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P105 EFFECT OF A CASE MANAGEMENT STUDY ON PRIMARY CARE USE AND PRESCRIBING FOR AECOPD
1S. M. Jones, 1P. Albert, 1C. J. Warburton, 2P. M. A. Calverley, 1L. Davies. 1University Hospital Aintree, Liverpool, UK, 2University of Liverpool, Liverpool, UK
Introduction Case management for chronic diseases is now common across the UK. We investigated the effect on primary care use and prescribing of an intensive case management programme following hospitalisation with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD).
Method Patients admitted to hospital with an exacerbation of COPD were invited to participate in a randomised controlled trial of case management targeting readmissions. Patients participating in the intervention arm had intensive case management (including hospital and home visits), exercise, education and access to support 7 days a week (phone line) and nurse/doctor review 5 days a week. Controls had usual care. Data on all GP and practice nurse visits to either surgery or home and prescriptions for antibiotics and steroids (including all primary and secondary care prescriptions) were collected during the 12-month study period.
Results 107 patients participated in the study, mean (SD) age 71 (8), forced expiratory volume in 1 s (FEV1) 0.94 (0.33) l and median (IQR) BODE score 8 (6, 9). The intervention arm contained 71 participants and 36 controls. Primary care data were available for 65 and 34 respectively and there was no difference in dropout rates between the groups. Patients in the intervention arm made fewer GP visits (median 4 (IQR 2, 7) vs 7.5 (4, 14); p<0.001) and received fewer primary care prescriptions for antibiotics (1 (0, 2) vs 3 (1, 7.5); p<0.001) and steroids (0 (0, 0) vs 2 (1, 4); p<0.001). Overall, the total number of diagnosed exacerbations did not differ between groups (4 (3, 6) vs control 3.5 (1, 7); p = 0.36) and no significant difference was seen in overall antibiotic prescribing (6 (3, 10) vs controls 4 (1, 9); p = 0.18). Patients in the intervention arm did receive more courses of oral steroids (4 (3, 10) vs 3 (2, 5); p = 0.02).
Conclusion Data show that active case management, which is associated with significant additional costs, changes the pattern of healthcare utilisation by these patients without affecting the total number of courses of antibiotic therapy or other important clinical outcomes. The results again demonstrate the importance of randomised controlled trials, as without a “usual care” arm, it would have been easy to conclude that case management reduced both the need for antibiotics and steroids for the management of exacerbations and health care utilisation.
P106 OXYGEN THERAPY IN ACUTE EXACERBATIONS OF COPD
1K. Perrin, 1M. Wijesinghe, 1B. Healy, 2M. Weatherall, 1R. Beasley. 1Medical Research Institute of New Zealand, Wellington, New Zealand, 2University of Otago, Wellington, New Zealand
Introduction and Objectives Guidelines on acute exacerbations of chronic obstructive pulmonary disease (AECOPD) recommend titrating oxygen flow to achieve saturations no higher than 92%. Previous studies have shown that these recommendations are often not followed in emergency care settings. We aimed to determine the frequency of high flow oxygen therapy among patients with AECOPD arriving at an emergency department by ambulance and to investigate the association between high flow oxygen therapy and poor clinical outcomes, and the risk of poor outcomes associated with background COPD severity markers.
Methods The study was a retrospective audit of all patients arriving by ambulance to the emergency department of Wellington Hospital, New Zealand with a primary diagnosis of COPD between June 2006 and June 2007. The medical records were reviewed and information on markers of severity, ambulance oxygen administration and clinical outcomes were documented. The main outcome measure was a composite of death, requirement for ventilation, or respiratory failure on arterial blood gas within 4 h of presentation. Associations between oxygen therapy and poor clinical outcomes were assessed by logistic regression.
Results 250 patients were admitted via ambulance with AECOPD, of whom 10 (4%) died and 122 (49%) died, required assisted ventilation or were in respiratory failure. On arrival, 181/242 (75%) subjects had an oxygen saturation >92%. Of 182 patients in whom ambulance oxygen therapy was clearly documented, 168 (92%) received >2 l/min. Increased oxygen flow rate was associated with poor clinical outcomes: the odds ratio for the main outcome measure was 1.1 (95% CI 1.0 to 1.3) per 1 l/min greater oxygen flow. In terms of background severity features, home nebuliser use, long-term oxygen therapy, previous respiratory failure or previous assisted ventilation were associated with a 2.7-, 5.3-, 5.3- and 3.9-fold increased risk of poor clinical outcomes, respectively.
Conclusion In this study most patients with AECOPD admitted to hospital following ambulance transfer have been administered high flow oxygen therapy and this was associated with poor clinical outcomes. Patients at increased risk of poor clinical outcomes can be identified by the presence of defined chronic severity markers.
P107 INFLAMMATORY PROFILE OF COPD EXACERBATIONS ASSOCIATED WITH DUAL BACTERIAL ISOLATES
J. J. P. Goldring, G. C. Donaldson, J. K. Quint, R. Baghai-Ravary, A. R. C. Patel, J. A. Wedzicha. Academic Unit of Respiratory Medicine, University College London Medical School, London, UK
Introduction COPD exacerbations are heterogeneous events and, accordingly, a diverse range of accompanying changes in airway and systemic inflammatory markers have been described with distinct patterns of inflammation being associated with differing aetiologies. We investigated the relationship between dual potentially pathogenic microbes (PPM), which occur in around 10% of exacerbations, and the associated inflammatory response.
Methods COPD patients who had been followed in our cohort for >1 year were sampled at their exacerbation visits prior to initiation of standard exacerbation therapy. An exacerbation was defined as an increase in two respiratory symptoms, including at least one major symptom (dyspnoea, sputum purulence or volume) for 48 h. Serum was taken for the acute phase response mediators interleukin-6 (IL6) and C-reactive protein (CRP). Spontaneously expectorated sputum was collected for standard microbiological culture and a subset was also assayed for IL8, a marker of neutrophilic inflammation and IL6.
Results There were 196 patients with 266 sputum samples (52% 0 PPM, 38% 1 PPM, 10% 2 PPM). Their mean age was 68.0 years (SD 8.1); 61% were male; forced expiratory volume in 1 s (FEV1)% predicted 47.1 (18.3) and 49.8 (36.7) pack years smoking history.
Conclusions The presence of a single PPM on sputum culture at exacerbation is associated with an increase in systemic and airway neutrophilic inflammation and a lower airway IL6 (table 1). Unexpectedly, dual PPMs are associated with less systemic inflammation than single PPMs and they share the same inflammatory profile as non-bacterial exacerbations. This suggests that dual PPMs may be non-contributory to exacerbations. Inhibitory competition arising from the acquisition of a second bacterial strain might explain their relative non-pathogenicity.