Management of acute COPD exacerbations in Australia: do we follow the guidelines?

Discussion

This prospective study of five tertiary care facilities across Australia demonstrated that there are variations in concordance to the COPD-X guideline for inpatient management of patients with AECOPD. Interventions with high concordance included performance of chest radiography, provision of treatment with oral corticosteroids and antibiotics, and administration of oxygen therapy. Discordance was seen to the recommendations of performing spirometry and referral to pulmonary rehabilitation, with rates varying substantially across sites. This study reflects actual clinical practice and has provided insight into the gaps in AECOPD management when compared to evidenced-based guidelines.

Patient characteristics were similar to those of other audits [10, 11, 19]. The median LOS in this group was 6 days. Our data are similar to previous Australian studies [10, 11] that reported a median LOS of 5 days, but shorter than international data where median LOS has been reported between 7 and 8 days [20–22]. The reason for the significant difference seen in LOS between Australian sites is not clear but may be related to variations in management or local protocols. CAT score was shown to impact LOS, demonstrating its value as a reportable patient outcome for use during hospital admission.

Smoking rates, while similar to other Australian data [10, 11], were higher than those reported by European studies [21, 22] (9% and 30%, respectively). Smoking rates in the Australian cohort are high when compared to the national average (9.3%) in the 65–75-year age group [23], highlighting the need for effective smoking cessation strategies for patients with COPD.

Our data support previous national [10, 19] and international [24] findings demonstrating underutilisation of spirometry. These results compare to previous national audits. A study by Khialani et al. [19] reported a measured FEV₁ in 17.2% of patients, while Pretto et al. [10] reported spirometry being recorded in 29%. COPD-X suggest that spirometry during admission is of value in assessing severity of an AECOPD [9], and may be useful in confirming diagnosis and assessing severity and clinically useful for ongoing management [25]. In our audit, not having spirometry performed during the admission increased the odds of 28-day readmission.

Several studies have demonstrated that valid and reproducible spirometry traces can be obtained in patients admitted with AECOPD, and is important in confirming the presence of airflow limitation where diagnosis of COPD is not confirmed [26, 27]. Poor spirometry uptake may be due to differences in recommendations by key guidelines on the need for spirometry testing during admission [4, 28]. While COPD-X argues that “even the sickest of patients can perform an FEV₁ manoeuvre” [28], the GOLD guidelines [4] do not routinely recommend that sick patients perform spirometry. It is also important to consider the practicality or capacity of emergency department staff to obtain acceptable spirometry traces. Patient admissions are not restricted to “office hours” when lung function laboratories are open. In addition, appropriate equipment and staff who are skilled in obtaining accurate measurements may not always be available at the times when patients present to the emergency department. However, acute care services need to be improving diagnostic accuracy in the assessment of COPD severity and demonstrating the importance of this diagnostic tool to primary care practitioners. Any admission to acute care services can present an opportunity for reassessment and classification of the severity of airflow limitation to guide decisions on appropriate treatment, particularly as poor use of spirometry in primary care has been shown to be associated with under and overdiagnosis of COPD patients [29].

COPD-X [9] recommend measurement of ABGs if the FEV₁ is <1.0 L or 40% predicted, or when oxygen saturations are <90%. Our study did not record peripheral oxygen saturation data and rates of spirometry on admission were low; however, while three quarters of all patients had either an ABG or VBG collected (156 patients, 75.3%), 18.9% of admissions who had a FEV₁ <1.0 L did not have blood gases taken. The reason(s) not to perform these measurements are unknown and our study was not designed to identify these, but these data highlights gaps in management. Early identification of hypercapnic respiratory failure is important, to identify both those at highest risk of death during admission and those who will benefit from treatment with NIV [5]. Failure to obtain blood gas measurements may lead to missed opportunities to provide NIV to those in acute respiratory failure. Blood gas collection occurred in 81.1% for those with a FEV₁ <1.0 L and in 75.3% of patients overall. Results compared to other Australian studies where collection rates (ABG or VBG) ranged between 62% and 77% [10, 19, 30, 31]. They also compare favourably to international literature from South East Asia, where rates of blood gas collection occurred in less than a quarter of patients admitted to the emergency department [31]. However, blood gas collection is consistently higher in Europe, with documented rates between 80% and 90% [13, 21, 22].

NIV was indicated in 32 patients, with 21 receiving ventilatory assistance. National [10, 19, 31] and international [13, 31] data highlight missed opportunities for the use of NIV in patients with acidosis. This equates to 11 (34%) patients who could have potentially benefited from this therapy. High-quality evidence now exists to support the use of NIV in addition to usual care for patients with acute hypercapnic respiratory failure; interestingly, the number needed to avoid one death is 12, very close to the number in our audit missing out on treatment [32]. NIV has been shown to reduce mortality by up to 46%, reduce the need for intubation by 65% and, on average, reduces the LOS for these patients by 3.5 days [32]. Our results confirm that NIV is underutilised.

Excellent concordance was seen for the recommendation to perform a chest radiograph, with almost 100% adherence seen in our study. Both national [10, 19, 30, 31] and international [13, 21, 31] data consistently demonstrate high concordance (>90% across studies) with this recommendation. Our study also demonstrates high concordance across all sites (range 90–100%) for corticosteroid prescription. These results are higher than those reported by Pretto et al. [10]. It also compares favourably to international data that demonstrate concordance rates between 82.3% [13] and 92% [21].

In most admissions (95.0%) audited, patients were prescribed antibiotics when there was evidence of change in sputum colour. These compare favourably to the study by Pretto et al. [10] but lower prescription rates were noted in studies that have examined Australian emergency department management of patients with AECOPD, where rates ranged between 58% and 75% [19, 30, 31]. Guidelines [9] recommend antibiotic cover for patients with purulent sputum. This audit did not specifically investigate presence of purulent sputum; however, it did ask if a change in sputum colour was noted. Our study also demonstrated high rates of antibiotic prescription in patients who had no documented change in sputum colour (85.7%). This indicates a potential overprescription of antibiotics in this group. Tang et al. [11] identified that 45% of patients were overprescribed antibiotic therapy. A number of studies have identified inappropriate prescription of antibiotic therapy in the AECOPD patient cohort [12, 33, 34]. Furthermore, a 2018 Cochrane review concluded that aside from AECOPD patients who are treated in an intensive care unit, the effects of antibiotic therapy use in this patient group is small [35]. Antibiotic resistance is a major public health problem [36], one contributing factor associated with the emergence of multidrug-resistant bacteria is inappropriate prescription of antibiotics [37]. Our data demonstrates that improvement is needed to ensure antibiotics are prescribed in those who would most benefit.

Rates of oxygen use during an acute exacerbation are high in both national [10, 11] and international [13, 21] literature within the COPD cohort, with its use recommended for those who are hypoxic. Similarly, oxygen use across all sites was high in our audit. It was difficult to assess the appropriateness of delivery in the absence of more specific clinical data. The written prescription of oxygen differed significantly between sites, with rates of prescription poor (3.2%) at two sites while significantly better rates observed at another (76.9%). Reasons for these differences in prescription rates are not clear from the data collected. The practice of prescribing oxygen therapy is poor internationally, with many reasons offered in the literature and multiple interventions trialled in efforts to improve this practice [38]. However, quality improvement projects in the UK have demonstrated improvements in the practice of oxygen prescription, the 2017–2018 audit demonstrating that 72% of admissions requiring oxygen having a prescription [39]. Notably, the Thoracic Society of Australia and New Zealand (TSANZ) did not release their clinical practice guidelines on oxygen use in adults until 2015, which was after the current audit was undertaken (2012–2013). However, the British Thoracic Society guidance [40] advocating for oxygen prescription has been published since 2008.

Less than a third of patients were referred to pulmonary rehabilitation. While this result is not unexpected or particularly poor, when comparing this to current guidance that asks clinicians to “consider pulmonary rehabilitation at any time following an exacerbation” [41], a rate of 32% certainly demonstrates room for improvement given the evidence that supports the efficacy of this intervention [42, 43]. Considering the metropolitan location of all study sites, one could reasonably expect to find the largest number of and easiest access to pulmonary rehabilitation programmes. The low referral rates demonstrate that there is scope to improve referral to pulmonary rehabilitation. Both national [10, 11] and international [24] data have consistently demonstrated low rates of referral to pulmonary rehabilitation programmes despite high-quality evidence demonstrating it improves quality of life, exercise capacity and reduces healthcare utilisation [42]. The TSANZ pulmonary rehabilitation guideline recommends provision of pulmonary rehabilitation within 2 weeks of discharge and efforts to improve referral are needed [43]. General practitioner follow-up was high overall (76.8%); however, significant differences were seen in referral rates between sites (range 16.7%–100%).

This study presented several strengths and limitations. To our knowledge, this is the first national audit conducted in multiple sites across five Australian states. This provides a representative sample from an Australia tertiary care perspective. The eligibility criteria were broad and inclusive, in order to reflect clinical practice. The prospective study design avoided the inclusion of patients whose diagnostic codes were incorrect, as only patients who had been assessed by a clinician as having an AECOPD were included. This design, however, also presents some limitations. While patients were identified prospectively, data were recorded from medical records, which led to some missing and/or inconsistently coded variables. Poor documentation of patient data in the patient notes may have led to perceived poor concordance even where none may have existed in practice. In addition, this was a real-world clinical audit conducted as part of usual clinical care. The real-world nature of this study meant that there were differences in the levels of data acquisition between sites.

Overall, important gaps in management were seen nationally when compared against the COPD-X guideline. There is scope for improvements in performance of FEV₁ and referral to pulmonary rehabilitation programmes. In addition, increased utilisation of NIV may reduce mortality and endotracheal intubation. Strategies that have demonstrated improvements in the quality of care for AECOPD have been highlighted in the literature and deserve serious consideration for inclusion within the Australian context. In the UK, continuous clinical audit was commenced in 2017 for COPD care. This strategy has seen real improvements in the quality of care received by patients admitted with AECOPD [39]. In addition, strategies such as the use of care bundles have been shown to decrease readmission rates in the AECOPD patient group [44]. Further exploration around the feasibility of such strategies is needed in Australia to improve best evidence uptake, clinical practice and patient outcomes.