Factors Associated with Hospital Admission among Emergency Department Patients with Chronic Obstructive Pulmonary Disease Exacerbation

Abstract

Objectives: To determine the patient factors associated with hospital admission among adults who present to the emergency department (ED) with acute exacerbations of chronic obstructive pulmonary disease (COPD) and to determine whether admissions were concordant with recommendations in the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines. Methods:The authors performed a prospective multicenter cohort study involving 29 EDs in the United States and Canada. By using a standard protocol, consecutive ED patients with COPD exacerbation were interviewed, and their charts were reviewed. Predictors of admission were determined by multivariate logistic regression.Results: Of 384 patients, 233 (61%; 95% confidence interval = 56% to 66%) were admitted. Multivariate analysis showed that a higher likelihood of admission was associated with older age, female gender, more pack-years of smoking, recent use of inhaled corticosteroid, self-reported activity limitation in the past 24 hours, higher respiratory rate at ED presentation, and a concomitant diagnosis of pneumonia. Patients who reported the ED as their usual site for problem COPD care, or who had mixed COPD and asthma, were less likely to be admitted. The authors confirmed five of the seven testable indications for hospital admission in the GOLD guidelines.Conclusions: Several patient factors were independently associated with hospital admission among ED patients with COPD exacerbations. Overall, concordance with admission recommendations in the GOLD guidelines was high. The authors also identified a few novel predictors of admission (female gender, ED as the usual site for problem COPD care, mixed diagnosis of COPD and asthma, recent use of inhaled corticosteroid) that require replication in future studies. ACADEMIC EMERGENCY MEDICINE 2007; 14:6-15 ª 2007 by the Society for Academic Emergency MedicineKeywords: chronic obstructive pulmonary disease, exacerbation, admission, emergency department C hronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality worldwide. COPD is the third most common cause of hospitalization in the United States, with an estimated 726,000 hospitalizations in 2000. 1 Chronic obstructive pulmonary disease exacerbation also accounts for approximately 1.5 million emergency department (ED) visits per year. 1 Despite the tremendous burden of hospital admissions and ED visits caused by COPD exacerbations, little is known regarding factors associated with hospital admission from the ED. Previous studies focused on risk factors for admission in stable COPD patients, 2,3 external factors (e.g., air pollution) and admission, 4 or prognostic factors for in-hospital mortality. [5][6][7] However, these studies did not address the decision making for admission among patients presenting to the ED

Predictive Model of Hospital Admission for COPD Exacerbation

“…Some authors from the United States, such as Rowe et al 27 and Tsai et al, 28 reported higher admission rates (49.3 and 62%, respectively) than we did. The differences observed are most likely attributable to our cohort originating from primary care, where the average severity of the disease is lower.…”

Population-Based Burden of COPD-Related Visits in the ED

“…This percentage is twice as large as the overall hospitalization percentage for all ED visits made by patients aged Ն 45 years in the NC DETECT data (25.8%). Regarding subsequent hospital admissions, older age was associated with increased likelihood of hospital admission, 17 although in our study, the increased risk plateaued at ages 65 to 79 years. Again, similar to Watson et al, 16 we did not fi nd sex differences in subsequent hospital admission.…”

Effectiveness and safety of a prehospital program of continuous positive airway pressure (CPAP) in an urban setting

“…Studies of this technology in the hospital setting have provided robust support for the routine use of NIV in patients with cardiogenic pulmonary edema and respiratory failure due to AECOPD. 5,12 NIV has been shown to decrease rates of intubation, improve physiologic parameters, and even decrease mortality in hospital. 6 Barriers to the widespread adoption of this treatment modality in the prehospital setting were largely due to the size, weight, and cost of older models; however, recent technological advances have led to increasing use.…”