Management of acute exacerbation of chronic obstructive pulmonary disease under a tiered medical system in China

Abstract

Background: The Chinese government has promoted the ‘tiered medical services’ policy in which diseases are classified by severity, mode of onset and difficulty of treatment since 2015 to optimize medical resources. We evaluated the diagnosis and treatment of acute exacerbation (AE) of chronic obstructive pulmonary disease (AECOPD) under the tiered system. Methods: We conducted a cross-sectional study. COPD characteristics and treatments were compared among hospitals in different tiers. Associations were examined by univariate and multivariable logistic regression analysis. In addition, multivariate logistic regression was performed to identify the possible influencing factors of antibiotics, glucocorticoids and anticoagulant usages. Results: Eligible COPD patients ( n = 432) were consecutively recruited from eight hospitals in different tiers in China. Patients in the countryside preferred the community hospitals, whereas patients in cities preferred second-tier and teaching hospitals when they suffer from AECOPD. It indicates most COPD patients are likely to treat their disease locally. The severity of COPD AE increased with tiers of hospitals ( p < 0.001). However, our results clearly show that most community hospitals can only deal with mild exacerbation of COPD. Approximately 90% of AE patients received antibiotics. We speculated that antibiotics abuse might exist in the three tiers of hospitals. Multivariate analysis demonstrated that long-term antibiotics usage (⩾14 days) was associated with moderate exacerbation [odds ratio (OR): 5.295, 95% confidence intervals (CI) 2.248–12.473, p < 0.001], radiographic progression (OR: 2.176, 95% CI: 1.047–4.522, p = 0.037), positive sputum etiology (OR: 3.073, 95% CI: 1.477–6.394, p = 0.003) and increased white blood cells (OR: 2.470, 95% CI: 1.190–5.126, p = 0.015). The proportion of glucocorticoids increased with the hospital hierarchy (18.6% versus 45.6% versus 69.2%, p < 0.001). The proportions of severe cases in the second-tier hospitals were 26.9%; however, non-invasive positive pressure ventilation (NPPV) rate was only 14.7%. Anticoagulant is not commonly used in AECOPD, and the community hospitals had the lowest proportion of anticoagulation regimen (1.7% versus 14.3% versus 20.5%, p = 0.002). Conclusions: The ‘tiered medical services’ policy in AECOPD management has been unsatisfactory in the past years. Irrational treatment strategies in different hospitals were still found when comparing with international guideline. Further reform of the policy is still needed to optimize the management of AECOPD in China.

Clinical evaluation of ventilation mode on acute exacerbation of chronic obstructive pulmonary disease with respiratory failure

“…Both VCV and PCV were able to effectively manage patients with AECOPD and respiratory failure, as demonstrated by improvements in the respiratory rate, tidal volume, arterial blood gas values (including pH, PaO 2 , and PaCO 2 ), and oxygenation indices (PaO 2 /FiO 2 ratio) during their ICU stay. This observation was consistent with a previous studies, thus suggesting that both ventilation modes can be used successfully to treat patients with AECOPD suffering from the respiratory failure[ 23 , 24 ].…”

Nebulized corticosteroids versus systemic corticosteroids for patients with acute exacerbation of chronic obstructive pulmonary disease: A systematic review and meta-analysis comparing the benefits and harms reported by observational studies and randomized controlled trials

“…Corticosteroids account for a large proportion of AECOPD treatments. In a study from China, in a medication analysis of 432 eligible AECOPD patients, the proportion of glucocorticoids applied increased with hospital grade (18.6% vs. 45.6% vs. 69.2%; p < 0.001) ( Liu et al, 2022 ). A cross-sectional study by the Veterans Health Administration in 2020 found that 23.9% of 26,536 patients with COPD without a history of severe or frequent exacerbations and without airflow disorders were treated with inhaled corticosteroids ( Griffith et al, 2020 ).…”

Treatment patterns in patients with stable COPD in China: analysis of a prospective, 52-week, nationwide, observational cohort study (REAL)

“…In this study, we showed that the majority of tertiary hospitals were located in urban versus rural areas (64.7% versus 35.3%), and others have shown that patients prefer to access a local hospital when they have an acute exacerbation. 28 In the REAL study, there were more patients with severe disease in secondary versus tertiary hospitals, and together with our data on treatment patterns, this indicates that many patients may not have received adequate treatment. Vogelmeier et al 12 reported that just over half the patients with one moderate baseline exacerbation and over one-third (36.9%) of patients with one severe baseline or multiple baseline exacerbations were not prescribed inhaled maintenance treatment at diagnosis, underscoring the importance of timely and appropriate prescription of pharmacological treatment in patients with stable COPD.…”

“…Finally, Chinese patients may prefer to combine TCM with pharmacological treatment, as shown in a recent survey on treatment preference among patients with COPD in China, 44 and this could be due to TCM being more affordable, especially to patients living in rural areas. 28 …”