Identifying Opportunities in COPD Disease Management

Abstract

Background: Therapies beyond inhaled medications have been demonstrated beneficial in patients with advanced COPD with history of exacerbations. Pulmonary rehabilitation (PR) benefits COPD patient healthcare quality-of-life and dyspnea, while PDE-4 inhibitors (eg, roflumilast) and prophylactic macrolide (most commonly azithromycin) use may offer benefits in reducing exacerbations. Typically, referrals to PR or additions of PDE-4 inhibitors and macrolides are considered and implemented by pulmonologists and/or those with subspecialty expertise in the treatment and management of COPD.

Methods: Three clinicians retrospectively reviewed the electronic medical record (EMR) of 96 patients hospitalized in 2019 with a diagnosis of COPD. Reviewers wanted to glean whether there were opportunities to improve care in patients who were primarily hospitalized for an exacerbation of their COPD. Reviewers evaluated hospital admission diagnosis, diagnostic testing, and therapies aimed at reducing exacerbations, and referrals or visits to outpatient pulmonary clinics, PR, and palliative care. Exemption was obtained through the University of California, Davis IRB #1759094-1.

Results: Of the 96 reviewed charts, 19 were excluded (20%) due to an incorrect COPD diagnosis and 12 (12%) were excluded due not having a PCP within the health system, leaving an N = 65. Of these 65 patients, 28 (45%) had a least one COPD-related admission in 2019. Two (7%) of the 28 COPD related admission patients had been prescribed roflumilast or chronic azithromycin treatments for the prevention of exacerbations. Four (14%) of the patients had been previously referred to PR, with 3 (11%) of them reaching and completing the program. Nine (32%) patients had at least one pulmonary outpatient visit in 2019. None of the hospitalized patients had been referred to palliative care.

Conclusions: Multiple opportunities for exacerbation prevention were missed in our cohort of the highest risk COPD patients. Guidelines recommend timely interventions to reduce the risk of COPD disease progression and exacerbations, but these often do not penetrate the sickest population of patients frequently admitted. Referrals to programs and disease specific clinics should be considered early in COPD but especially in patients with history of exacerbations.