data expressed as mean (inter-country range). *P value calculated by chi-square test or ANOVA as appropriate Global (n=425) Small hospitals (n=140) Medium hospitals (n=145) Large hospitals (n=140) p value* The unit has the capacity to non-invasively ventilate all eligible patients (%) 67.5 (0-90.9)66.7 ( )68.3 (0-100)67.4 (0-100)0.966 The unit has the capacity to invasively ventilate all eligible patients (%) 71.6 (0-100)69.6 ( )69.2 (0-100)75.7 (0-100)0.493 Unit with early supported discharge program (%)32 (0-75.2)15.8 (0-60)36.8 (0-100)43.2 (0-85.4)<0.001 Percentage of admissions that enter the early discharge program (%) 37.3 (15-90)45.7 ( )36.8 (5-90)34.5 ( )0.224 The unit takes care of long term oxygen therapy (%)87.4 ( )84.9 ( )86.8 (40-100)90.6 (50-100)0.337 The unit takes care of home mechanical ventilation (%) 59.5 ( )56.1 ( )53.5 (0-100)69.1 ( )0.017 Percentage of eligible patients that receives pulmonary rehabilitation (%) 42.1 ( )42.6 (10-55)48.9 (20-80)36.9 (11-100)0.220

24 Results: association with care Lopez-Campos JL, et al. Submitted. Global (n=425) Small hospitals (n=140) Medium hospitals (n=145) Large hospitals (n=140) p value* Spirometry result available at admission59.3 ( )68.0 ( )54.6 ( )58.6 ( )<0.001 Arterial Blood Gas performed at admission82.4 ( )76.9 ( )82.2 (0-100)85.6 ( )<0.001 Chest radiograph performed at admission98.6 ( )98.4 ( )98.4 ( )98.9 ( )0.040 Controlled oxygen therapy used84.9 ( )81.0 ( )85.4 ( )86.8 ( )<0.001 Short-acting bronchodilator use91.1 ( )89.2 ( )90.9 ( )92.6 ( )<0.001 Non-use of Intravenous methylxanthines85.8 ( )84.4 ( )85.9 ( )86.5 ( )0.030 Systemic corticosteroids given82.3 ( )79.1 ( )81.7 ( )84.8 ( )<0.001 Antibiotics correctly prescribed by sputum purulence or MV61.4 ( )61.7 ( )61.1 ( )61.6 ( )NS NIV correctly prescribed by blood gas test (pH 6kPa) 85.2 ( )85.6 ( )85.1 ( )84.9 ( )0.025 IMV correctly prescribed by blood gas test (pH 8kpa) 95.4 ( )96.3 ( )95.5 ( )94.8 ( )0.026 Fulfilled all 10 recommendations15.3 ( )15.9 ( )13.5 (0-27.4)16.5 ( )<0.001 GOLD 2010 statements according to hospital size Data expressed as mean (inter-country range). *P value calculated by chi-square test or ANOVA as appropriate

25 Contents Methods Description of centres Guidelines adherence Conclusions Association with care

26 Conclusions The reasons for apparent non compliance are not available to us In some cases there may be good reason to deviate from the recommended management In other cases this will represent poor medical practice

27 Conclusions The variation between countries is substantial but the variation between hospitals within a single country is large too It is likely that quality of care delivered to patients is unacceptably variable Size of hospital and resources do not account for all the variability We all have a responsibility to consider how to improve care across all units


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