Background
Methods
Statistical analysis
Results
Center characteristics
All | Small hospital | Large hospital |
P
†
| |
---|---|---|---|---|
Number of participating hospitals, n
| 59 | 27 | 32 | |
Public hospital (%) | 93.2 | 85.2 | 100 | 0.039 |
University hospital (%) | 83.1 | 63 | 100 | < 0.001 |
Beds per center ≥ 500 (%) | 62.7 | 18.5 | 100 | < 0.001 |
Beds per center, median (P25–75) | 651 (349–943) | 332 (231–436) | 903 (702–1199) | < 0.001 |
Hospital with a respiratory ward (%) | 83.1 | 63 | 100 | < 0.001 |
Number of inpatient respiratory beds ≥ 20 (%) | 83.7 | 52.9 | 100 | < 0.001 |
Number of pulmonology staff members ≥ 5 (%) | 81.4 | 59.3 | 100 | < 0.001 |
Number of pulmonology staff members, median (P25–75) | 10 (5–13) | 5 (2–8) | 13 (10–16) | < 0.001 |
Pulmonology residents available (%) | 67.8 | 33.3 | 96.9 | < 0.001 |
Number of annual outpatient respiratory visits, median (IQR) | 15,447 (12004–25,680) | 12,004 (4355–13,556) | 23,985 (16070–27,838) | < 0.001 |
Number of annual outpatient respiratory visits ≥ 10,000 (%) | 81.4 | 59.3 | 100 | < 0.001 |
≥ 15 min of follow-up at general outpatient respiratory visit (%) | 44.1 | 48.1 | 40.6 | 0.562 |
Specialized COPD outpatient clinic available (%) | 47.5 | 40.7 | 53.1 | 0.343 |
≥ 15 min of follow-up at specialized COPD outpatient visit (%) | 64.4 | 74.1 | 56.3 | 0.154 |
Outpatient respiratory nursing clinic availability (%) | 45.8 | 44.4 | 46.9 | 0.852 |
Functional respiratory laboratory available (%) | ||||
- Spirometry | 100 | 100 | 100 | 1 |
- Diffusing capacity | 100 | 100 | 100 | 1 |
- Plethysmography | 100 | 100 | 100 | 1 |
- Respiratory muscle strength | 84.7 | 66.7 | 100 | < 0.001 |
- 6MWT available | 94.9 | 88.9 | 100 | 0.090 |
- Cardiopulmonary exercise testing available | 62.7 | 40.7 | 81.3 | 0.001 |
Inhalation technique educational program available (%) | 30.5 | 15.6 | 48.1 | 0.007 |
Respiratory rehabilitation program available (%) | 74.6 | 66.7 | 81.3 | 0.2 |
- Hospital-based | 61.4 | 61.1 | 61.5 | 0.617 |
- Home-based | 6.8 | 11.1 | 3.8 | |
- Mixed | 31.8 | 27.8 | 34.6 |
Audited patient characteristics and clinical conditions
Patients (N = 4508) | Hospitals (N = 59) |
p
†
| |||
---|---|---|---|---|---|
N
| % or median (IQR) | Median | IQR | ||
Sex (male), (%) | 4.508 | 86 | 87.5 | 82.1–93.2 | < 0.001 |
Age (years), median (P25–75) | 4.508 | 69.7 (63–77.7) | 70 | 69–72 | < 0.001 |
≤ 55 (%) | 8.5 | 8.2 | 5.8–11.7 | ||
56–69 (%) | 38.7 | 38.1 | 30–42.6 | ||
≥ 70 (%) | 52.8 | 53.3 | 47.1–61.7 | ||
Pack-years, median (P25–75) | 4.508 | 47 (34–70) | 45 | 40–51 | < 0.001 |
Active smokers, (%) | 4.508 | 23.1 | 22 | 18–29 | < 0.001 |
BMI kg/m2, median (P25–75) | 4.508 | 28.0 (24.4–31.1) | 27.8 | 26.6–28.5 | 0.03 |
≤ 21 (%) | 7.1 | 6.7 | 4.1–9.2 | ||
22–29 (%) | 60.8 | 58.8 | 56.1–64 | ||
≥ 30 (%) | 32.1 | 31.4 | 26.2–37.7 | ||
Charlson index, median (P25–75) | 4.508 | 2 (1–4) | 2 | 2–3 | < 0.001 |
≥ 3 (%) | 44.9 | 44.5 | 40–56.6 | ||
Dyspnea (MRC-m) | 4.508 | < 0.001 | |||
0 + 1 (%) | 27.3 | 23.8 | 11.6–44.5 | ||
≥ 2 (%) | 41.4 | 38.3 | 28.3–54 | ||
Missing (%) | 13.2 | 8.9 | 1.6–21.6 | ||
Level of dyspnea not referred to (%) | 18.1 | 11.6 | 3.3–30 | ||
CAT questionnaire >10, (%) | 869 | 62.4 | 64 | 47.9–83.8 | < 0.001 |
Chronic bronchitis criteria, (%) | 4.508 | 41.7 | 41 | 28.3–51 | < 0.001 |
Chronic colonization, (%) | 4.508 | 6.0 | 5 | 3.2–8.3 | < 0.001 |
Symptoms suggestive of asthma,(%) | 4.508 | 26.5 | 18.3 | 10.8–35 | < 0.001 |
% FEV1, median (P25–75) | 4.508 | 50 (37–63) | 51 | 47–54 | 0.03 |
< 50% | 49.1 | 45.5 | 41.5–53.3 | ||
50–64% | 28 | 28.5 | 22.3–31.7 | ||
≥ 65% | 22.9 | 23.8 | 15–30 | ||
Number of moderate/severe exacerbations in the last year, median (P25–75) | 3.196 | 1.1 (0–2) | 1 | 0–1 | 0.03 |
Number of hospital admissions in the last year, median (P25–75) | 4508 | 0.5 (0–1) | 0 | 0–0 | 0.03 |
BODE value, median (P25–75) | 632 | 3.9 (3–5) | 4.5 | 3–5.5 | < 0.001 |
GOLD group | 985 | < 0.001 | |||
A (%) | 22.7 | 14.3 | 0–25.9 | ||
B (%) | 18.7 | 16.7 | 0–24.1 | ||
C (%) | 18.7 | 20 | 9.8–33.3 | ||
D (%) | 39.9 | 40 | 23.5–55.6 | ||
GesEPOC Phenotype | 4.508 | < 0.001 | |||
- Non-exacerbator, (%) | 27.5 | 24.4 | 11.4–28 | ||
- Exacerbator, (%) | 18.8 | 15.7 | 3.4–22 | ||
- Missing, (%) | 53.7 | 52.3 | 44–58.9 | ||
LAMA monotherapy, (%) | 4.391 | 10.0 | 10 | 4.8–15.3 | 0.03 |
LAMA-LABA combination, (%) | 4.391 | 22.7 | 20.3 | 14.5–27.9 | < 0.001 |
LABA+ ICS combination, (%) | 4.391 | 7.7 | 6.7 | 3.4–9.8 | 0.03 |
Triple therapy (LAMA + LABA + CSI), (%) | 4.391 | 49.1 | 50.8 | 39.3–60.3 | < 0.001 |
Long-term oxygen therapy, (%) | 4.508 | 26.6% | 25 | 17.1–33.3 | 0.03 |
Home ventilation, (%) | 4.508 | 7.5% | 5 | 2.5–11.6 | < 0.001 |
Respiratory rehabilitation, (%) | 4.508 | 9 | 5 | 0–11.8 | < 0.001 |
Respiratory care follow-up (years), (%) | 4.508 | 4 (2–7) | 4 | 3.5–5 | 0.03 |
Adequacy of medical care according to CPG
Criteria of good clinical practice evaluated in EPOCONSUL | N of criteria fulfilled | Patients (N = 4.508) % | Hospitals (N = 59) Median | Inter-hospital range |
p
†
|
---|---|---|---|---|---|
Clinical evaluation category | |||||
1. Was degree of dyspnea evaluated during current visit? 2. Was the number of hospital admissions in the last 12 months collected during current visit? 3. Was the number of moderate or severe exacerbations in the last 12 months collected during current visit? 4. Was current smoking habit information collected? 5. Was regular exercise data collected during current visit? 6. Are comorbidities identified in the clinical record? | 6 criteria | 18.3 | 14.6 | 0–100 | < 0.001 |
>3 criteria | 65.5 | 70 | 11.7–100 | < 0.001 | |
≤3 criteria | 34.5 | 30 | 0–88.3 | < 0.001 | |
COPD evaluation category | |||||
1. Alfa-1-antitrypsin serum level determination available? 2. COPD severity defined in the report? 3. COPD GOLD type defined in the report? 4. COPD phenotype according to GesEPOC defined in the report? 5. 6MWT carried out on any occasion? 6. Diffusion capacity measured on any occasion? 7. Lung volumes measured on any occasion? 8. Chest CT scan carried out on any occasion in exacerbator phenotype? | 8 criteria | 1.5 | 0 | 0–14.6 | < 0.001 |
> 4 criteria | 30.1 | 27 | 0–89.3 | < 0.001 | |
≤ 4 criteria | 69.9 | 73 | 10.7–100 | < 0.001 | |
Therapeutic intervention category | |||||
1. Is treatment adherence evaluated in any way? 2. Is inhalation technique evaluated in any way? 3. Is Pneumococcal vaccination recommended? 4. Is exercise advised during the visit? 5. Have arterial blood gases been measured on any occasion in patients on long-term oxygen therapy? 6. Is a specific intervention for smoking cessation for active smokers offered? | 6 criteria | 9.3 | 3.3 | 0–45.1 | < 0.001 |
> 3 criteria | 22.4 | 12.5 | 0–100 | < 0.001 | |
≤ 3 criteria | 77.6 | 87.5 | 0–100 | < 0.001 |
Adherence to CPG recommendations based on patient and center characteristics
Multilevel variability analysis of adherence to CPG recommendations
Intra-class correlation (ICC) | Median Odds Ratio (MOR) | Variables | Adjusted OR (95% CI) |
p
| |
---|---|---|---|---|---|
Adherence to good clinical practice criteria in clinical evaluation (≥3 criteria fulfilled) | |||||
Empty model 1 | 0.36670 | 3.73040 | |||
Model 2: center variables1
| 0.31866 | 3.26487 | |||
Model 3: patient variables2
| 0.36831 | 3.74755 | |||
Full model 4 (center and patient) | 0.31850 | 3.26345 | Large hospital | 0.40 (0.21–0.79) | 0.008 |
Outpatient respiratory nursing clinic available | 2.47 (1.26–4.83) | 0.008 | |||
Active smokers | 1.32 (1.10–1.58) | 0.003 | |||
Charlson index ≥3 | 1.35 (1.15–1.59) | < 0.001 | |||
Number of hospital admissions in the last year ≥1 | 6.33 (5.02–7.98) | < 0.001 | |||
GesEPOC phenotype | |||||
Not exacerbator (reference) | |||||
Exacerbator | 0.79 (0.61–1.101) | 0.063 | |||
Missing | 0.36 (0.29–0.44) | < 0.001 | |||
To be taken care in specialized COPD outpatient clinic) | 2.10 (1.56–2.72) | < 0.001 | |||
1: included variables in the final center model: large hospital and outpatient respiratory nursing clinic available 2: included variables in the final patient model: active smokers, Charlson index ≥3, number of hospital admissions in the last year ≥1, to be taken care in specialized COPD outpatient clinic and GesEPOC phenotype exacerbator. | |||||
Adherence to good clinical practice criteria in COPD evaluation (≥4 criteria fulfilling) | |||||
Empty model 1 | 0.30343 | 3.13266 | |||
Model 2: center variables1
| 0.26684 | 2.83994 | |||
Model 3: patient variables2
| 0.29100 | 3.02953 | |||
Full model 4 (center and patient) | 0.24413 | 2.67316 | Respiratory ward not available (reference) | ||
Respiratory ward < 20 beds | 7.09 (2.53–9.90) | < 0.001 | |||
Respiratory ward ≥20 beds | 3.00 (1.37–6.60) | 0.006 | |||
Age ≤ 55 | 1.58 (1.19–2.09) | 0.001 | |||
Sex (male) | 0.77 (0.61–0.96) | 0.022 | |||
Charlson index ≥3 | 0.80 (0.68–0.94) | 0.008 | |||
FEV1 < 50% | 1.68 (1.42–1.99) | < 0.001 | |||
Dyspnea (MRC-m) | |||||
0–1 (reference) | |||||
≥ 2 | 1.39 (1.13–1.72) | 0.002 | |||
Missing | 0.69 (0.51–0.93) | 0.017 | |||
Level of dyspnea not referred to | 0.65 (0.49–0.86) | 0.003 | |||
GesEPOC phenotype | |||||
Non-exacerbator (reference) | |||||
Exacerbator | 1.16 (0.93–1.44) | 0.185 | |||
Missing | 0.17 (0.14–0.21) | < 0.001 | |||
Treatment at a specialized COPD outpatient clinic | 3.25 (2.49–4.23) | < 0.001 | |||
1: variables included in the final center model: in-patient respiratory clinic ≥20 present and specialized COPD outpatient clinic available. 2: variables included in the final patient model: age ≤ 55, gender (male), Charlson index ≥3, FEV1 < 50%, dyspnea, GesEPOC exacerbator phenotype and being treated in specialized COPD outpatient clinic. | |||||
Adherence to good clinical practice criteria in therapeutic intervention (≥3 criteria fulfilled) | |||||
Empty model 1 | 0.52169 | 6.09155 | |||
Model 2: center variables1
| 0.46935 | 5.08927 | |||
Model 3: patient variables2
| 0.49994 | 5.64024 | |||
Full model 4 (center and patient) | 0.44731 | 4.74211 | University hospital | 0.26 (0.08–0.85) | 0.026 |
Outpatient respiratory nursing clinic availability | 3.69 (1.50–9.11) | 0.005 | |||
Age ≤ 55 | 0.60 (0.42–0.86) | < 0.005 | |||
Sex (male) | 0.72 (0.55–0.93) | 0.014 | |||
Charlson index ≥3 | 1.19 (0.99–1.42) | 0.062 | |||
Number of hospital admissions in the last year ≥1 | 1.71 (1.38–2.11) | < 0.001 | |||
GesEPOC phenotype | |||||
Non-exacerbator (reference) | |||||
Exacerbator | 0.90 (0.71–1.15) | 0.404 | |||
Missing | 0.36 (0.29–0.46) | < 0.001 | |||
Treatment at a specialized COPD outpatient clinic | 2.61 (2.01–3.40) | <0.001 | |||
1: variables included in the final center model: university hospital and outpatient respiratory nursing clinic availability 2: variables included in the final patient model: age ≤ 55, gender (male), Charlson index ≥3, number of hospital admissions in the last year ≥1, GesEPOC exacerbator phenotype and being treated in specialized COPD outpatient clinic |