Prospective Multicenter Study of Relapse Following Emergency Department Treatment of COPD Exacerbation

doi:10.1378/chest.125.2.473

Chest

Volume 125, Issue 2, February 2004, Pages 473-481

https://doi.org/10.1378/chest.125.2.473 Get rights and content

Study objectives

To determine the incidence and risk factors of relapse after an emergency department (ED) visit for COPD exacerbation.

Design

Prospective cohort study as part of the Multicenter Airway Research Collaboration.

Setting

Twenty-nine North American EDs.

Patients

ED patients with COPD exacerbations, age ≥ 55 years. For the present analysis of post-ED relapse, the cohort was restricted to COPD patients who had been discharged from the ED directly to home.

Measurements and results

Eligible patients underwent a structured interview to assess their demographic characteristics, COPD history, and details of the current COPD exacerbation. Data on ED medical management and disposition were obtained by chart review. Patients were contacted by telephone 2 weeks later regarding incident relapse events (ie, urgent clinic or ED visit for worsening COPD). The cohort consisted of 140 COPD patients. Over the next 2 weeks, patients demonstrated a consistent daily relapse rate that summed to 21% (95% confidence interval, 15 to 28%) at day 14. In a multivariate model, the significant risk factors for relapse were the number of urgent clinic or ED visits for COPD exacerbation in the past year (odds ratio [OR], 1.49 [per five visits]), self-reported activity limitation during the past 24 h (OR, 2.93 [per unit on scale of 1 [none] to 4 [severe]), and respiratory rate at ED presentation (OR, 1.76 [per 5 breaths/min]).

Conclusions

Among patients discharged to home after ED treatment of a COPD exacerbation, one in five patients will experience an urgent/emergent relapse event during the next 2 weeks. Both chronic factors (ie, a history of urgent clinic or ED visits) and acute factors (ie, activity limitations and initial respiratory rate) are associated with increased risk. Further research should focus on ways to decrease the relapse rate among these high-risk patients. The clinicians may wish to consider these historical factors when making ED decisions.

Section snippets

Subjects

This study combines data from two prospective cohort studies performed from November 1999 to June 2000, and from December 2000 to May 2001 as part of the Multicenter Airway Research Collaboration (MARC). MARC is part of the Emergency Medicine Network (EMNet), a large collaboration with > 130 participating EDs across North America (http://www.emnet-usa.org). Using a standardized protocol, investigators at 29 EDs in 15 US states and 3 Canadian provinces provided 24 h/d coverage for a median

Results

Of 853 potentially eligible patients, 222 patients (26%) who reported only asthma and 47 patients (6%) for whom a diagnosis was missing were excluded from current analysis. We also excluded 385 patients (66%) who were not discharged to home (ie, admitted to observation unit, 5 patients [1%]; admitted to a regular ward, 300 patients [51%]; admitted to the ICU, 63 patients [11%]; or transferred to another hospital or received other disposition, 17 patients [3%]). Among the 199 patients with COPD

Discussion

This study confirms previous findings that a substantial proportion of patients treated for COPD exacerbation experience significant relapse events in the days and weeks after ED treatment. A wide range of relapse rates following COPD exacerbation have been reported, as follows: 12%⁸ and 17%⁹ within 48 h; 22 to 32% within 2 weeks¹⁰¹¹¹²; and 13 to 21% in 1 month.¹³¹⁴¹⁵ Despite significant improvements in the prognosis of other diseases such as coronary artery disease during the past decade,³⁴ it

EMNet Steering Committee

Edwin D. Boudreaux, PhD; Barry E. Brenner, MD, PhD; Carlos A. Camargo, Jr., MD (Chair); Rita K. Cydulka, MD; Theodore J. Gaeta, DO, MPH; and Michael S. Radeos, MD, MPH.

EMNet Coordinating Center

Carlos A. Camargo, Jr., MD, FCCP (Director); Sunday Clark, MPH; Jennifer A. Emond, MS; Jessica L. Hohrmann, MPH; Gabrielle C. Hunter; and Sunghye Kim, MD (all at Massachusetts General Hospital, Boston, MA).

Principal Investigators at the 29 Participating Sites

F.C. Baker III (Maine Medical Center, Portland, ME); M.P. Blanda (Summa Health System, Akron, OH); E.D. Boudreaux (Earl K.

ACKNOWLEDGMENT

ACKOWLEDGMENT: We thank the MARC investigators for their ongoing dedication to emergency airway research.

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The aim of the present study was to determine the factors affecting the relapse of COPD exacerbated patients in the emergency department (ED). This study combines data from two prospective cohort studies. Patients included in the study were above 18 years of age, had a previous diagnosis of COPD, and presented to the ED for the treatment of acute exacerbation. All the information relevant to the study was collected during the patient's visit to the ED. Relapse was defined as an unscheduled visit to an ED or primary physician within 2 weeks of initial ED visit for worsening COPD symptoms. Telephone follow-up was done on all patients at the end of 2 weeks.
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: Dr. Kim was supported by grant K30 HL04095, Ms. Clark by grant T32 ES07069, and Dr. Camargo by grant R01 HL63841 from the National Institutes of Health (Bethesda, MD). Dr. Rowe is supported by the Canadian Institutes of Health Research as a Canada Research Chair (Ottawa, ON, Canada). The project was supported by an unrestricted grant from Boehringer Ingelheim (Ridgefield, CT, and Burlington, ON, Canada).

^†: A list of MARC site investigators is located in the ^Appendix.

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Chest

Clinical InvestigationsCOPDProspective Multicenter Study of Relapse Following Emergency Department Treatment of COPD Exacerbation

Study objectives

Design

Setting

Patients

Measurements and results

Conclusions

Section snippets

Subjects

Results

Discussion

EMNet Steering Committee

EMNet Coordinating Center

Principal Investigators at the 29 Participating Sites

ACKNOWLEDGMENT

Chest

Chest

Chest

Chest

Ann Emerg Med

Ann Emerg Med

Chest

Chest

J Clin Epidemiol

Chest

Chest

Respir Med

Chest

J Clin Epidemiol

Chest

Chest

COPD exacerbation

Chest

Effect of exacerbation of quality of life in patients with chronic obstructive pulmonary disease

Am J Respir Crit Care Med

US emergency department visits for COPD exacerbations between 1992–1998 [abstract]

Am J Epidemiol

Cost comparison of hospital- and home-based treatment models for acute chronic obstructive pulmonary disease

Aust Health Rev

Outpatient antibiotic therapy and short term mortality in elderly patients with chronic obstructive pulmonary disease

Can Respir J

A multivariate model for the prediction of relapse after outpatient treatment of decompensated chronic obstructive pulmonary disease

Arch Intern Med

Acute infective exacerbations of chronic bronchitis

QJM

Factors associated with relapse after ambulatory treatment of acute exacerbations of chronic bronchitis: DAFNE Study Group

Eur Respir J

Factors associated with hospital admissions and repeat emergency department visits for adults with asthma

Thorax

Clinical Investigations
COPD
Prospective Multicenter Study of Relapse Following Emergency Department Treatment of COPD Exacerbation