Management of COPD exacerbations in primary care: A clinical cohort study

Abstract

Chronic obstructive pulmonary disease (COPD) exacerbations are associated with lung function decline, lower quality of life, and increased mortality, and can be prevented by pharmacological treatment and rehabilitation.
To examine management including examination, treatment, and planned follow-up of COPD exacerbation visits in primary care patients and to explore how measures and management at exacerbation visits are related to subsequent exacerbation risk.
A clinical population of 775 COPD patients was randomly selected from 56 Swedish primary healthcare centres. Data on patient characteristics and management of COPD exacerbations were obtained from medical record review and a patient questionnaire. In the study population of 458 patients with at least one exacerbation, Cox regression analyses estimated the risk of a subsequent exacerbation with adjustment for age and sex.
During a follow-up period of 22 months, 238 patients (52%) had a second exacerbation. A considerable proportion of the patients were not examined and treated as recommended by guidelines. Patients with a scheduled extra visit to an asthma/COPD nurse following an exacerbation had a decreased risk of further exacerbations compared with patients with no extra follow-up other than regularly scheduled visits (adjusted hazard ratio 0.60 (95% confidence interval 0.37 to 0.99), p=0.045).
Guidelines for examination and emergency treatment at COPD exacerbation visits are not well implemented. Scheduling an extra visit to an asthma/COPD nurse following a COPD exacerbation may be associated with a decreased risk of further exacerbations in primary care patients.

Full text

Prim Care Respir J 2013; 22(4): 393-399
RESEARCH PAPER
Management of COPD exacerbations in primary care: a
clinical cohort study
*Josefin Sundh1, Eva Österlund Efraimsson2†, Christer Janson3, Scott Montgomery4,5,
Björn Ställberg6, Karin Lisspers6
1Department of Respiratory Medicine, Örebro University Hospital & School of Health and Medical Science, Örebro University, 701 85 Örebro,
Sweden
2School of Health and Social Studies, Dalarna University, 79188 Falun, Sweden
3Department of Medical Sciences, Respiratory Medicine and Allergology, Uppsala University, 75105 Uppsala, Sweden
4Clinical Epidemiology and Biostatistics, Örebro University Hospital & School of Health and Medical Science, Örebro University, 701 85 Örebro,
Sweden
5Clinical Epidemiology Unit, Department of Medicine, Karolinska University Hospital, Karolinska Institute, 171 76 Stockholm, Sweden
6Department of Public Health and Caring Science, Family Medicine and Preventive Medicine, Uppsala University, 75122 Uppsala, Sweden
†Eva Österlund Efraimsson deceased May 2013
Received 11th March 2013; revised 2nd June 2013;
accepted 18th June 2013; online 10th October 2013
Abstract
Background: Chronic obstructive pulmonary disease (COPD) exacerbations are associated with lung function decline, lower quality of
life, and increased mortality, and can be prevented by pharmacological treatment and rehabilitation.
Aims: To examine management including examination, treatment, and planned follow-up of COPD exacerbation visits in primary care
patients and to explore how measures and management at exacerbation visits are related to subsequent exacerbation risk.
Methods: A clinical population of 775 COPD patients was randomly selected from 56 Swedish primary healthcare centres. Data on
patient characteristics and management of COPD exacerbations were obtained from medical record review and a patient questionnaire.
In the study population of 458 patients with at least one exacerbation, Cox regression analyses estimated the risk of a subsequent
exacerbation with adjustment for age and sex.
Results: During a follow-up period of 22 months, 238 patients (52%) had a second exacerbation. A considerable proportion of the
patients were not examined and treated as recommended by guidelines. Patients with a scheduled extra visit to an asthma/COPD nurse
following an exacerbation had a decreased risk of further exacerbations compared with patients with no extra follow-up other than
regularly scheduled visits (adjusted hazard ratio 0.60 (95% confidence interval 0.37 to 0.99), p=0.045).
Conclusions: Guidelines for examination and emergency treatment at COPD exacerbation visits are not well implemented. Scheduling
an extra visit to an asthma/COPD nurse following a COPD exacerbation may be associated with a decreased risk of further exacerbations
in primary care patients.
© 2013 Primary Care Respiratory Society UK. All rights reserved.
J Sundh et al.Prim Care Respir J 2013; 22(4): 393-399
http://dx.doi.org/10.4104/pcrj.2013.00087
Keywords primary care, COPD, exacerbation, management, nurse
* Corresponding author: Dr Josefin Sundh, Department of Respiratory Medicine, Örebro University Hospital & School of Health and Medical Science, Örebro
University, 701 85 Örebro, Sweden. Tel +46 196025597, +46 702349517 Fax +46 19186526 E-mail: josefin.sundh@orebroll.se
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http://dx.doi.org/10.4104/pcrj.2013.00087
Introduction
Chronic obstructive pulmonary disease (COPD) exacerbations are a
major global cause of morbidity.1,2 They are known to cause lung
function decline,1frequent hospital admission2generating a
substantial financial burden for society,3worsening quality of life,4,5
and increased mortality.2,6,7 Previous studies have shown that
exacerbation risk can be reduced by pharmacological8-10 and non-
pharmacological11,12 interventions during the stable phase.
International guidelines for COPD exacerbations recommend
careful examination and treatment with inhaled bronchodilators,
antibiotics, and oral steroids.13-15 Studies of exacerbation
management in hospitalised COPD patients have shown that
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management is not always optimal,16,17 indicating a need to explore
the management of COPD exacerbations in primary care patients.
In Sweden, management of the majority of COPD patients
involves regular visits in primary care and a smaller number involves
regular visits to secondary care outpatient clinics.18 During acute
exacerbations, patients with regular visits in primary care might
present either at their primary healthcare centre (PHCC) or in the
accident and emergency department of the nearest hospital.
The first aim of this study was to examine the management of
exacerbations in Swedish primary care COPD patients during
emergency visits in PHCCs or in hospitals by describing
examinations, treatment, and planned follow-up. The second aim
was to study the associations of these measures with the risk of a
subsequent exacerbation.
Methods
Setting
In Sweden it is recommended that PHCCs have a specific
asthma/COPD clinic with access to spirometry, pulse oximeters,
nebulisers, and oxygen.19 Each general practitioner (GP) is
responsible for the diagnosis, treatment, and follow-up of COPD
patients and can refer patients to the asthma/COPD clinic for
spirometry and patient education. A Swedish asthma/COPD clinic
should involve a responsible GP and a trained specialist nurse.18-21 The
role of the asthma/COPD nurse is to perform and interpret
spirometry, peak expiratory flow (PEF) and pulse oximetry, to provide
patient education comprising pathophysiology, treatment,
inhalation technique and smoking cessation,22 and to cooperate
with the patient’s GP in planning treatment and follow-up.21 In
secondary care, an asthma/COPD nurse is often available for
outpatients.
Population and data collection
Participants were sampled from a larger cohort of COPD patients at
56 PHCCs in seven Swedish counties.23-26 Data were obtained from
medical record review and a patient questionnaire, and the
procedures are presented in Figure 1. The final study population
included the 458 (59.1%) primary care COPD patients who
presented with one or more exacerbations in PHCCs or at the
accident and emergency department of a hospital during 2000-
2003. Information on exacerbation visits was obtained using records
from both PHCCs and nearby hospitals. Information on clinical
resources was obtained in 2005 using a clinical questionnaire to the
clinical directors of the participating centres.
Measures
Sex, age, level of education, and smoking status were obtained from
patient questionnaires. The dichotomous education variable
identified education for at least two years beyond the compulsory
period of nine years. Information about co-morbidity, lung function,
and exacerbations was obtained from medical records. All first and
second exacerbations were identified by careful record review of
characteristics of patient visits. An exacerbation was defined as an
unscheduled or emergency visit at a PHCC or hospital due to
increased dyspnoea, increased cough, increased sputum production,
purulent sputum, or an airway infection. In addition, the visit should
result in either treatment with oral or parenteral steroids, inhalation
using nebulised bronchodilators, treatment with antibiotics, hospital
admission due to COPD symptoms, or alteration to maintenance or
rescue medication. A minimum of 14 days was the defined period
between exacerbations, as previously used in a Swedish study.27
Information was collected on examination, treatment, and planned
extra follow-up at exacerbation visits (Table 1). Heart disease
(ischaemic heart disease or heart failure), type 1 or 2 diabetes
mellitus, and depression (diagnosis combined with pharmaceutical
therapy) were identified. Lung function data were available for 184
patients (40.2%). Forced expiratory volume in one second (FEV1)
was expressed as percentage of predicted using the European
Community for Steel and Coal reference value.28 The subgroup of
patients with spirometry data was divided by COPD stage according
to the Global Initiative for Chronic Obstructive Lung Disease (GOLD)
recommendations.15 Information about nurse-led asthma/COPD
clinics, nebulisers, pulse oximeters, and spirometers was obtained
from the clinical questionnaires.
Statistical analysis
The analyses were performed using PASW Version 20.0 (SPSS Inc,
Chicago, Illinois, USA) and Stata (StataCorp LP, College Station,
Texas, USA). Cross-tabulations and the χ2test examined differences
in measures at exacerbation visits in primary versus secondary care,
and between patients with one and more than one exacerbation
visits. Kaplan-Meier and Cox regression analyses assessed time from
first to second exacerbation, with adjustment for age and sex. The
proportional hazards assumption was violated for the following
measures: added rescue medication, altered maintenance
treatment, and extra scheduled visits to nurse and doctor as tested
by Schoenfeld residuals and graphically. For this reason, all analyses
were right-truncated for follow-up to 22 months as hazards were
proportional to this time.
The analyses were repeated with further adjustment for lung
function in a subgroup of 184 patients with spirometry data.
Associations with follow-up by doctor or nurse were further
investigated through stratification and interaction by sex, age,
prescribed steroid course, and lung function. Hazard ratios (HR) with
Figure 1. Patient population flow chart
COPD patients randomly selected from 56 PHCCs
n=1084
COPD patients consented to complete questionnaires
and record review
n=775
COPD patients with one or more exacerbations during
the study period
n=458
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95% confidence intervals (95% CI) were presented and a p value
<0.05 was considered statistically significant.
Ethics
The study was approved by the Regional Ethical Review Board of
Uppsala University (Dnr 2010/090). Written consent to use the
information for future analysis was obtained for all participating
patients in 2005.
Results
A median number of 2 (range 1–49) exacerbations was observed over
the four-year study period, and the distribution is presented in Figure
2. Examinations and prescriptions by first emergency visit in a PHCC
and in a hospital are described in Table 1 and Figure 3.
Of the 458 patients with at least one exacerbation, 238 patients
had a second exacerbation within 22 months (Table 2). The analyses
were repeated without the 22-month right-truncation with no
material alteration of the results (data not shown). Table 2 shows the
characteristics of patients with one or more than one exacerbations.
Female sex and treatment with a course of oral steroids were
both statistically significantly and independently associated with an
increased risk of a subsequent exacerbation (Table 3). Added
maintenance and rescue medication and an extra planned visit to a
Examinations and measures N (%) Exacerbation Exacerbation p Value
visit PHCC visit hospital
(n = 391, 85%) (n = 67, 15%)
PEF
Before inhalation of bronchodilators 213 (47.5%) 179 (46.9%) 34 (51.5%) 0.484
After inhalation of bronchodilators 121 (26.6%) 103 (26.4%) 18 (27.7%) 0.829
Saturation 65 (14.3%) 18 (4.6%) 47 (72.3%) <0.0001
Lung auscultation 440 (96.7%) 375 (96.4%) 65 (98.5%) 0.381
Heart rate 135 (29.6%) 82 (21.0%) 53 (80.3%) <0.0001
Arterial blood gas 23 (5.0%) 1 (0.3%) 22 (33.3%) <0.0001
X-ray lungs 64 (14.0%) 30 (7.7%) 34 (51.5%) <0.0001
CRP 237 (52.0%) 191 (49.0%) 46 (69.7%) 0.002
Electrocardiogram 37 (8.1%) 20 (5.1%) 17 (25.8%) <0.0001
Hospital admission or acute referral to hospital 39 (8.6%) 12 (3.1%) 27 (40.9%) <0.0001
Inhaled nebulised bronchodilators 186 (40.6%) 144 (36.8%) 42 (62.7%) <0.0001
Course of steroids 128 (27.9%) 93 (23.8%) 35 (52.2%) <0.0001
Course of antibiotics 274 (59.8%) 233 (59.6%) 41 (61.2%) 0.805
Planned extra follow-up
No extra visit 324 (70.7%) 278 (71.1%) 46 (68.7%) Ref
Extra visit or call doctor 86 (18.8%) 65 (16.6%) 21 (31.3%) 0.034
Extra visit nurse 48 (10.5%) 48 (12.3%) 0 (0%) <0.0001
Examinations performed and measures taken at exacerbation visit 1 according to medical records, in total and distributed over level of care.
CRP=C reactive protein, PEF=peak expiratory flow.
Table 1. Measures at exacerbation visit 1
Figure 2 Number of exacerbation visits Figure 3 Emergency at therapy exacerbation visits
12345678>9
Number of exacerbations
0
20
40
60
80
100
120
140
160
180
200
Number of patients
II+S S
S+A
A
I+A
I+S+A
n=18
(4.6%)
A
I+A
I
I+S
S
S+A
I+S+A
n=17
(25.3%)
PHCCs Hospitals
Total number of exacerbations among patients with at least one exacerbation
during the study period of four years.
PHCCs=Primary health care centers. I=Inhaled nebulised bronchodilators,
S=Steroid course, A=Antibiotic course.
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nurse compared with no extra scheduled visits were statistically
significantly and independently associated with a decreased risk of a
subsequent exacerbation (Table 3, Figure 4).
When examining only patients with the first visit in primary care,
the HR for the association between an extra planned visit to a nurse
and reduced risk for subsequent exacerbation was 0.64 (95% CI
0.39 to 1.05), p=0.077.
In the subgroup of 184 patients with lung function data, the
association of a steroid course with increased risk of a new
exacerbation remained both after adjustment for sex and age (HR
1.94 (95% CI 1.25 to 3.02), p=0.003) and additional adjustment for
lung function (HR 1.88 (95% CI 1.20 to 2.94), p=0.006). The
association of female sex with a higher risk of a subsequent
exacerbation remained after adjustment for age (HR 1.65 (95% CI
1.04 to 2.61), p=0.032) and was somewhat attenuated after
adjustment for lung function (HR 1.59 (95% CI 1.01 to 2.52),
p=0.050). The same pattern was shown for an extra planned visit to
a nurse; the association with a reduced exacerbation risk was
statistically significant after adjustment for age and sex (HR 0.48
(95% CI 0.25 to 0.91), p=0.025) but not after additional adjustment
for lung function (HR 0.55 (95% CI 0.28 to 1.07), p=0.77). The
associations with the risk of a second exacerbation for added rescue
medication and maintenance medication were eliminated by further
adjustment for lung function (data not shown). Higher COPD stage
was associated with a higher risk of a subsequent exacerbation (data
not shown).
Patients treated with a steroid course statistically significantly
more often had a planned follow-up by a doctor (39.5%) than by a
nurse (20.8%) (p=0.027; p for interaction=0.043). Stratification and
interaction analyses by sex, age, and lung function showed no
differences in the adjusted associations with second exacerbation
risks for extra scheduled visits to a doctor or nurse (data not shown).
The clinical questionnaire revealed that 36 of the participating 56
PHCCs (64%) and seven of the 14 secondary care clinics (50%) had
a specific nurse-led asthma/COPD clinic. In the PHCCs, nebulisers for
inhalation of bronchodilators were available in 50 centres (89%),
pulse oximeters in 46 centres (82%), and spirometers in 52 centres
(93%). All 14 secondary care clinics had access to pulse oximetry and
nebulisers, and 13 (93%) had their own spirometer.
Discussion
Main findings
The main finding of this multicentre study of primary care COPD
Characteristics and
Patients with Patients with
p
measures
1 exacerbation >2 exacerbations
Value
All (n=458) 220 (48%) 238 (52%)
Sex (n=458)
Male 92 (41.8%) 73 (30.7%) Ref
Female 128 (58.2%) 165 (69.3%) 0.013
Educational level*
Lower 151 (69.6%) 169 (72.8%) Ref
Higher 66 (30.4%) 63 (27.2%) 0.446
Current daily smoker**
No 146 (66.7%) 165 (69.3) Ref
Yes 73 (33.3%) 73 (30.7%) 0.542
Age (years)
<50 18 (8.2%) 16 (6.7%) 0.876
51-60 51 (23.2%) 60 (25.2%) 0.204
61-70 90 (40.9%) 111 (46.6%) 0.101
>70 61 (27.7%) 51 (21.4%) Ref
Comorbidity
Heart disease 50 (22.7%) 45 (18.9%) 0.314
Depression 35 (15.9%) 32 (13.4%) 0.456
Diabetes 19 (8.6%) 23 (9.2%) 0.703
Lung function ***
Stage 1 38 (42.2%) 22 (23.4%) Ref
Stage 2 30 (33.3%) 41 (43.6%) 0.017
Stage 3 20 (22.2%) 27 (28.7%) 0.034
Stage 4 2 (2.2%) 4 (4.3%) 0.171
Level of care
exacerbation visit 1
PHCC 197 (89.5%) 194 (81.5%) Ref
Hospital 23 (10.5%) 44 (18.5%) 0.015
Added maintenance therapy
76 (34.5%) 51 (21.4%) 0.002
Added rescue therapy 28 (12.7%) 14 (5.9%) 0.011
Acute inhalation therapy 90 (40.9%) 96 (40.6%) 0.901
Course of steroids 46 (20.9%) 82 (34.5%) 0.001
Course of antibiotics 128 (58.2%) 146 (61.3%) 0.490
Planned extra follow-up
No extra visit 147 (66.8%) 177 (74.4%) Ref
Extra visit or call doctor 43 (19.5%) 43 (18.1%) 0.444
Extra visit nurse 30 (13.6%) 18 (7.6%) 0.029
Study period truncated at 22 months.
Number with available information: *n=449, **n=457, ***n=184.
Table 2. Comparison of patients with and without an
additional exacerbation
Figure 4 Planned follow-up and time to second
exacerbation
0
Follow-up time (months)
0
Cumulative survival of patients with
only one exacerbation (%)
510152025
Time to second exacerbation
20
40
60
80
100
Kaplan-Meier curves for extra planned follow-up by doctor or nurse
compared with no extra scheduled visits.
Solid line = extra planned visit to nurse, broken line = extra planned visit or
telephone call by doctor, dotted line = no extra scheduled visits.
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patients is that a considerable proportion of patients consulting for an
exacerbation were not examined, treated, and planned for follow-up
as recommended in the guidelines.
Furthermore, we found that female sex and treatment with
steroid courses were associated with a higher risk of a subsequent
exacerbation, and that added rescue or maintenance medication and
an extra planned visit to an asthma/COPD nurse following an
exacerbation were associated with a reduced risk of subsequent
exacerbations.
Interpretation of findings in relation to previously
published work
Interestingly, not only patients in COPD stage 3 but also those in
stage 2 statistically significantly more often had two or more
exacerbations compared with patients in COPD stage 1. Thus, even
patients with moderate disease might often have exacerbations,
which supports the intention of the recent GOLD updates to
consider exacerbation frequency as well as symptoms and lung
function when assessing the disease.15 The number of patients in
stage 4 is too small to draw firm conclusions.
National and international guidelines support careful examination
at exacerbation visits.13-15 This study suggests that management
should be improved – especially with respect to measuring oxygen
saturation and heart rate – in order to identify patients with severe
exacerbations in need of hospital admission. Recommendations were
better followed when primary care patients with exacerbations were
managed in hospitals, but management was not optimal at any level
of care.
It is interesting that courses of oral steroids and nebulised
bronchodilators were more often used in secondary care while
antibiotics were equally common in primary and secondary care. The
difference in treatment of exacerbations in PHCCs and hospitals might
at least partly reflect differences in the severity of the exacerbations,
but is still unexpected. However, treating exacerbations with
antibiotics and steroids is evidence-based29-32 and recommended in
international guidelines.13-15 Our study showed no association between
treatment with antibiotics and subsequent exacerbation, and an
increased risk of treatment with a course of oral steroids. We believe
that this is at least partly because the patients receiving steroids had
more severe disease with greater risk of new exacerbations.
Our findings are consistent with studies of exacerbation
management in hospitalised COPD patients,16,17 but we are not aware
of other similar studies describing the management of COPD
exacerbations in primary care patients in both PHCCs and hospitals.
Women are known to have an increased susceptibility to develop
COPD.33 Biological explanations such as through hormones have
been suggested.34 The association with a higher risk for a subsequent
exacerbation among women in this study is consistent with several
studies of secondary care patients35,36 but has not been shown
previously for primary care patients.
Information from the clinical questionnaires revealed that only
about two-thirds of the participating PHCCs and about half of the
participating hospital clinics in this study had specific nurse-led
asthma/COPD clinics. A Swedish study examining resources in PHCCs
in western Sweden found that 82% of PHCCs had a nurse specifically
responsible for COPD,37 and a more recent Swedish study found that
the proportion of asthma/COPD clinics was even higher (87%).18 In
the same studies, the presence of pulse oximeters and nebulisers was
equal or slightly higher than in our study. Since our study examines
management in an earlier calendar period than the other Swedish
studies, this indicates that national recommendations regarding
structure of COPD care have been better implemented over time.
The organisation of COPD care has been studied in several
countries. Nurse-led asthma/COPD clinics are common in the UK,38,39
and nurse-based information programmes have been used in the
Netherlands with a beneficial effect on exacerbation frequency.40 An
integrated care system including a nurse case manager associated
with a reduced risk of hospital admissions due to COPD exacerbations
has been described in Spain and Belgium.41 A previous meta-analysis
in the UK examined nurse-led management interventions for COPD
with no certain positive effects.42 However, the organisation of nurse-
led asthma/COPD clinics might differ between countries. Our finding
that an extra scheduled visit to a nurse after an exacerbation might
be associated with a reduced risk of a subsequent exacerbation is
consistent with a Swedish study where patients in PHCCs with nurse-
led asthma/COPD clinics had fewer exacerbations.18
A possible explanation for the decreased exacerbation risk
following an extra scheduled visit to a nurse could be selection bias,
if patients chosen for follow-up by nurse were generally healthier
Characteristics and measures Unadjusted HR (95% CI) p Value Adjusted HR (95% CI) p Value
Sex
Male Ref Ref
Female 1.40 (1.06 to 1.85 0.016 1.40 (1.06 to 1.86) 0.019
Acute inhalation treatment 1.14 (0.88 to 1.48) 0.307 1.16 (0.89 to 1.50) 0.267
Course of steroids 1.56 (1.19 to 2.04) 0.001 1.58 (1.21 to 2.07) 0.001
Course of antibiotics 1.08 (0.83 to 1.40) 0.580 1.05 (0.81 to 1.36) 0.734
Added rescue treatment 0.54 (0.31 to 0.93) 0.025 0.53 (0.31 to 0.91) 0.022
Added maintenance treatment 0.72 (0.53 to 0.98) 0.038 0.73 (0.54 to 1.00) 0.048
Planned extra follow-up
No extra scheduled visit Ref Ref
Extra visit or call to doctor 0.81 (0.58 to 1.13) 0.214 0.82 (0.59 to 1.15) 0.254
Extra visit nurse 0.58 (0.36 to 0.94) 0.026 0.60 (0.37 to 0.99) 0.045
Study period truncated to 22 months. Adjusted for sex and age.
Table 3. Cox regression analyses for preventive measures
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than patients with planned doctor follow-up. This could be consistent
with the higher rate of steroid courses among those with planned
follow-up by a doctor. On the other hand, COPD stage did not differ
significantly between the doctor and nurse follow-up groups. Thus,
our findings are unlikely to be explained entirely by selection bias.
Another possible explanation is that patients with a first
exacerbation visit at a hospital could have more severe exacerbations
and none of these patients had an extra planned nurse visit. A sub-
analysis of patients with the first exacerbation visit in a PHCC was
examined. This resulted in a HR of similar magnitude but was no
longer statistically significant, which is partially explained by reduced
power due to fewer patients. We believe that exacerbation visits at
hospitals do not necessary signal more severe exacerbations. In
Sweden, primary care patients have limited access to GPs during
evenings and weekends and so may present at hospitals.
We believe the association between an extra planned nurse visit
could indicate reactivity of the PHCC management team to the
exacerbation to optimise care. It could be a marker for generally
better COPD care with integrated management. The nurse may have
more time to develop a comprehensive view of the patient and help
to implement strategies to reduce exacerbation risk.
Strengths and limitations
Strengths of this study are that it is longitudinal and comprises a real
clinical population of COPD patients without exclusion criteria,
randomly sampled from multiple centres. This ensures a high level of
generalisability. Further, the data from medical records were initially
recorded prospectively and should be reliable and not subject to
different recall bias.
A limitation is that lung function data were only available for a
subset of the study population, although most clinics had access to
spirometry. Possible explanations might be that spirometry had been
performed but not reported in the records or that patients had a
diagnosis confirmed by spirometry before the study. Patients with
severe disease might have been particularly unable or unwilling to
perform a lung function test. It has been demonstrated that many
COPD diagnoses are based on clinical findings rather than
spirometry.23
We did not have access to records prior to the study period 2000-
2003 so earlier spirometry data were unavailable. Another potential
issue is that 32% of the spirometry measurements were based on
pre-bronchodilator values but we speculate that, in most of these
cases, spirometry with reversibility test had also been performed
previously.
Only exacerbation visits in PHCCs and hospitals in the seven
counties of the study area were examined. However, we believe that
failure to identify exacerbation visits abroad or in other parts of the
country must constitute a very small number, not influencing the
results of the study. COPD exacerbations may sometimes be labelled
and treated incorrectly, and we may have missed some exacerbations
or included non-exacerbation events. However, our standardised
definition should ensure accurate identification of the vast majority of
exacerbations. The exacerbations were not graded by severity, but
our definition captured exacerbations associated with a healthcare
visit and prescribed treatment, indicating severity relevant to use of
healthcare resources and patient well-being.
Finally, in our investigation of extra planned visits we cannot be
certain that the visits occurred. However, we believe an extra
scheduled visit could still serve as a surrogate marker for fulfilled visits
and responsive COPD management.
Implications for future research, policy and practice
This study shows that the guidelines for exacerbation management
should be better implemented, especially in PHCCs where the
majority of exacerbation visits among primary care patients take
place. Previous studies have shown that educational programmes of
management in stable COPD have improved compliance with
guidelines,43,44 and it should also be possible to apply this to the
management of exacerbations.
The issue of how COPD care should be organised is very
important, and this study showed that very few patients were
scheduled for extra follow-up. We believe that the finding that an
extra scheduled visit to a nurse is as good as a scheduled visit to a
doctor and even might reduce the risk of subsequent exacerbation is
important and could be a way of optimising resources in COPD care.
However, the findings should be confirmed in appropriate studies
with adequate statistical power.
Conclusions
Guidelines for management of COPD exacerbation visits are not
followed optimally and ought to be better implemented. Integrated
management including nurse-led asthma/COPD clinics might assist in
optimising COPD care relevant to exacerbation risk.
Handling editor Arnulf Langhammer
Statistical review Gopal Netuveli
Acknowledgements The authors thank Ulrike Spetz-Nyström and Eva
Manell for reviewing the patient records, and all participating centres. .
Conflicts of interest The authors declare that they have no conflicts of
interest in relation to this article. BS is an Associate editor of the PCRJ, but was not
involved in the editorial review of, nor the decision to publish, this article.
Contributorship All authors made substantial contributions to the conception
and design of the study and editing of the manuscript and all authors have approved
the submitted paper. CJ is the guarantor of the study.
Funding The study was supported by grants from the county councils of the
Uppsala-Örebro Health Care region, the Swedish Heart and Lung Association, the
Swedish Asthma and Allergy Association, the Bror Hjerpstedts Foundation, and the
Örebro Society of Medicine.
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