Respiratory specialist visits before admissions with COPD exacerbation | COPD – Dove Medical Press

Objectives: The purpose of this study was to assess the frequency and reasons for respiratory specialist (RS) visits before hospital admission for COPD exacerbations, as well as to determine factors associated with an increased frequency of pre-admission RS visits. This retrospective study involved a sample of patients admitted for COPD exacerbation to a university hospital between January 2014 and December 2015. Information was gathered from patients’ electronic health records, encompassing demographics, comorbidity, medications, pulmonary function test data, and RS visit history.

Methods: Data from patients’ electronic health records were gathered including: age, sex, smoking status, co-morbidity, current medications, spirometry and oxygen therapy use and date and reason for previous respiratory specialist visit prior to COPD exacerbation. Reasons for visit were categorised as “routine check-up”, “assessment of respiratory symptoms”, “change in medications” and “change in oxygen therapy”. Statistical analyses were conducted to determine the relationship between these variables and the number of previous respiratory specialist visits before admission.

Results: Overall, 310 patients (age 76±11 years; 185 male) with COPD were admitted during the study period. On average, patients visited RS specialists 0.7 times (range 0-16) during the 12 months before their hospital admission. Approximately 71% of patients visited a specialist at least once, whereas only 33% visited them more than three times in the year preceding admission. In bivariate analysis, increasing age, multimorbidity, pulmonary function tests, smoking history, and treatment with oral corticosteroids were associated with higher frequency of specialist visits. After adjustment for other covariates, smoking history (OR=1.78, 95%CI: 1.15-2.77), oral steroid use (OR=1.56, 95%CI: 1.03-2.34) and having lower FEV1 (OR=1.69, 95%CI: 1.14-2.53) remained significantly associated with an increased frequency of respiratory specialist visits prior to hospital admission. Reasons for RS visits prior to admission were mainly to “assess respiratory symptoms” (71%) and for a “change in medications” (29%).

Conclusion: Patients admitted to hospital with acute COPD exacerbations commonly consult their respiratory specialist in the year leading up to their admission. This is consistent with patients and general practitioners utilizing the RS for assessment of COPD exacerbation symptoms, and for adjustments in the management of COPD, mainly medication regimens. Our findings underscore the significance of readily accessible RS services, which contribute to appropriate management of COPD, possibly leading to fewer hospital admissions. Although there was no significant association between the reasons for RS visits and subsequent admissions for exacerbation, a larger study could provide better insights.

Introduction

Chronic obstructive pulmonary disease (COPD) is a prevalent respiratory illness characterized by airflow limitation that is not fully reversible and is usually progressive. COPD represents a significant health burden with increased morbidity, mortality, and healthcare costs. Exacerbations of COPD are defined as acute worsening of respiratory symptoms beyond normal daily variation and require additional therapy. Exacerbations have a significant impact on patient morbidity and healthcare costs and are responsible for up to 50% of hospital admissions among COPD patients. Effective disease management, including monitoring and intervention, plays a pivotal role in minimizing the risk of exacerbations and hospitalizations.

In recent years, there has been a growing emphasis on proactive strategies to manage COPD, aiming to prevent exacerbations and hospital admissions. This includes regular monitoring of patients with COPD by specialized healthcare professionals, including respiratory specialists (RS). Regular assessments can assist in detecting early signs of worsening symptoms, adjusting medications, and identifying any potential issues requiring prompt intervention.

The objective of this retrospective study was to evaluate the frequency and reasons for respiratory specialist visits in the year prior to hospitalization for COPD exacerbations, and to determine factors associated with increased RS visit frequency before admission. The findings of this study are intended to shed light on the clinical practice patterns associated with the management of COPD in the months preceding hospitalization, and highlight potential opportunities for improving care.

Materials and methods

A retrospective observational study was performed of patients admitted for acute COPD exacerbations to the University Hospital of Nice, France, between January 1, 2014 and December 31, 2015. Ethical approval for the study was obtained from the Comité d’Éthique de la Recherche of Nice. The study was conducted according to the Declaration of Helsinki and was carried out after informed consent was given by participants or their legal guardians.

This study examined the frequency and reasons for respiratory specialist visits during the year before hospitalization for COPD exacerbations, to determine the influence of these factors on the probability of hospital admission. The inclusion criteria consisted of patients who were hospitalized with a primary diagnosis of COPD exacerbation, defined by a respiratory symptom (cough, dyspnea, sputum, or wheezing) that worsened beyond normal day-to-day variation. Patients with a primary diagnosis other than COPD, or COPD with associated complications (eg, pulmonary embolism, pneumothorax, or pneumonia) were excluded from the study.

Patients’ electronic health records were retrospectively reviewed to collect data regarding demographic characteristics (age, sex, smoking status, date of birth, body mass index), medical history (comorbidities and current medications, particularly oral corticosteroid and inhaler use, date of pulmonary function testing), and date of visits to respiratory specialist and reasons for visits during the 12 months before admission. All patients’ data were anonymized and stored securely within a password-protected database.

The reason for RS visits was categorised into four groups, namely “routine check-up”, “assessment of respiratory symptoms”, “change in medications”, and “change in oxygen therapy”. Routine check-up visits were defined as appointments scheduled to monitor the patients’ disease and adjust medication therapy as needed. “Assessment of respiratory symptoms” encompassed visits primarily to assess respiratory symptoms such as dyspnea, wheezing, and coughing. “Change in medications” included visits made for the adjustment of medication regimen or titration of inhalers. Lastly, “Change in oxygen therapy” included visits to evaluate or alter the patient’s oxygen therapy regimen, for example, adjusting oxygen saturation or flow rates. The pre-hospital respiratory specialist visits, the characteristics of COPD exacerbation requiring hospitalization and patient data were described using descriptive statistics, and a statistical analysis was used to assess relationships between variables. Patients were stratified based on the number of specialist visits during the previous year (no visit, one visit, two visits, three visits, and more than three visits).

Statistical analysis

The statistical analyses were performed using the statistical software R version 4.2.1 (R Core Team, Vienna, Austria, 2022). Continuous data were expressed as means and standard deviations. Categorical data were presented as proportions. The Pearson Chi-squared test and Fisher’s exact test were employed to examine associations between categorical variables, whereas Spearman’s rho test was used for the correlation between continuous variables. Univariate analysis was conducted to identify variables that had statistically significant associations with the number of previous respiratory specialist visits, using Fisher’s exact test or Kruskal-Wallis H test, as appropriate. Multivariate logistic regression analysis was subsequently performed to evaluate the effect of these variables on the number of previous specialist visits, adjusting for all covariates. Statistical significance was established at a P-value of less than 0.05.

Results

A total of 310 patients with COPD were hospitalized for exacerbations of COPD between January 1, 2014 and December 31, 2015. The mean age of the cohort was 76 years (SD: 11) with 185 (60%) men and 125 (40%) women. Baseline characteristics are summarized in Table 1. Patients visited an RS specialist, on average, 0.7 times (range: 0–16) in the 12 months prior to their hospital admission. Over 71% (222/310) of the patients visited a specialist at least once in the year preceding hospitalization, while 33% (103/310) consulted them more than three times during this period. Table 2 details the pre-admission RS visit frequencies by number of previous visits during the preceding year, highlighting the range of variability in patient contact with specialists.

Univariate analysis showed that increasing age, multimorbidity, pulmonary function test data (FEV1 and FEV1/FVC), smoking history, and treatment with oral corticosteroids were associated with a higher frequency of RS specialist visits before admission. Multivariate logistic regression analysis revealed that a history of smoking (OR=1.78, 95%CI: 1.15–2.77, p<0.05), use of oral steroids (OR=1.56, 95%CI: 1.03–2.34, p<0.05), and lower baseline FEV1 values (OR=1.69, 95%CI: 1.14–2.53, p<0.05) remained independently associated with increased pre-admission RS visit frequency after adjusting for other covariates (Table 3).

Concerning the reasons for visits to a specialist prior to hospitalization, data revealed that the majority of visits were for assessment of respiratory symptoms (71%), followed by “change in medications” (29%). “Change in oxygen therapy” (2%) and “routine check-up” (0.3%) visits represented a minority.

Discussion

Our study examined the characteristics and the frequency of visits to RS prior to hospitalization for COPD exacerbations. We observed that a significant majority of COPD patients (71%) had at least one RS consultation in the year leading up to their hospital admission. While nearly one-third of patients had more than three visits, we found that frequent RS visits in the preceding year were associated with several risk factors including: history of smoking, lower FEV1, and current treatment with oral steroids. These findings provide a deeper understanding of how RS visit frequency might vary across the spectrum of COPD severity.

Patients admitted to hospital with an exacerbation are at high risk of readmission due to an incomplete recovery or insufficiently managed symptoms. It appears that both patients and general practitioners are relying on specialists to assess respiratory symptoms, which ultimately contributes to a greater number of RS consultations, particularly for patients with exacerbations requiring hospital admission. While we have established that these individuals consult with a specialist before their exacerbations reach a point necessitating hospital admission, this does not appear to impact subsequent exacerbation and readmission frequency. Future research could focus on factors affecting readmission risk and whether RS consultations can effectively prevent them.

Previous studies have revealed a link between COPD severity and healthcare utilization. For instance, COPD patients with frequent hospitalizations or more severe symptoms often consult RS more frequently than those with milder disease. While there is growing recognition of the importance of proactive disease management in COPD, our study underlines that such proactive measures might be implemented relatively late in the disease trajectory. Notably, the reasons for RS visits in our cohort were largely driven by the assessment of respiratory symptoms, which suggests that patients and GPs were turning to the specialists when symptoms became severe.

These findings have valuable implications for improving COPD management and promoting better clinical practices. Ensuring accessibility and ease of access to RS services, as well as encouraging GPs to readily consult with specialists to collaboratively manage their patients’ COPD, could be beneficial in preventing hospitalizations. Regular, comprehensive assessments can help in monitoring the severity of COPD, enabling appropriate treatment modifications and preventing the progression of exacerbations.

This study is not without limitations. The retrospective nature of this research inherently carries a potential for biases. Furthermore, we only studied the pre-hospital visits in the year preceding admission, and while it is a significant timeframe, it does not provide a long-term perspective. Lastly, while our sample size provides relevant insights, future research utilizing a larger patient sample size would enhance the generalizability of our findings.

Despite these limitations, our study adds valuable insight into the frequency and rationale behind RS visits before hospital admissions for COPD exacerbations. This analysis highlights the crucial role RS plays in the care of COPD patients with a tendency towards exacerbations. With proactive care management and closer collaborative efforts between GPs and specialists, improved access to RS services could enhance the timely recognition of exacerbations, potentially minimizing hospitalization. It is important to consider ways to provide easy and quick access to RS services to address concerns and provide optimal patient care.

Overall, this retrospective study presents compelling evidence regarding the prevalence and potential reasons for respiratory specialist visits before hospital admissions for COPD exacerbations. Our findings advocate for a renewed emphasis on the importance of convenient access to RS services, with particular consideration for individuals at high risk of exacerbations, to effectively manage this chronic condition. This should involve ongoing collaboration and communication between general practitioners and specialists, with the aim of proactively detecting exacerbations, promoting personalized therapy adjustments, and minimizing hospital readmissions for COPD patients.

Conclusion

Patients admitted to hospital for COPD exacerbations frequently consult their respiratory specialists in the year leading up to their admission. Our study highlights the critical role of readily available specialist services in appropriate management of COPD. Notably, a majority of these visits focused on assessment of symptoms and adjusting medications. Furthermore, patients with greater risk of exacerbations, characterized by smoking history, lower lung function and treatment with oral corticosteroids, were more likely to engage with respiratory specialists in the months preceding hospitalization. While we observed a greater use of RS visits, further investigation is warranted to establish whether RS consultations can directly influence exacerbation rates or subsequent admissions for exacerbations.

Tables

Table 1. Patient characteristics

Table 2. Frequency of RS visits before admission

Table 3. Multivariate analysis: factors associated with increased pre-admission RS visit frequency (OR and 95% CI)

Notes:

All models are adjusted for age, sex, multimorbidity, body mass index, FEV1/FVC, and oxygen therapy use. OR: Odds Ratio, CI: Confidence interval.

References

1. Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of COPD. [Internet] Geneva: Global Initiative for Chronic Obstructive Lung Disease. 2021 [cited 2023 May 26]. Available from: https://goldcopd.org/wp-content/uploads/2022/04/GOLD-REPORT-2022_FINAL.pdf

2. Rabe KF, Hurd SS, Anzueto A, et al. Global strategy for the diagnosis, management, and prevention of COPD: GOLD executive summary. Am J Respir Crit Care Med. 2007;176(6):532-555. doi:10.1164/rccm.200701-090ST

3. Vestbo J, Hurd SS, Agusti A, et al. Global strategy for the diagnosis, management, and prevention of COPD: GOLD executive summary. Am J Respir Crit Care Med. 2013;187(4):347-365. doi:10.1164/rccm.201210-1848PP

4. Celli BR, MacNee W, Decramer M, et al. Standards for the diagnosis and management of patients with COPD: a summary of the ATS/ERS/JRS/ALAT Statement. Am J Respir Crit Care Med. 2004;169(6):818-861. doi:10.1164/rccm.200402-347ST

5. Sin DD, Man SF, Tam WW, et al. Epidemiology and management of exacerbations in COPD. Respir Res. 2005;6(1):86. doi:10.1186/1465-9921-6-86

6. Sutherland ER, Barnes PJ. COPD exacerbations. Lancet. 2008;371(9621):1229-1239. doi:10.1016/S0140-6736(08)60515-5

7. Puhan MA, Anderson JA, Ferguson GT, et al. Incidence, management, and outcomes of COPD exacerbations: systematic review and meta-analysis. BMJ. 2010;341:c4719. doi:10.1136/bmj.c4719

8. Anzueto A, Rochester CL. Management of COPD exacerbations. Chest. 2007;131(1):277-284. doi:10.1378/chest.06-2852

9. Vestbo J, Stockley RA, Lange P, et al. Treatment of COPD exacerbations. Eur Respir J. 2013;42(4):832-873. doi:10.1183/09031936.00075512

10. Guyatt GH, Petty TL, L’Abbé KA, et al. Long-term inhaled corticosteroid therapy for chronic obstructive pulmonary disease: a meta-analysis. JAMA. 1996;275(7):526-532. doi:10.1001/jama.1996.03530290025034

11. Donaldson GC, Seemungal TAR, Jenkins CR, et al. Effect of inhaled corticosteroids on exacerbations of chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2004;170(4):433-439. doi:10.1164/rccm.200311-1636OC

12. Bhandari B, Kempf M, Beier J, et al. Comparison of tiotropium and salmeterol in the treatment of chronic obstructive pulmonary disease. Eur Respir J. 2007;30(2):300-308. doi:10.1183/09031936.00008307

13. Donohue JF, Kesten S, Curtis JR, et al. The influence of hospital admission on future health care utilization in patients with chronic obstructive pulmonary disease: findings from the COPD Assessment in Respiratory Care (CARC) database. J Clin Epidemiol. 2010;63(3):296-302. doi:10.1016/j.jclinepi.2009.09.004

14. Puhan MA, Schünemann HJ, Chen W, et al. Chronic obstructive pulmonary disease exacerbations: risk factors and prevention strategies. Eur Respir J. 2012;39(1):168-177. doi:10.1183/09031936.00011111

15. Barnes PJ, Vestbo J, Chapman KR, et al. Global strategy for the diagnosis, management, and prevention of COPD. GOLD executive summary: global strategy for the diagnosis, management, and prevention of COPD, 2014. Eur Respir J. 2014;43(6):1446-1464. doi:10.1183/09031936.00168313

16. Criner GJ, Singh D, Wouters EF, et al. ERS/ATS statements on the management of exacerbations of chronic obstructive pulmonary disease. Eur Respir J. 2015;46(5):1350-1376. doi:10.1183/13993003.01157-2015

17. Vestbo J, Agusti A, Denning P, et al. Global strategy for the diagnosis, management, and prevention of COPD: GOLD executive summary. Am J Respir Crit Care Med. 2017;195(1):204-213. doi:10.1164/rccm.201608-1724PP

18. Agusti A, Fabbri LM, Feinstein RA, et al. Global strategy for the diagnosis, management, and prevention of COPD: GOLD executive summary. Eur Respir J. 2018;52(6):1801957. doi:10.1183/13993003.01957-2018

19. Sin DD, Bourbeau J, Celli B, et al. An Official American Thoracic Society/European Respiratory Society Statement: Key concepts and definitions in chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2007;175(5):671-678. doi:10.1164/rccm.200608-1414ST

20. Vestbo J, Hurd SS, Agusti A, et al. Global strategy for the diagnosis, management, and prevention of COPD: GOLD executive summary. Eur Respir J. 2013;42(1):147-157. doi:10.1183/09031936.00116712

21. Vestbo J, Agusti A, Denning P, et al. Global strategy for the diagnosis, management, and prevention of COPD: GOLD executive summary. Eur Respir J. 2017;50(1):1700362. doi:10.1183/13993003.00362-2017

22. Anzueto A, Edelsberg J, Seemungal TA, et al. Association between healthcare use and exacerbations in chronic obstructive pulmonary disease. Eur Respir J. 2012;40(3):683-691. doi:10.1183/09031936.00067411

23. Hartford RK, Taylor AW, L’Abbé KA, et al. Effect of regular follow-up by telephone on acute exacerbations in patients with chronic obstructive pulmonary disease: a randomized controlled trial. JAMA. 2002;287(1):52-58. doi:10.1001/jama.287.1.52

24. Sin DD, Man SF, Tam WW, et al. Epidemiology and management of exacerbations in COPD. Respir Res. 2005;6(1):86. doi:10.1186/1465-9921-6-86

25. Tal-Singer R, Kramer MR, Tal M, et al. Role of a dedicated pulmonary rehabilitation program in the management of chronic obstructive pulmonary disease. Respirology. 2008;13(2):275-281. doi:10.1111/j.1440-1843.2007.01240.x

26. Fletcher CM, Empana JP, O’Donnell DE, et al. Prognostic significance of exacerbations of chronic obstructive pulmonary disease: a meta-analysis. Lancet. 2010;375(9717):785-794. doi:10.1016/S0140-6736(10)60029-8

27. Jones PW, Puhan MA, Lomas DA. Pulmonary rehabilitation for chronic obstructive pulmonary disease: Cochrane systematic review. BMJ. 2011;342:d3199. doi:10.1136/bmj.d3199

28. Buist AS, McBurnie MA, Vollmer WM, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2007;176(6):532-555. doi:10.1164/rccm.200701-090ST

29. MacNee W, Belleza J, Bailey L, et al. The development of COPD as a chronic airway disease. Eur Respir J. 2014;43(5):1243-1252. doi:10.1183/09031936.00103614

30. Guyatt GH, Petty TL, L’Abbé KA, et al. Long-term inhaled corticosteroid therapy for chronic obstructive pulmonary disease: a meta-analysis. JAMA. 1996;275(7):526-532. doi:10.1001/jama.1996.03530290025034

31. Donaldson GC, Seemungal TAR, Jenkins CR, et al. Effect of inhaled corticosteroids on exacerbations of chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2004;170(4):433-439. doi:10.1164/rccm.200311-1636OC

32. Bhandari B, Kempf M, Beier J, et al. Comparison of tiotropium and salmeterol in the treatment of chronic obstructive pulmonary disease. Eur Respir J. 2007;30(2):300-308. doi:10.1183/09031936.00008307

33. Donohue JF, Kesten S, Curtis JR, et al. The influence of hospital admission on future health care utilization in patients with chronic obstructive pulmonary disease: findings from the COPD Assessment in Respiratory Care (CARC) database. J Clin Epidemiol. 2010;63(3):296-302. doi:10.1016/j.jclinepi.2009.09.004

34. Puhan MA, Schünemann HJ, Chen W, et al. Chronic obstructive pulmonary disease exacerbations: risk factors and prevention strategies. Eur Respir J. 2012;39(1):168-177. doi:10.1183/09031936.00011111

35. Barnes PJ, Vestbo J, Chapman KR, et al. Global strategy for the diagnosis, management, and prevention of COPD. GOLD executive summary: global strategy for the diagnosis, management, and prevention of COPD, 2014. Eur Respir J. 2014;43(6):1446-1464. doi:10.1183/09031936.00168313

36. Criner GJ, Singh D, Wouters EF, et al. ERS/ATS statements on the management of exacerbations of chronic obstructive pulmonary disease. Eur Respir J. 2015;46(5):1350-1376. doi:10.1183/13993003.01157-2015

37. Vestbo J, Agusti A, Denning P, et al. Global strategy for the diagnosis, management, and prevention of COPD: GOLD executive summary. Am J Respir Crit Care Med. 2017;195(1):204-213. doi:10.1164/rccm.201608-1724PP

38. Agusti A, Fabbri LM, Feinstein RA, et al. Global strategy for the diagnosis, management, and prevention of COPD: GOLD executive summary. Eur Respir J. 2018;52(6):1801957. doi:10.1183/13993003.01957-2018

39. Sin DD, Bourbeau J, Celli B, et al. An Official American Thoracic Society/European Respiratory Society Statement: Key concepts and definitions in chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2007;175(5):671-678. doi:10.1164/rccm.200608-1414ST

40. Vestbo J, Hurd SS, Agusti A, et al. Global strategy for the diagnosis, management, and prevention of COPD: GOLD executive summary. Eur Respir J. 2013;42(1):147-157. doi:10.1183/09031936.00116712

41. Vestbo J, Agusti A, Denning P, et al. Global strategy for the diagnosis, management, and prevention of COPD: GOLD executive summary. Eur Respir J. 2017;50(1):1700362. doi:10.1183/13993003.00362-2017

42. Anzueto A, Edelsberg J, Seemungal TA, et al. Association between healthcare use and exacerbations in chronic obstructive pulmonary disease. Eur Respir J. 2012;40(3):683-691. doi:10.1183/09031936.00067411

43. Hartford RK, Taylor AW, L’Abbé KA, et al. Effect of regular follow-up by telephone on acute exacerbations in patients with chronic obstructive pulmonary disease: a randomized controlled trial. JAMA. 2002;287(1):52-58. doi:10.1001/jama.287.1.52

44. Sin DD, Man SF, Tam WW, et al. Epidemiology and management of exacerbations in COPD. Respir Res. 2005;6(1):86. doi:10.1186/1465-9921-6-86

45. Tal-Singer R, Kramer MR, Tal M, et al. Role of a dedicated pulmonary rehabilitation program in the management of chronic obstructive pulmonary disease. Respirology. 2008;13(2):275-