Review
Impact of care pathways for in-hospital management of COPD exacerbation: A systematic review

https://doi.org/10.1016/j.ijnurstu.2011.06.006Get rights and content

Abstract

Background

In-hospital management of COPD exacerbation is suboptimal, and outcomes are poor. Care pathways are a possible strategy for optimizing care processes and outcomes.

Objectives

The aim of the literature review was to explore characteristics of existing care pathways for in-hospital management of COPD exacerbations and to address their impact on performance of care processes, clinical outcomes, and team functioning.

Methods

A literature search was conducted for articles published between 1990 and 2010 in the electronic databases of Medline, CINAHL, EMBASE, and Cochrane Library. Main inclusion criteria were (I) patients hospitalized for a COPD exacerbation; (II) implementation and evaluation of a care pathway; (III) report of original research, including experimental and quasi experimental designs, variance analysis, and interviews of professionals and patients about their perception on pathway effectiveness.

Results

Four studies with a quasi experimental design were included. Three studies used a pre–post test design; the fourth study was a non randomized controlled trial comparing an experimental group where patients were treated according to a care pathway with a control group where usual care was provided. The four studied care pathways were multidisciplinary structured care plans, outlining time-specific clinical interventions and responsibilities by discipline. Statistic analyses were rarely performed, and the trials used very divergent indicators to evaluate the impact of the care pathways. The studies described positive effects on blood sampling, daily weight measurement, arterial blood gas measurement, referral to rehabilitation, feelings of anxiety, length of stay, readmission, and in-hospital mortality.

Conclusions

Research on COPD care pathways is very limited. The studies described few positive effects of the care pathways on diagnostic processes and on clinical outcomes. Though due to limited statistical analysis and weak design of the studies, the internal validity of results is limited. Therefore, based on these studies the impact of care pathways on COPD exacerbation is inconclusive. These findings indicate the need for properly designed research like a cluster randomized controlled trial to evaluate the impact of COPD care pathways on performance of care processes, clinical outcomes, and teamwork.

Introduction

Patients with chronic obstructive pulmonary disease (COPD) experience frequent exacerbations of symptoms (Chenna and Mannino, 2010, Izquierdo et al., 2009, Seemungal et al., 2009). COPD exacerbations are characterized by a change in baseline dyspnea, cough, and/or sputum, that is beyond normal day-to-day variations, is acute in onset, and may warrant additional treatment in a patient with underlying COPD (Burge and Wedzicha, 2003). The annual rate of COPD exacerbations varies from 0.5 to 3.5 exacerbations per patient (Chenna and Mannino, 2010, Seemungal et al., 2009).

COPD exacerbations contribute tremendously to the disease burden. They are a leading cause of hospital admission worldwide, with 35% of COPD patients having at least one admission a year and up to 40% of admitted patients having two or more readmissions a year (Cao et al., 2006, Garcia-Aymerich et al., 2003, Izquierdo et al., 2009). These acute hospital admissions account for the majority (52–84%) of the overall direct costs related to COPD. In the Confronting COPD Survey conducted in 2003, the annual direct costs per patient were found to be higher in the USA (US$4119/€3028) and Spain (US$3196/2349€) and to be lower in the Netherlands (US$606/€446) and France (US$522/€384) (Wouters, 2003). COPD exacerbations also have a serious impact on functional status (Bourbeau, 2009, Chenna and Mannino, 2010) and patients’ quality of life (Chenna and Mannino, 2010, Seemungal et al., 1998, Wang and Bourbeau, 2005), and up to 30% of patients die within one year after hospitalization (Groenewegen et al., 2003, Yohannes et al., 2005). Furthermore, we see high variation in outcomes after hospitalization for COPD exacerbation; for example, for 30-day mortality (range 5.2–17.2%) (Agabiti et al., 2010), 1-year mortality (23–37%) (Groenewegen et al., 2003, Yohannes et al., 2005), and 1-year readmission rate (37–67%) (Cao et al., 2006, Garcia-Aymerich et al., 2003, Gudmundsson et al., 2005, Izquierdo et al., 2009).

Several worldwide established evidence-based clinical practice guidelines (CPGs) are available for the assessment and management of patients with COPD (Pierson, 2006); for example, the guidelines of the Global Initiative for Chronic Obstructive Pulmonary Disease (GOLD) (Global Initiative for Chronic Obstructive Lung Disease, 2010); the American Thoracic Society (ATS)-European Respiratory Society Task Force (ERS) (Celli and Macnee, 2004); and the National Institute for Clinical Excellence (NICE, 2004). These guidelines are remarkably consistent, as only two discrepancies with regard to sputum culture and performance of spirometric tests were found. For these two recommendations no research evidence is available, and so both advices are derived from expert committee reports or opinions and/or clinical experience of respected authorities. Sputum culture is useful in identifying bacterial infections and in directing antibiotic therapy. ATS-ERS guidelines recommend sputum cultures for all patients hospitalized with an exacerbation, while GOLD and NICE guidelines only recommend sputum cultures and antibiograms for patients with purulent sputum and in which an infectious exacerbation does not respond to the initial antibiotic treatment (Celli and Macnee, 2004, GICOLD, 2010, NICE, 2004). With regard to spirometric tests, ATS-ERS and GOLD guidelines do not routinely recommend spirometric tests because these tests are difficult for a sick patient to perform properly and therefore can be inaccurate during acute exacerbations (Celli and Macnee, 2004;GOLD, 2010). On the other hand, NICE guidelines recommend measuring spirometry in all patients before discharge (NICE, 2004).

Several studies concerning in-hospital management of COPD exacerbation show that guideline adherence is poor and varies highly across organizations (Decramer et al., 2003, Hosker et al., 2007, Lodewijckx et al., 2009). Lodewijckx et al. (2009) reviewed delivered care in more than 70,000 patients hospitalized with COPD exacerbation. Results showed that non-pharmacological management is extremely suboptimally performed, especially with regard to smoking cessation intervention (30–42% of active smokers), education regarding inhaler therapy (20%), and referral to pulmonary rehabilitation (3–18%). Also diagnostic and pharmacological management were found to be suboptimal, especially with regard to arterial blood gas measurement (performed in 44–79% of patients), and administration of corticosteroids (administered in 62–85% of patients). Decramer et al. (2003), who questioned management of COPD in 86 pulmonologists in Belgian Hospitals, also found several areas of non-adherence to recommendations of international guidelines, especially with regard to pulmonary revalidation, smoking cessation, and non-invasive ventilation. Finally, Hosker et al. (2007) explored hospital care for COPD exacerbation in 233 UK units and found large differences in organization of care. To illustrate, a considerable number of hospitalized COPD patients had no access to a specialist respiratory ward (35% of patients had no access), a pulmonary rehabilitation program (36%), or an early discharge scheme (56%).

One possible strategy to standardize care processes and to optimize outcomes after hospitalization for COPD exacerbation is the implementation of a care pathway, also known as clinical pathway or critical pathway (Campbell et al., 1998, Panella et al., 2003, Pearson et al., 1995, Vanhaecht et al., 2009, Zander and Bower, 2000). Care pathways are complex interventions for the mutual decision making and organization of predictable care for a well-defined group of patients during a well-defined period, with the aim to enhance the quality of care across the continuum by improving risk-adjusted patient outcomes, promoting patient safety, increasing patient satisfaction, and optimizing the use of resources (Vanhaecht, 2007).

In several reviews positive effects of care pathways on clinical outcomes, performance of care processes, costs, teamwork, and patient satisfaction are reported (Rotter et al., 2010, Sermeus et al., 2005, Van Herck et al., 2004). Most of care pathways were developed for surgery (50%) such as hip fracture surgery and knee arthroplasty, and for medical conditions (30%) such as asthma, pneumonia, and stroke. Other domains included were emergency care, psychiatry, palliative care and rehabilitation. However, none of the reviews reported on COPD care pathways. Therefore, two main research questions are explored in this review:

  • 1.

    What are the characteristics of existing care pathways for in-hospital management of COPD exacerbation with regard to development, implementation, components, and pathway performance.

  • 2.

    What is the impact of existing care pathways for in-hospital management of COPD exacerbation on performance of care processes, clinical outcomes, and team functioning?

Section snippets

Methods

The methodology used for this review is based on the PRISMA Statement (Preferred Reporting Items for Systematic Reviews and Meta-Analyses of studies that evaluate healthcare interventions) (Liberati et al., 2009, Moher et al., 2009), and on systematic review methods developed by the NHS Centre for Reviews and Dissemination (NHS Centre for Reviews and Dissemination, 2009).

Results

The literature search of the electronic databases revealed a total of 140 publications. After exclusion of the duplicates and quality appraisal, four articles were selected (Fig. 1) (Farley, 1995, Marley, 2000, McManus et al., 2005, Santamaria et al., 2004) (Fig. 1). These four articles included three studies on development and impact of COPD exacerbation care pathways (Farley, 1995, McManus et al., 2005, Santamaria et al., 2004). The fourth paper (Marley, 2000) provided additional information

Discussion

COPD exacerbation is worldwide a leading cause of hospital admission. However, care for patients hospitalized with COPD exacerbation is suboptimal according to recommendations of international guidelines, and outcomes during and after hospitalization are poor and vary highly. These findings indicate the critical need for standardization and optimalisation of the care processes for patients hospitalized with COPD exacerbation. Care pathways are known to improve care processes and to optimize

Acknowledgements

This study was supported by the Clinical Research Fund of the University Hospitals Leuven (Belgium), and by Pfizer Belgium, Pfizer Italy, Pfizer Ireland, and Pfizer Portugal who provided an unrestricted educational grant. The funding sources played no role in the methodology and execution of this review.
Conflicts of interest

None declared.

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