X4. Uptake and impact of guidelines for exacerbations

Although there are many COPD guidelines around the world, there has been little evaluation of their uptake into clinical practice, or their impact on clinical outcomes.  A study of the compliance to COPD-X (Gerber 2018) recommendations in 381 COPD patients attending the EDs of two hospitals within one local Australian health service, has demonstrated moderately satisfactory results, with compliance to individual recommendations of the order of 74-90%, and to the whole list of recommendations of 49%, indicating  some room for further improvement.  Highest levels of compliance were seen in the most severe COPD cases.  This study did not show a reduction in LOS with greater compliance, however this analysis did not adjust for severity.

A retrospective study of 134 patients admitted with an exacerbation of COPD at an Australian tertiary hospital demonstrated poor adherence to COPD-X recommendations for managing exacerbations. Controlled oxygen therapy to achieve SpO2 88-92% was provided in 42% of cases and referral to pulmonary rehabilitation was made in only 17.9% of cases. Furthermore, smoking cessation counselling was provided to 40% of patients and a review of immunisation status only occurred in 2% of cases (Sha 2020).

A European study found that hospitalised COPD patients with an exacerbation received on average only 41% of key diagnostic, pharmacological and non-pharmacological recommendations from clinical guidelines, including low uptake of provision of smoking cessation advice, inhaler technique education and referral to pulmonary rehabilitation (Seys 2017).

An audit of COPD patients in the Outpatient respiratory clinics of 59 Spanish hospitals (Calle Rubio 2017) demonstrated that clinical practice, at least as recorded in the case notes, fell well short of recommendations in GOLD and Spanish national guidelines for COPD.

A prospective cohort study of 415 patients with an exacerbation of COPD who presented at 46 EDs in 5 Asia-Pacific countries, 65% of these arriving by ambulance, and 78% of those being admitted to hospital, of which 7% to an ICU and median LOS 4 days highlights the public health and acute care hospital burden of COPD exacerbations (Kelly 2018). Clinical management findings against COPD-X benchmarks are to be interpreted with caution as they are based on case-note audit but were indicative of excessive use of uncontrolled oxygen therapy and a suboptimal use of a combination of inhaled corticosteroid/bronchodilator therapy, arterial blood gas measurement and also treatment with non-invasive ventilation.

An audit of 801 patients with COPD who presented to 66 European and 46 Australasian participating emergency departments (ED) with breathlessness demonstrated a low adherence to COPD-X and GOLD guideline management recommendations with respect to the use of systemic corticosteroids and antibiotics, especially in the European sites (Kelly 2019). Use of non-invasive ventilation when indicated was equally low in both regions. The authors propose novel use of care bundles and supportive clinical support systems in EDs to reduce the evidence–practice gap.

A tertiary hospital in Israel introduced an electronic clinical decision support tool for use in COPD patient discharge and reported a very significant increase in adherence to guidelines with respect to prescription of appropriate inhalers, recommendations regarding vaccination and smoking cessation as well as follow up in outpatient clinics (Epstein 2019).