Chronic obstructive pulmonary disease (COPD) is a common condition with 900 000 diagnosed patients in England and Wales and nearly as many undiagnosed.^1,2 This equates to a prevalence of 11% in those aged over 45 years, with an even higher prevalence in those aged over 65 years.³ Elderly people cite respiratory conditions as the third most common cause of chronic illness and disability—three times more common than neurological diseases including stroke.⁴ It is likely that most of this burden results from COPD. There were 30 000 deaths from COPD in the UK in 1999, the mean age of death ranging from 74 years in severe disease to 77 years in mild disease.^1,5 Internationally, COPD is projected to be the fifth most common cause of combined mortality and disability by 2020.⁶

Mortality related to exacerbations of COPD is high, both during hospitalisation and for 3 months thereafter.⁷ Advanced age is an adverse prognostic factor, with age above 80 giving a relative risk of death of 3.0 compared with age under 65.⁷ It is, however, not known whether this is an inevitable consequence of age related functional decline, co-morbidity and disease severity, or whether it is in part the consequence of age related deficiencies in the organisation or processes of care or, indeed, whether such deficiencies exist.

Previous large scale audits of COPD admissions in the UK revealed large variability in both process of care and outcome not explained by case mix variability.^7–,⁹ In 2003 the British Thoracic Society and Royal College of Physicians led the largest ever UK-wide audit of hospital care of patients admitted with COPD exacerbations providing new and extensive data. The current paper examines, from these data, differences in process and outcome of care of elderly patients compared with that of younger patients and, in particular, whether any age related differences in the process of care are related to outcome(s). Secondly, the paper explores the potential effect of different models of care (supervised by respiratory physician v general physician v geriatrician and, if the latter, admission to an age related v an integrated unit) on process and outcome.

METHODS

RESULTS

Patient and organisational data were available for 234 units. A few patients (5%) were entered more than once into the audit (multiple admissions), but only their first episode was analysed. Data are expressed in percentage and absolute terms and, where data were missing, the denominator is adjusted accordingly. There were 7529 patients, but 15 were excluded as neither age nor sex was recorded. The mean (SD) age was 71 (10) years, with 24% aged under 65 years, 40% aged 65–74 years, 29% aged 75–84 years, and 7% aged ⩾85 years.

DISCUSSION

The fact that severe COPD (and its burden on secondary care) is a disease of the elderly is reinforced by the current data: three quarters of admissions were over the age of 65 and more than one third were over 75 years.

The management of COPD patients does vary with age. The NICE guidelines on management should apply regardless of age, but the present data show quite clearly that fewer old people receive the full package of investigations or management recommended.² The reasons for this are unclear as there are overlapping organisational features that could contribute.

Some hospitals organise acute admissions primarily by age and it is not surprising that, if older people are selectively admitted under CoE physicians, fewer will be seen by respiratory physicians or respiratory nurses. However, even in hospitals with integrated admission policies there are disturbing age related deficiencies in other aspects of the process of care.

Despite clear evidence of the benefit of systemic corticosteroid therapy in this situation (improved lung function and gas exchange, reduction in hospital stay^12–,¹⁷), elderly patients were less likely to receive systemic corticosteroids. They were less likely to have blood gases checked on admission and, when gases were done and demonstrated acidosis, the elderly were less likely to be offered ventilatory support even though non-invasive ventilation (without intubation) has few contraindications.¹⁸ A quarter of those over 85 years of age neither had gases checked nor received oral steroids. These process deficiencies occurred largely irrespective of the specialty to which elderly patients were admitted. If these basic and important markers of care are not being performed for older people, it raises questions about the more detailed aspects of their care not measured in this study.

Early discharge schemes are well documented as being safe and liked by patients. The lower rate of acceptance of elderly patients (admitted under geriatricians) onto early discharge schemes, though probably contributing to the greater length of stay seen in the elderly, is arguably of less concern. The audit made no attempt to assess the appropriateness of referral or acceptance of individuals onto such schemes and did not collect data on cognitive impairment, a relative contraindication to inclusion. Nonetheless, the non-significant trend to lower use of such schemes in age related units, coupled with their lower use by geriatricians, suggests either impaired access to or impaired awareness of the presence or value of these evidence based services.^19–,²² Hospital organisation and physician awareness rather than clinical need may therefore dictate availability to the patient.

Reassuringly, despite the fact that older patients admitted under both general physicians and geriatricians were less likely to receive ventilatory support if acidotic (table 3⇑), there was no overall age related difference in provision of ventilatory support to acidotic patients (table 2⇑) which suggests that acidotic elderly patients were more likely to be admitted under respiratory physicians initially.

Even after allowing for considerable age related differences in case mix between elderly and younger patients, advanced age was a major adverse prognostic factor for inpatient mortality and 3 month mortality. Indeed, in an almost identical replication of the results of the previous national audit,⁷ patients aged over 85 years were three times more likely to die than those aged under 65 years. There were similar (again independent) age related differences in LOS, but no such differences in readmission rates.

Analysing predictors of outcomes of care in an observational study is difficult. Although consecutive cases were included from a large number of hospitals and the total number of cases is large, there are many potential confounding influences. One challenge is to find a reliable comparator. For the outcome of death we performed the logistic regressions using age of patients within the study and then separately using the age specific mortality for the UK population. The SMR due to COPD exacerbations compared with the national expected mortality is less marked in the very old, largely because they have an increased underlying mortality risk. However, absolute numbers of deaths in the very old are much greater and thus there is a greater opportunity to intervene and save lives, which makes the deficiencies in process of care more worrying.

Readmission rates were not related to age but were related to whether or not the patient had been admitted previously. This might suggest that non-disease related (and unmeasured) factors (patient/carer expectations, social support) are more important. Alternatively (and arguably more likely), previous admission may simply be a marker of severity.

We were not able to show whether an age related admissions policy is better or worse than an integrated system. Indeed, none of the measured factors (access to respiratory specialist care during admission, type of admission policy, type of admitting physician) had any independent bearing on mortality rate, LOS, or readmission of elderly patients. Similarly, we did not find any statistical link between process of care and outcome despite some potentially important differences in process of care between those admitted under geriatricians and respiratory physicians. The age related process deficiencies that did exist did not appear to contribute to the excess mortality in the elderly. The reasons for this are unclear. It may be that the age related process differences were relatively small in terms of the relative proportions of patients in each age group suffering a disadvantage. While this is superficially reassuring (especially given the large proportion of elderly patients), what this study cannot tell us is whether the outcome of individual patients was affected by poor process of care. Nor can it differentiate those patients who would have died because of disease severity regardless of treatment from those who could have benefited from treatments not given. Furthermore, there must remain concern that the quality of care (and the patient experience) was not the same across the age range.

This lack of association may have other explanations and could imply that some interventions such as corticosteroids are less helpful in the elderly. Randomised controlled trials of COPD exacerbations have (with few exceptions) included relatively young patients, unrepresentative of the age spectrum seen in clinical practice as reflected in the present audit.^10,12–,¹⁸ Further studies examining interventions in older patients are necessary if this concern is to be resolved.

Finally, the lack of association may indicate a limitation within the data collected as this audit was not and could not be comprehensive. Some features of patient care can only be studied in a randomised controlled trial. This study could not, for example, examine the appropriateness of interventions and, even though this is the largest UK study of acute COPD hospital care ever undertaken, the power to differentiate different organisational and process aspects of care in an observational study is limited.

In conclusion, this audit shows that there are more deaths among the oldest cohort of patients and there is more that can be done to ensure a “NICE guidelines standard of care” for the oldest patients. This particularly applies to non-respiratory specialists, but even the specialists are far from perfect. Many of the recommendations in the guidelines derive from strong evidence which suggests that better care should be delivered with the potential for the lives of more older people to be saved.