British guidelines for the management of chronic obstructive pulmonary disease (COPD) were first published in 1997.¹ Over the subsequent 6 years there has been an enormous increase in our understanding of the underlying causes and mechanisms of acute exacerbations of COPD,^2–4 as well as the realisation that, in addition to being a major cause of morbidity and mortality, acute exacerbations place an enormous burden on healthcare resources.

COPD is the third largest cause of respiratory death in the UK after pneumonia and cancer, causing over 30 000 deaths per year. Age adjusted emergency admission rates for COPD in the UK rose by more than 50% between 1991 and 2000, and about one quarter of all hospital inpatient bed days used for treating acute respiratory disease are for COPD,⁵ amounting to nearly one million hospital bed days per year.⁶

With such a significant proportion of inpatient resources being consumed by acute exacerbations of COPD, understanding how well and effectively they are managed in hospital becomes a matter of much more than academic interest. In order to obtain information on this, the British Thoracic Society (BTS) and the Clinical Effectiveness and Evaluation Unit (CEEU) of the Royal College of Physicians undertook a national audit in 1997.^7,8

Data were collected from 38 acute hospitals across the UK on the management of 1400 acute admissions with COPD. The main findings were that 14% of cases died within 3 months of admission, the median length of stay was 8 days, and 34% of the patients were readmitted within 3 months of the initial inpatient episode. There were, not surprisingly, large variations between hospitals for many of the outcome measures studied and, disappointingly, the median standards of care observed in routine clinical practice fell below those recommended by the BTS guidelines.^7,8

An important conclusion from this audit was that the wide variations observed in both process of care and in outcomes could not be accounted for by case mix alone, and that resource and organisational factors might be relevant. In this issue of Thorax Roberts et al⁹ report the results of a further audit designed to test the hypothesis that death from acute COPD might be related to the size and type of hospital to which patients are admitted—for example, teaching hospital or large or small district general hospital (DGH)—and to factors such as medical staffing ratios and the availability of non-invasive ventilation (NIV).

The authors obtained information from 30 units in England and Wales using prospective case ascertainment with retrospective case note audit of consecutive cases admitted over an 8 week period for each hospital. Despite the limitations of the study which the authors freely acknowledge (it was only a pilot study, small number of hospitals, some data collection may have been incomplete and/or inaccurate), the results are of extreme importance. Mortality was highest in the small DGHs and lowest in the teaching hospitals. Although the performance status of patients being admitted to small DGHs was worse, this did not account for the higher mortality observed. Small DGHs also had the lowest medical staffing ratios and were less likely to offer an NIV service.

It is imperative that these findings are verified in a much larger national audit which is currently being conducted by the BTS and CEEU. This should allow for a far more detailed analysis and, in addition to accurate data collection on individual patients, participating hospitals must provide comprehensive information on their local resources for the management of acute COPD, including details of clinical staffing (medical and nursing, specialist and non-specialist, routine and out of hours), workload figures, provision of NIV service, availability of high dependency and intensive care beds. Only by the rigorous interrogation of a much larger data base will it be possible to take account of various confounding factors and decide whether or not resource and organisational issues are, indeed, responsible for differences in outcome.

New British guidelines for the management of COPD, produced under the auspices of the National Institute of Clinical Excellence (NICE), will be published early in 2004. Many clinicians are already anticipating the new evidence based recommendations on the hospital management of acute exacerbations. But it is essential that the new guidelines are not regarded as aspirational and unachievable in the real world at a time when, for example, the majority of patients who need NIV do not actually receive it despite its proven benefit and cost effectiveness.^7,10,11

The conclusions of Roberts et al⁹ should be of great interest to all those who wish to optimise patient care, and the results of the audit currently being undertaken will be eagerly awaited. The strength of national comparative audits such as those conducted by the BTS and CEEU is that they allow teams and hospitals to compare themselves with the results being achieved by their peers and which therefore are, by definition, achievable. If variations in mortality rates between hospitals are, indeed, due to organisational and resource factors, then much more must be done to address these. The lack of a national service framework for respiratory disease must not be allowed to become an excuse for not making COPD a local priority where audit data clearly show this to be necessary.¹²

In a recent editorial in Thorax, Partridge¹³ highlighted a number of key areas where we currently fail to provide adequately for people with COPD, and pointed out that we all have an obligation to raise the profile of this common disease. Admission to hospital for an acute exacerbation is when our patients are most vulnerable; ensuring that appropriate standards of care are provided is the responsibility of every respiratory physician.