Development and evaluation of a tool to optimise inhaler selection prior to hospital discharge following an exacerbation of COPD

Abstract

INTRODUCTIONMortality and re-admissions after a hospitalised exacerbation of chronic obstructive pulmonary disease (COPD) are high and resistant to change. COPD guidelines do not give practical advice about the optimal selection of inhaled drugs and device in this situation. We hypothesised that a failure to optimise inhaled drug and drug delivery prior to discharge from hospital after an exacerbation would be associated with a modifiable increased risk of re-admission and death. We designed a study to (i) develop a practical inhaler selection tool to use at the point of hospital discharge and (ii) implement this tool to understand the potential impact on modifying inhaler prescriptions, clinical outcomes, acceptability to clinicians and patients, and the feasibility of delivering a definitive trial to demonstrate potential benefit.METHODSWe iteratively developed an inhaler selection tool for use prior to discharge following a hospitalised exacerbation of COPD using surveys with multi-professional clinicians and a focus group of people living with COPD. We surveyed clinicians to understand their views on the minimum clinically important difference (MCID) for death and re-admission following a hospitalised exacerbation of COPD. We conducted a mixed methods implementation feasibility study using the tool at discharge, and collated 30- and 90-day follow-up data including death and re-admissions. Additional we observed the tool being used and interviewed clinicians and patients about use of the tool in this setting.RESULTSWe completed the design of an inhaler selection tool through two rounds of consultations with 94 multi-professional clinicians, and a focus group of four expert patients. Regarding MCIDs, there was majority consensus for the following reductions from baseline being the MCID: 30-day readmissions 5–10%, 90-day readmissions 10–20%, 30-day mortality 5–10% and 90-day mortality 5–10%. 118 patients were assessed for eligibility and 26 had the tool applied. A change in inhaled medication was recommended in 9/26 (35%). Re-admission or death at 30 days was seen in 33% of the switch group and 35% of the no-switch group. Re-admission or death at 90 days was seen in 56% of the switch group and 41% of the no-switch group. Satisfaction with inhalers was generally high, and switching was associated with a small increase in the Feeling of Satisfaction with Inhaler questionnaire (FSI) questionnaire of 3/50 points. Delivery of a definitive study would be challenging.CONCLUSIONWe completed a mixed-methods study to design and implement a tool to aid optimisation of inhaled pharmacotherapy prior to discharge following a hospitalised exacerbation of COPD. This was not associated with fewer re-admissions, but was well received and one third of people were eligible for a change in inhalers.