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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
