GLASGOW AND EDINBURGH-- Many patients with acute exacerbations of chronic obstructive pulmonary disease (COPD) can be safely discharged from the hospital earlier than is commonly thought—as long as treatment is continued at home under supervision, two new Scottish studies suggest.[1,2] However, early discharge should be considered only for patients with uncomplicated cases of COPD.

“Exacerbations of COPD are amongst the most common medical admissions and certainly are the most common respiratory emergency admission. The burden of this disease is enormous,” explained William MacNee, MD, one of the authors of the first study. Researchers in the United States, United Kingdom, and elsewhere have been investigating alternatives that would provide patients with safe, effective care while lowering the cost of treatment.

One approach—used in both of the Scottish studies—employs an Acute Respiratory Assessment Service (ARAS), composed predominantly of trained nurses who work under physician supervision.[3] These nurses evaluate COPD patients in the emergency room or on the hospital floor to identify those who are candidates for early discharge (almost immediately or within a few days of admission). The ARAS nurses also visit the patients at home to monitor their compliance with, and response to, treatment. “This type of ‘hospital at home’ intermediate care is already being adopted widely in the United Kingdom and also on the European mainland,” said Robin D. Stevenson, MD, who was a coauthor of the second study.

The two studies used somewhat different methods: in Edinburgh, appropriate patients were discharged almost immediately, whereas the Glasgow study gave all patients a brief period of inpatient care, thus increasing the proportion of patients available for early discharge. However, both studies found that for many patients with acute COPD exacerbations, prolonged hospitalization can be avoided.

IMMEDIATE DISCHARGE

In the first study, Dr. MacNee and colleagues initially evaluated 718 patients with acute exacerbations of COPD who were admitted to an emergency room on a weekday during one 18–month period.[1] About half of these patients were not included in the study because they required hospital admission for one of the following reasons: impaired consciousness, acute confusion, acute changes on chest film, or an arterial pH below 7.35. An additional 25% were excluded because of comorbidities, poor social circumstances, or lack of consent. The remaining 184 (26%) patients were randomized in a 1:2 ratio to standard treatment or to early discharge with home support provided by an ARAS nurse. A total of 62 patients were assigned to hospital admission; the other 122 were discharged.

The patients admitted to the hospital received usual care. Home treatment consisted of antibiotics, corticosteroids, nebulized bronchodilators, and, if necessary, oxygen. The patients treated at home were visited by an ARAS nurse the day after hospital discharge and every two to three days thereafter until the ARAS team believed that the patients no longer required home support. The patients’ primary care physicians were informed of their progress.

Eight weeks after initial presentation in the emergency room, patients in both groups were examined at home. Pulmonary function was measured with spirometry, and quality of life was assessed. In addition, the patients treated at home and their primary care physicians were asked to rate their satisfaction with care.

Both the hospitalized patients and those given home care improved with treatment, and the extent of the improvement was comparable in the two groups. (If anything, there may have been slightly greater improvement in the home care group.) The median time to discharge was slightly longer in the patients given home care than in those treated in the hospital (seven days vs five days); this difference, said the researchers, “may have reflected the fact that the nurses’ home visits were not always daily.” The early discharge group received an average of 3.8 visits at home from the visiting nurse.

At eight weeks’ follow–up, the rate of readmission was higher among the patients who received standard treatment than among those given home care (34% vs 25%), but this difference was not statistically significant. In addition, the two groups had similar spirometric measurements and similar assessments of their quality of life.

More than two thirds of the patients treated at home returned the questionnaire that asked them to rate their satisfaction with the care they received: 95% of the respondents were “completely satisfied,” and 90% believed that home care was just as good as or better than hospital care. The patients’ primary care physicians were also satisfied with the treatment that had been administered.

The cost of home care was roughly half that of hospital care. The researchers acknowledge, however, that because many hospital costs are fixed, the actual savings from a switch to home care would not be as great as was shown in their study.

REDUCED INPATIENT CARE

The randomized trial conducted by Dr. Stevenson and colleagues was also confined to patients with uncomplicated COPD.[2] In this study, an ARAS nurse visited the medical floors of one urban hospital each weekday for 14 months to identify all patients who had been admitted for exacerbations of COPD. Of the 412 patients so identified, about half were excluded because of suspected or actual coexisting medical conditions that required hospital care. Other patients were excluded from the study because they were homeless, were participating in other clinical trials, or refused consent.

Of the 81 patients included in the study, 40 were randomized to standard hospital care. The other 41 patients were randomized to early discharge, which generally occurred on the next working day after recruitment. These patients were visited by an ARAS nurse the morning after discharge and, thereafter, at intervals determined by the nurse. At–home treatment could be adjusted by the nurse after discussion with the ARAS medical staff. Both groups of patients were evaluated two months after initial hospital discharge.

The mean duration of hospitalization was 3.2 days for the early discharge patients and 6.1 days for those given standard care. The two groups had a similar readmission rate (about 30%). The mean duration of hospitalization after readmission was similar in the two groups (7.8 days vs 8.8 days, respectively). The number of patients who died within 60 days of initial admission was slightly lower in the early discharge group than in the standard treatment group (one vs two, respectively).

Dr. Stevenson emphasized that the benefits of early discharge apply only to patients with uncomplicated exacerbations who do not have acidotic respiratory failure. He added, “We believe that initial assessment in hospital is essential in this model of care. All patients should have a chest radiograph and arterial blood gases, with additional investigation as necessary.”

“The main difference between an ARAS–based system and earlier models of home care for COPD patients is that in the ARAS model medical and nursing care is restricted to the acute illness and no attempt is made to provide long–term supervision, which in previous studies has not been cost–effective,” Dr. Stevenson told RESPIRATORY REVIEWS. The ARAS model “uses nurses’ time more economically and takes advantage of the fact that the greatest degree of improvement in these patients takes place in the first two days after hospital admission, thus increasing the number of patients who will be eligible for home care.”

--Kristin Della Volpe

References
1. Skwarska E, Cohen G, Skwarski KM, et al. Randomised controlled trial of supported discharge in patients with exacerbations of chronic obstructive pulmonary disease. Thorax. 2000;55:907-912.

2. Cotton MM, Bucknall CE, Dagg KD, et al. Early discharge for patients with exacerbations of chronic obstructive pulmonary disease: a randomised controlled trial. Thorax. 2000; 55:902-906.

3. Gravil JH, Al-Rawas OA, Cotton MM, et al. Home treatment of exacerbations of chronic obstructive pulmonary disease by an acute respiratory assessment service. Lancet. 1998; 351:1853-1855.