The Society of Hospital Medicine (SHM) is pleased to make this Implementation Toolkit available as a tool to help you to improve the care of patients who are hospitalized for an exacerbation of chronic obstructive pulmonary disease (COPD).
This Toolkit will help you make changes to COPD care at both the individual patient and the institutional levels, and is intended for use by clinicians on the front lines of patient care as well as medical directors, vice-presidents of quality, vice-presidents of medical affairs and chief medical officers. Given the interdisciplinary nature of inpatient quality improvement efforts, SHM anticipates that this Toolkit will be useful to a broad range of hospital stakeholders, including nurses, nurse practitioners, physician assistants, pharmacists, respiratory therapists and pulmonary rehabilitation nurses.
Chronic obstructive pulmonary disease encompasses a spectrum of progressive pulmonary disorders including emphysema and chronic bronchitis. It is estimated that 15 million adults in the U.S. are diagnosed with COPD,1 but many experts feel that this is a gross underestimate due to underdiagnosis.2
COPD is a tremendous healthcare burden in the U.S. and worldwide. In 2008, COPD, as part of chronic lower respiratory diseases, became the third leading cause of death in the United States,3 and also accounted for nearly 140,000 deaths per year as of 2012.4 The prevalence of COPD nationwide is around six percent, but much state-to-state variability exists.1
The healthcare burden of COPD is also substantial from a readmission and economic standpoint. Patients hospitalized with acute exacerbations of COPD (AECOPD) account for nearly 70 percent of the estimated $50 billion in annual expenditures for COPD3. More than 20 percent of those admitted with AECOPD are readmitted within 30 days.14 Readmissions related to COPD lead to costs that are nearly 20 percent higher than the index admissions.15 Beginning in in 2014 the Centers for Medicare and Medicaid Services (CMS) added hospitalization due to COPD to its Hospital Readmission Reduction Program.
The prevalence of COPD continues to rise, but the demographics of the disease have evolved over the past decade. While the prevalence of COPD in older patients has remained elevated (>11.6 percent among those >65), it has increased among younger populations (3.2 percent among the 18-44 age group), and >50 percent of patients with a diagnosis of COPD are under the age of 65.1 Since 2000, COPD has been more prevalent in women than men. As the death rate has declined in men since 2000, it has persisted at nearly the same rate in women, with more women dying from COPD than men
Smoking is felt to be a major contributor to the development and progression of COPD.5 However, a significant number of patients (10-20 percent) diagnosed with COPD are nonsmokers, suggesting genetic and other environmental factors involved in the risk of developing COPD.6
A history of asthma is also strongly associated with COPD.1 The American College of Physicians (ACP), American Thoracic Society/European Respiratory Society (ATS/ERS) and the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines all recommend strategies for primary prevention and treatment including smoking cessation and early diagnosis using spirometry,8, 9 which has become more accessible than it has been in the past.
The standard of care in the inpatient setting as recommended in these guidelines for treating AECOPD includes the use of bronchodilator therapy, oxygen, steroids and the selective use of antibiotics. While these have been shown to be effective in treating COPD and reducing inpatient mortality and readmissions, it is smoking cessation and reducing exposure to secondhand smoke that can alter the progression of lung disease.10,11
However, despite the longstanding availability of clinical guidelines, studies conducted in the U.S. and elsewhere have documented the persistence of large gaps in care quality16, 17,18 and substantial variation across hospitals in the management of patients with COPD. One study found that more than half of active smokers are not offered tobacco cessation resources.12 Nearly 60 percent of patients with severe COPD are not prescribed maintenance bronchodilator therapy13 and 25 percent of patients with AECOPD are discharged without any bronchodilator therapy.12
Although opportunities to improve quality are well known, there has been less progress identifying effective strategies for translating evidence into practice.
Given the enormous clinical and economic burden imposed by COPD it is critical that hospitals begin to direct quality improvement (QI) resources to improving care for these patients. The following sections will summarize best practices in COPD and outline strategies for making changes to care that have the potential to improve patient outcomes and reduce healthcare related costs at your institution. It is SHM’s hope that this toolkit will enable providers and healthcare systems to bring evidence-based treatment to the bedside for their patients with COPD.
This implementation toolkit is supported in part by a non-educational sponsorship from Sunovion Pharmaceuticals.
The Chronic Obstructive Pulmonary Disease (COPD) Toolkit is an online resource for visitors to the Society of Hospital Medicine's website. All content and links have been reviewed by COPD Toolkit Project Team, however the Society of Hospital Medicine does not exercise any editorial control over content associated with the external links that have been made available via this website.