Effects of a written action plan on COPD exacerbation recovery

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                                                               ERS Berlin 2008




                       Effects of a written action plan on
                              COPD exacerbation recovery

Erik Bischoff1, M.Sc., M.D. : PhD student and family medicine resident

Co-investigators: Dina Hamd2, Maria Sedeno2, Andrea Benedetti2,3, Tjard Schermer1,

Sarah Bernard4, Francois Maltais4, Jean Bourbeau2,3
1. Department of Family Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands;

2. Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute, McGill University Health Centre, Montréal, Canada;

3. Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Canada;

4. Centre de recherche, Hôpital Laval, Institut Universitaire de Cardiologie et de Pneumologie de l’Université Laval, Sainte-Foy, Canada.
                            Written action plan for COPD exacerbations



    Background


      Exacerbations:
      Acute events of sustained symptom worsening                   Rabe et al. Am J Resp Crit Care Med, 2000


      Decrease in quality of life   Bourbeau et al. Eur Respir J, 2007


      Recovery varies between 7 and 14 days              Seemungal et al. Am J Resp Crit Care Med, 2000


      Underreporting: delay in treatment           Langsetmo et al. Am J Resp Crit Care Med, 2008


      Early treatment improves recovery           Wilkinson et al. Am J Resp Crit Care Med, 2004


      Self-management programs may be effective                   Bourbeau et al. Arch Intern Med, 2003




Bischoff et al.                                                                                                  ERS Berlin 2008
                                 Written action plan for COPD exacerbations



    Objectives
       Primary:
                 To assess the effect of appropriate action plan use, i.e. initiation of both
                  antibiotics and prednisone within 3 days of exacerbation onset, on exacerbation
                  recovery time;

                 To assess the effect of appropriate action plan use on the use of healthcare
                  services;


       Secondary:
                 To explore predisposing factors to appropriate action plan use.


Bischoff et al.                                                                              ERS Berlin 2008
                                       Written action plan for COPD exacerbations



    Methods
    Data from the Canadian Pulmonary Rehabilitation RCT
                       (Randomized Clinical Trials CIHR gov NCT00169897) :
    Home-based versus hospital-based pulmonary rehabilitation;
    Canadian hospital outpatient clinics (10) recruited 252 COPD patients;
    Eligibility:
        Inclusion criteria                                           Exclusion criteria:
                  1)     6 min walking distance > 110 m;             1)   Asthma as a primary diagnosis;
                  2)     40 years or older;                          2)   LHF, terminal disease, dementia,
                  3)     current or ex-smoker (>10pack years);             uncontrolled psychiatric illness;

                  4)     stable COPD for the previous four weeks;    3)   Participation previous rehab programs

                  5)     FEV1 post BD < 70% pred.                          and long-term care.

                         and FEV1/FVC < 0.70;
                  6)     MRC dyspnea scale of at least 2.

Bischoff et al.                                                                                            ERS Berlin 2008
                                     Written action plan for COPD exacerbations



    Methods

Enrollment             Pre-randomisation                                 Post-randomisation
                            4 weeks                     8 weeks                               9 months


                                             Home-based rehabilitation

                  Living Well with COPD

                                             Hospital-based rehabilitation



                  V1                        T1 –T10                          V2                                            V3




Bischoff et al.                                                                                          ERS Berlin 2008
                                Written action plan for COPD exacerbations



    Methods
       Definitions:
           Exacerbation: worsening of 2 or more ‘major’ symptoms ≥ 24 hours;

           Appropriate use: initiation of both antibiotics and prednisone < 3 days time
              delay.

       Statistical analyses:

           Intraclass correlation coefficient (ICC): exacerbations clustered within patients;

           Main study objective: multivariate linear and logistic models;

           Secondary study objective: multivariate multilevel logistic model, manual

              backward elimination.

Bischoff et al.                                                                        ERS Berlin 2008
                                Written action plan for COPD exacerbations



    Results                          Baseline characteristics


                                                      Patients with ≥ 1 exacerbations (n=143)
     Age, years                                                            65.1 ± 8.7
     Male                                                                  76 (53%)
     Years of education                                                    11.1 ± 4
     Current smoker                                                       25 (17.5%)
     Pack years                                                          56.0 (42-75)
     Post-BD FEV1 %                                                       43.4 ± 13
     MRC ≥ 4                                                              44 (31%)
     ER visits COPD prev. 12 months                                      1.78 ± 1.35
     ICS and LABD                                                         110 (77%)
     6-min walking distance (meters)                                    344 (285-404)
     Depressive symptoms                                                  39 (30%)
     Cardiac disease                                                      33 (23%)
  Data are expressed as mean ±sd, median (25th-75th percentile) or number (%)
Bischoff et al.                                                                                 ERS Berlin 2008
                                   Written action plan for COPD exacerbations



     Results                          Effect of action plan use on exacerbation outcomes


                               Exacerbation recovery time, days

Appropriate AP use             Mean (SD)       Median                         B           SE (B)         p-value
                                               (25th-75th percentile)
                  Yes (n=87)     10.9 (5.6)          10.0 (7.0 – 12.0)            -5.08       1.29         0.0001
                  No (n=130)    16.0 (10.7)          12.0 (9.0 – 21.0)


                               Healthcare utilization ¶
Appropriate AP use             Yes (n=107)     No (n=105)                     OR          95% CI         p-value

                  Yes (n=85)        42                      43                    0.93     0.54 – 1.61       0.80
                  No (n=127)        65                      62
¶   unscheduled doctor visit, emergency department visit and/or hospitalization



Bischoff et al.                                                                                          ERS Berlin 2008
                             Written action plan for COPD exacerbations


                                  Relationship between appropriate action plan use
Results                           and exacerbation recovery time (days)
                                           Categories or units   B        SE (B)   p-value
Exacerbation recovery time
  Appropriate action plan use              yes vs no             -5.18    1.38     0.0001
  Number of exacerbation symptoms          3 vs 2 symptoms       4.28     1.34     0.002
  Contacting the case manager              yes vs no             4.67     1.33     0.001
  Age                                      each year             -0.12    0.09     0.18
  Sex                                      female vs male        -0.59    1.60     0.72
  Post-BD FEV1                             each % predicted      0.070    0.055    0.21
  ICS and LABD                             yes vs no             0.95     1.69     0.57
  Influenza vaccination                    yes vs no             -2.11    1.69     0.21
  Smoking status                           current vs ex         -1.58    1.60     0.33
  Cardiac disease                          yes vs no             1.50     1.62     0.57
  Depressive symptoms                      sum score             -0.21    0.21     0.32
  Pulmonary rehabilitation                 home vs hospital      -2.02    1.36     0.14
                             Written action plan for COPD exacerbations


                                  Relationship between appropriate action plan use and
Results                           use of healthcare services
                                         Categories or units   OR         95% CI        p-value
Use of healthcare services
  Appropriate action plan use            yes vs no             0.86       0.44 – 1.70   0.67
  ER COPD visit prior to study           each visit            1.39       1.03 – 1.86   0.031
  Sex                                    female vs male        2.01       0.92 – 4.39   0.081
  Age                                    each year             1.01       0.97 – 1.06   0.67
  Smoking status                         current vs ex         0.71       0.32 – 1.59   0.40
  Post-BD FEV1                           each % predicted      1.01       0.98 – 1.04   0.46
  ICS and LABD                           yes vs no             1.22       0.52 – 2.84   0.65
  Influenza vaccination                  yes vs no             1.30       0.57 – 2.97   0.54
  Cardiac disease                        yes vs no             1.18       0.53 – 2.66   0.68
  Depressive symptoms                    sum score             0.93       0.84 – 1.03   0.18
  Contacting the case manager            yes vs no             0.61       0.32 – 1.18   0.14
  Number of exacerbation symptoms        3 vs 2 symptoms       1.36       0.71 – 2.61   0.36
  Pulmonary rehabilitation               home vs hospital      0.80       0.41 – 1.55   0.50
                              Written action plan for COPD exacerbations


                                   Predisposing factors to appropriate action plan use
    Results


                                                    Univariate analyse     Multivariate analyse

      Variable                 Category or unit     OR       95% CI        OR      95% CI

      Influenza vaccination    yes vs no            3.84     1.75 – 8.43   4.82    1.71 – 13.54

      Cardiac disease          yes vs no            2.46     1.29 – 4.71   3.05    1.26 – 7.39

      Age                      each year            0.98     0.95 – 1.01   0.96    0.92 – 1.00

      Post-BD FEV1             each % predicted     0.41     0.17 – 0.98   0.98    0.95 – 1.00




Bischoff et al.                                                                             ERS Berlin 2008
                               Written action plan for COPD exacerbations



    Conclusions

        40% of the patients failed to use their action plan appropriately, i.e. initiation of
         antibiotics and prednisone < 3 days time delay;

        Appropriate use of a written action plan

           reduced exacerbation recovery time with statistical and clinical significance;

           did not reduce the use of healthcare services;

        Patients receiving influenza vaccination, having a cardiac disease, having more
         severe airflow obstruction, and being younger had an increased likelihood of
         appropriately using the written action plan.



Bischoff et al.                                                                             ERS Berlin 2008
                                 Written action plan for COPD exacerbations



    Implications

    Written action plans should deserve a more prominent role in exacerbation
         management;

    In implementing written action plans, it is important to
           consider patient characteristics because some of these characteristics can
                  influence the likelihood of the “appropriate use”;

           include continuous reinforcement by case managers;

           have well-designed care delivery systems with easy access to care.




Bischoff et al.                                                                     ERS Berlin 2008
                            Written action plan for COPD exacerbations



Acknowledgements
 Thanks to all the participating Canadian centres:
    Hôpital Laval, Sainte-Foy                    Centre Hospitalier Universitaire Associé, Québec
    Chest Institute, Montréal                    Centre hospitalier de la Baie des Chaleurs, Maria
    Mont-Sinaï, Montréal                         Queen Elizabeth II Health Sciences Centre, Halifax
    Hôpital Sacré Coeur, Montréal                St Paul’s Hospital, Vancouver
    Jewish Rehabilitation Hospital, Laval        Hôpital Hôtel-Dieu de Lévis, Lévis


Thanks to Reinier Akkermans, statistician at the Department of Family Medicine,

      Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands

Funded by:
       Canadian Institutes of Health Research RCT programme
       Réseau en Santé Respiratoire du FRSQ



                                                                                                 ERS Berlin 2008

				
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