ABSTRACT
Guideline adherence rates for the treatment of chronic obstructive pulmonary disease (COPD) exacerbation are low. The aim of this study is to perform an importance-performance analysis as an approach for prioritisation of interventions by linking guidelines adherence rates to expert consensus rates for the in-hospital management of COPD exacerbation. We illustrate the relevance of such approach by describing variation in guideline adherence across indicators and hospitals. A secondary data analysis of patients with an acute COPD exacerbation admitted to Belgian, Italian and Portuguese hospitals was performed. Twenty-one process indicators were used to describe adherence to guidelines from patient record reviews. Expert consensus on the importance for follow-up of these 21 indicators was derived from a previous Delphi study. Three of the twenty-one indicators had high level of expert consensus and a high level of adherence. Eleven of the twenty-one indicators had high level of expert consensus but a low level of adherence. For none of the 378 patients included in this study were all process indicators adhered to, patients received 41.0% of the recommended care on average, and only 34.1% of the patients received 50% or more of the care they should receive. There was also a large variation within and between hospitals regarding the care received. This study confirms the findings of previous studies, indicating that COPD exacerbations are largely undertreated. Importance-performance analysis provides a decision-making tool for prioritising indicators. All hospitals in this study would benefit from having in place a quality framework for systematic follow-up of these indicators.
Introduction
For the management of chronic obstructive pulmonary disease (COPD), well-established guidelines, such as Global Initiative for Obstructive Lung Disease (GOLD) statements, are available (Citation1–3). A guideline is however no guarantee that it is used. Research shows that guideline adherence is far from optimal (Citation4,Citation5). This is also the case for COPD-related guidelines. A US study found that patients with COPD received 58% of the recommended care Citation(4). Recent data from the European COPD audit, performed by the European Respiratory Society (ERS), showed that only 15.3% of the patients, admitted with a COPD exacerbation, received full adherence to the GOLD statement, and patients received 83.2% of the recommended care. The adherence to guidelines varied significantly across hospitals and countries (Citation6,Citation7). One of the explanations might be that too many recommendations are given in the guidelines and that not all recommendations have equal importance.
In general, the quality of care patients with a COPD exacerbation receive should be improved (Citation4,Citation5). Care activities with known associations to patient outcomes should therefore be prioritised. However, it is hard to set priorities as most of the care activities mentioned in the GOLD statement are to some degree related with patient outcomes Citation(1). The difficulty thus lies in targeting the right areas for improvement. An alternative method of prioritizing care activities is by linking care activities that have a high level of evidence (importance) with guideline adherence rate (performance). Such importance-performance analysis was originally proposed in marketing research Citation(8). In healthcare, importance-performance analysis was for example found to be a good method to improve quality of pediatric care because importance moderates performance and quality Citation(9).
The aim of this study is to perform an importance-performance analysis as an approach for prioritisation of interventions by linking guideline adherence rates to expert consensus on the importance for follow for the in-hospital management of COPD exacerbation. We illustrate the need for such approach by describing variation in guideline adherence across indicators and hospitals.
Methods
Study population
This secondary data analysis is part of the European Quality of Care Pathways Study (EQCP study) (Citation10–12). The EQCP study is an international cluster randomised controlled trial conducted in a convenience sample of Belgian, Italian and Portuguese hospitals that were randomly assigned to a control or intervention group to study the effect of implementing a care pathway on several process and outcome measures. Study participants were patients experiencing a COPD exacerbation. Findings show that implementing a care pathway reduces 30-day readmission rates Citation(12). Before the intervention (i.e., implementation of a care pathway), adherence was measured in the intervention group (pre-test data). After the intervention, adherence was measured in both the intervention (post-test data) and the control group. Here, data from the intervention group (pre-test data only) and control group were used because these reflect usual care. Belgian hospitals included 111 patients in 9 hospitals between April 2009 and July 2009 (pre-test data) and 100 patients in 5 hospitals between October 2010 and November 2011 (control group). Italian hospitals included 26 patients in 3 hospitals between October 2011 and March 2012 (pre-test) and 62 patients in 5 hospitals between January 2013 and April 2014 (control group). Portuguese hospitals included 73 patients in 5 hospitals between January 2011 and November 2011 (pre-test data) and 6 patients in 1 hospital between January 2013 and April 2014 (control group). Thus, a total of 378 patients admitted to 28 hospitals were included in this analysis. An overview of the patient flow chart is shown in
Figure 1. Flowchart patient inclusion.
Patient inclusion criteria for the EQCP study were: (i) admitted with a COPD exacerbation as primary diagnosis, (ii) hospitalised for at least 48 hours, (iii) admitted in a ward where COPD exacerbations were usually treated, (iv) ability to understand and read the native language and (v) written informed consent was given. Exclusion criteria were: (i) patient could only be included in the study once, specifically at their first admission during the study period, (ii) being included in another study of which the measurements could influence the measurements or outcomes of the EQCP study or (iii) the patient needed invasive positive pressure ventilation at admission in the hospital. The need of noninvasive positive pressure ventilation was not an exclusion criterion Citation(10). A national European Pathway Association coordinator was appointed in each country. Enrolment of the hospitals occurred by the European Pathway Association in close collaboration with this national coordinator (Citation10,Citation12).
Quality indicators
Adherence to clinical guidelines was evaluated by reviewing in-hospital patient records. Adherence was measured by the process indicators based on clinical practice guidelines/statements (GOLD, American Thoracic Society-European Respiratory Society [ATS-ERS] and National Institute for Health and Care Excellence [NICE]), process flows (Map of Medicine) and outcome studies Citation(10). These process indicators were defined on the basis of a Delphi study, which provided information on expert consensus on the importance of follow-up of an indicator for in-hospital management of patients with a COPD exacerbation (Citation13,Citation14). Thirty-five experts from 15 countries participated in this study and rated all the indicators on a 6-point Likert scale. The proportion of experts who scored 5 or 6 indicated importance Citation(14). Process indicators with a level of expert consensus above 50% were included (Citation14,Citation15). Adherence to guidelines was measured as a proportion and was measured at patient level. This proportion has as numerator the number of individual process indicators adhered to and as denominator the number of relevant process indicators. Eight indicators not relevant to all patients are: administration of controlled oxygen therapy in patients hypoxemic during admission, arterial blood gas measurement 1 or 2 days prior to discharge in patients hypoxemic during a COPD exacerbation, prescription of home oxygen therapy in patients with hypoxemic at discharge, nutritional management in patients with overweight, education regarding inhaler therapy in patients in which inhaler therapy is prescribed, nutritional management in patients with underweight, education regarding home oxygen therapy in patients in which home oxygen is prescribed and smoking cessation intervention in active smokers at admission. Indicators with a level of expert consensus above 75% were classified as high on the level of importance. The 21 process indicators were classified in three core processes: diagnostic (2 process indicators), pharmacological (4 process indicators) and non-pharmacological management (15 process indicators) Citation(14). Indicators with an adherence above 80% were classified as high on level of performance. The diagram of adherence rates and expert-rated importance allows an importance-performance plot to be created. Four quadrants are identified in this type of analysis. The first quadrant contains interventions that are highly valued by experts and where adherence is high. Healthcare providers should in this case keep up the good work. The second quadrant captures interventions that hospitals should focus on to optimise adherence. These interventions are highly valued by experts, whilst adherence rates are low. The third quadrant includes low priority interventions that are relatively less important based on expert consensus and adherence is low. The fourth quadrant represents overuse; there is no consensus among experts on the effectiveness of these interventions, whilst adherence is high Citation(8).
Ethical approval
This study is registered at ClinicalTrials.gov (NCT00962468). Ethical approval was obtained at country (for Belgium ML5617, Italy 625, 21/07/2011 and Portugal 6497/2011) and organisational level, and written informed consent was obtained from patients Citation(10).
Statistical analysis
Patient characteristics, hospital characteristics, and the association between performance (guideline adherence) and importance (expert rated) are first described. A cut-off of 75% was defined as a high level of importance. This is the cut-off used in the international Delphi study Citation(16). A cut-off of 80% was set to represent performance. This cut-off was based on the proportion of recommended care provided for patients admitted with a COPD exacerbation (83.2%) based on the European COPD audit performed by ERS Citation(6). For each indicator, the median and interquartile range (IQR) were calculated to describe variation between hospitals. Variation in adherence rates across and within hospitals is shown by a boxplot. Analyses at patient and hospital level were performed in SPSS version 22.0 and R using packages easyGgplot2 and ggplot2.
Results
Patient and hospital characteristics
The mean age of the 378 patients was 69.5 years, 71.5% were men, 88.7% were active or ex-smokers, and a large majority (83.9%) had a Charlson comorbidity index Citation(16) higher than two. About half (42.9%) of the 28 hospitals were teaching hospitals, and about one in five hospitals (21.4%) had more than 600 beds. These hospitals had an annual volume of more than 300 patients with a COPD exacerbation. The average number of patients per hospital included in this study is 13.5 and ranges between 5 and 20. These and other characteristics are shown for the total sample and by country in
Table 1. Patient and hospital characteristics.
Importance-performance analysis
The importance-performance plot is shown in . As shown in , fourteen process indicators, i.e., those in the two upper quadrants, were found to be important by more than 75% of the experts and are considered high level of importance indicators. Three of these high level of importance indicators had a level of performance above 80% (upper right quadrant). Performance of these indicators should be maintained. Eleven of the high level of importance indicators are underuse interventions. These interventions were performed for less than 80% of the patients (upper left quadrant) and can thus be classified as high priority interventions. Nine of these underuse interventions do not achieve performance of 50% or more. Worth noting is that these interventions are mainly non-pharmacological management interventions. In the bottom left quadrant, ten low priority interventions are shown where both importance and performance are low. No possible overuse interventions were identified (bottom right corner) where importance is low and performance is high.
Figure 2. Importance-performance analysis. The labels within the circles correspond with the process indicators mentioned in (D01, performance of arterial blood gases (ABG) measurement during first 24 hours of admission; D02, performance of chest X-ray during first 24 hours of admission; P01, prescription of antibiotics, P02, prescription of short-acting bronchodilators during hospitalisation, P03, prescription of long-acting bronchodilators during hospitalisation; P04, prescription of 30–40 mg of oral prednisolone daily for 7–10 days; NP01, administration of controlled oxygen therapy in patients hypoxemic during admission; NP02, assessment of smoking status, NP03, patient received influenza vaccination within the past year; NP 04, ABG measurement 1 or 2 days prior to discharge in patients hypoxemic during a COPD exacerbation; NP05, patient received pneumococci vaccination within the past five years; NP06, prescription of home oxygen therapy in patients with hypoxemic at discharge; NP07, nutritional assessment (BMI); NP08, referral to pulmonary revalidation during the past year; NP09, nutritional management of patients with overweight; NP10, adequate discharge management; NP11, education regarding inhaler therapy in patients in which inhaler therapy is prescribed; NP12, performance of revalidation tests during the past year (inclusive current hospitalization); NP13, nutritional management in patients with underweight; NP14, education regarding home oxygen therapy in patients in which home oxygen is prescribed; NP15, smoking cessation intervention in active smokers at admission). The horizontal line shows the high or low level of importance (75%), whilst the vertical line shows the high or low level of performance (80%). The larger the circle, the larger the IQR. The highest IQR, Q3–Q1, and shown by the largest circles, was noticed for D02, performance of chest X-ray during first 24 hours of admission, and NP06, prescription of home oxygen therapy in patients with hypoxemic at discharge. The lowest IQR, shown by the smallest circle, was noticed for NP12, performance of revalidation tests during the past year.
Adherence to guidelines
As displayed in , adherence to the individual process indicators varied on patient level between 96.4%, for administration of controlled oxygen therapy in patients hypoxemic during admission and 2.6%, for smoking cessation intervention in active smokers at admission. Lowest adherence to guidelines can mainly be seen for indicators related to patient education (such as oxygen therapy), nutritional assessment, pulmonary revalidation and discharge management. None of the patients received all the care they should have received. For the diagnostic care activities, the received recommended care was 68.1%, whilst this was 42.7% for the activities related to pharmacological management and 34.5% for the activities related to non-pharmacological management. Overall, at patient level, adherence ranged from 0% to 85.7%. On average, patients received 41.0% of the recommended care. Only 34.1% (129 of the 378 patients) received 50% or more of the recommended care. describes the large variation between hospitals, ranging from 18.8% to 59.4%. Large variation is also noticed within hospitals. The average IQR for the first quartile of hospitals (best performing hospitals) was 12.6, whilst the average for the last quartile of hospitals (lowest performing hospitals) was 9.2. The patients with the best and worst performed care interventions were outliers. In the next section, these findings are compared to those reported in previous studies and implications are discussed.
Table 2. Overview process indicators for the in-hospital management of a COPD exacerbation.
Figure 3. Adherence to guidelines at hospital level. The figure gives an overview of the variation between and within hospitals according to adherence rate to guidelines. On the left side, the hospital with the highest median score on the adherence rate to guidelines is mentioned, whilst on the right side, the hospital with the lowest median score is mentioned. The vertical lines show the first and fourth quartiles.
Discussion
In-hospital management for patients with a COPD exacerbation is suboptimal compared with the international clinical guidelines recommendations. We see high variation within and between hospitals. Patients on average receive 41% of the recommended care. Even for the 14 indicators that were rated by experts as highly important, only three were performed for more than 80% of the patients.
There is sound evidence that the adherence to the GOLD statements leads to lower patient experience of all COPD-related symptoms and reduces the in-patient all-cause hospitalisation and emergency department visits Citation(18) and reduces 30-day readmission rate (Citation1,Citation19). Based on the Estudi dels Factors de Risc d'Agudització de la MPOC (EFRAM) study, smoking cessation and adequate provision of oxygen therapy were suggested interventions in the prevention of readmissions (Citation20,Citation21). Reduced risk of readmission is also associated with high levels of usual physical activity, suggesting the beneficial effect of pulmonary rehabilitation in preventing readmission Citation(21). Adherence rates for 9 of our 21 process indicators are available, and results are in line with ours (Citation6,Citation22–26).
Focusing on all the 21 process indicators at once can be burdensome and complex. The suggested importance-performance analyses can help hospitals to select three to five care interventions, which they could focus on Citation(27). These interventions are preferably interventions with high level of importance and low level of performance. Based on the importance-performance analysis, five priority interventions can be identified. Smoking cessation is internationally seen as the most effective intervention in the reduction of progression, morbidity and mortality associated with COPD, and it should be considered as the most important intervention. Smoking cessation should thus be the first priority for all COPD patients who smoke (Citation1,Citation28). In our study, smoking cessation had the lowest performance rate of all 21 indicators, with a performance rate of only 2.6%.This is the lowest performance rate found in the literature (Citation23,Citation29,Citation30). Education regarding home oxygen therapy in patients in which home oxygen is prescribed and education regarding inhaler therapy in patients in which inhaler therapy is prescribed are high level of importance indicators but had a performance of, respectively, 3.8% and 10.6%. These two interventions should be priorities as inappropriate use of oxygen therapy and poor inhaler technique are associated as risk factors for readmission, and the correct use of inhalation medication decreases the rate of exacerbations and healthcare costs (Citation20,Citation28). The fourth priority should be performance of revalidation tests during the past year. Exercise testing is a useful indicator of health status impairment and predictor of prognosis Citation(1). Pulmonary rehabilitation has an impact on not only improved exercise capacity but also patient outcomes, e.g., decreased hospitalisation, decreased length of stay and improved quality of life Citation(28). In our study, the performance rate for referral to pulmonary rehabilitation after a COPD exacerbation was 28.8% and is in line with previous research (Citation23,Citation25,Citation30). The updated NICE guidelines recommend that patients admitted with a COPD exacerbation should start with pulmonary rehabilitation within four weeks Citation(31). The last priority should be adequate discharge management as only 11.1% of the patients received this. Early supported discharge can lead to reduced mortality and readmission rates Citation(32). Corticosteroids should be prioritised based on our importance-performance analysis, but the timespan for administrating corticosteroids has changed Citation(33), and due to inadequate information, it is not possible to calculate the adherence to the new evidence. Therefore, no recommendations can be made for focusing on this indicator. Previous studies also showed that corticosteroids adherence is high (82.3–96.2%) (Citation6,Citation22,Citation26).
A first limitation of this study is that generalisation of the findings is limited because a convenience sample was used. Second, patients included in this study were hospitalised for at least 48 hours, which implies that less severe patients were possibly excluded. Third, patients were admitted to a ward where COPD exacerbations were usually treated. Our findings could thus lead to an overestimation of the adherence to guidelines for patients with a COPD exacerbation as these wards have more experience in treating patients with a COPD exacerbation. On the other hand, our results may be an underestimation of the adherence to guidelines as the information regarding the adherence to guidelines was collected based on data available in the patient record analysis. When something was not mentioned in the record, this was seen as not performed. The idea behind this is that several healthcare providers are assigned to patients, and when an action is not mentioned in the record, the other healthcare providers are not aware of this, which can lead to duplication of actions. To have a detailed measure of how guidelines are adhered to, there is a need for accurate recording of the care process Citation(34).
This is the second European COPD audit evaluating clinical practice. The first European COPD audit was performed by ERS and showed variation between hospitals and across countries for the 10 recommended care interventions. These 10 recommended care interventions are a selection of the interventions patients should receive when they are admitted with a COPD exacerbation Citation(6). Next to the evaluation of the complete in-hospital management for these patients, the main novelty of this study is the evaluation of an importance-performance analysis as an approach for prioritising interventions to improve the quality of care.
As COPD is the fourth leading cause of death, with 149 000 deaths in the United States in 2013 Citation(35), actions should be taken to improve care. Non-adherence to guidelines can be explained by managerial issues, e.g., communication gap between management and prescribers, lack of persuasion from the administration, and scientific issues, e.g., faulty guideline development process, guideline is not-up-to-date, guideline is not relevant or disagreement with the guideline, guideline is too complicated to follow-up and difference in clinical scenario than mentioned in guidelines (Citation36,Citation37). Actions to improve care should thus contain clinical information and management information. Care pathways can be used as a framework as they are based on evidence, and in the development of care pathways, various healthcare providers should be involved Citation(38). The suggested importance-performance analysis can be used for the development of a care pathway, focusing on the above described five priorities. If the involved healthcare providers believe that patients should have more control over their own health, they will make changes for making more information available to the patients and better educate them Citation(39). In the improvement process, beliefs, values and experiences of the healthcare providers are important Citation(39).
Conclusions
This study indicates that in-hospital COPD exacerbations are largely undertreated. Importance-performance analysis provides a decision-making tool for prioritizing indicators. All hospitals in this study would benefit from having in place a quality framework for systematic follow-up of these indicators.
Acknowledgments
We thank all professionals in the participating Belgian, Italian and Portuguese hospitals who were involved in the data collection. We thank the local coordinators for the coordination of the study in their country.
Declaration of Interest Statement
Financial support: we acknowledge Pfizer SA who supported this research by providing an unrestricted educational grant. We also acknowledge the support of the Clinical Research Fund of University Hospitals Leuven, Belgium. The funders had no role in the design, data collection, analysis, interpretation of data, writing of the report, or decision to submit the report for publication.
MD has been part of Advisory Board for AstraZeneca, Boehringer-Pfizer, GSK, Nycomed, Novartis, Altana and Dompé. He has performed consulting work for Boehringer-Pfizer, GSK, and Novartis. He also received lecture fees from these companies. All of the above amounted to less than 10.000 euro per annum. He received a research grant of 45,000 euro/year from AstraZeneca and 25, 000 euro/year from GSK. KV, WS and MP are board members of European Pathway Association.
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