ABSTRACT
Introduction: It remains unclear whether long-term non-invasive ventilation (LT-NIV) for patients with chronic obstructive pulmonary disease (COPD) improves survival and reduces admissions as results from randomized trials are inconsistent. We aim to determine whether LT-NIV initiated after an admission with acute hypercapnic respiratory failure (AHRF) can affect survival and admission rate in COPD patients. Methods: A randomized controlled open-label trial, allocating patients with COPD to LT-NIV or standard of care immediately after an admission with AHRF treated with acute NIV. LT-NIV was aimed to normalize PaCO2 using high-pressure NIV. Results: The study was discontinued before full sample size due to slow recruitment. 28 patients were randomized to LT-NIV and 27 patients to standard of care. 42% of patients had a history of ≥ 2 admissions with AHRF. Median IPAP was 24 cmH2O (IQR 20-28). The primary outcome, time to readmission with AHRF or death within 12 months, did not reach significance, hazard ratio 0.53 (95% CI 0.25-1.12) p = 0.097. In a competing risk analysis, adjusted for history of AHRF, the odds ratio for AHRF within 12 months was 0.30 (95% CI 0.11-0.87) p = 0.024. The LT-NIV group had less exacerbations (median 1 (0-1) vs 2 (1-4) p = 0.021) and readmissions with AHRF (median 0 (0-1) vs 1 (0-1) p = 0.016). Conclusion: The risk of the primary outcome, time to readmission with AHRF or death within 12 months was numerically smaller in the LT-NIV group, however, did not reach significance. Nevertheless, several secondary outcome analyses like risk of AHRF, number of episodes of AHRF and exacerbations were all significantly reduced in favour of high-pressure LT-NIV, especially in patients with frequent AHRF.
ABSTRACT
OBJECTIVE: To examine whether the quality of care among Danish patients with chronic obstructive pulmonary disease (COPD) has improved since the initiation of a national multidisciplinary quality improvement program. METHODS: We conducted a nationwide, population-based prospective cohort study using data from the Danish Clinical Register of COPD. Since 2008, the register has systematically monitored and audited the use of recommended processes of COPD care. RESULTS: Substantial improvements were observed for all processes of care and registration fulfillment increased to well above 85% for all indicators. Compared with 2008, a higher proportion of COPD outpatients in 2011 received annual measurements of the forced expiratory volume in 1 s in percent of predicted [relative risk (RR) 2.14, 95% confidence interval (CI), 2.09; 2.19], assessment of body mass index (RR 2.24, 95% CI, 2.19; 2.29), assessment of dyspnea using the Medical Research Council scale (RR 2.25, 95% CI, 2.20; 2.31), registration of smoking status (RR 2.41, 95% CI, 2.35; 2.47), smoking cessation recommendation (RR 3.40, 95% CI, 3.18; 3.64) and offering of pulmonary rehabilitation (RR 2.78, 95% CI, 2.65; 2.90). Moderate variation in quality of care fulfillment between regions and hospital clinics still existed in 2011. The proportion of patients with mild to moderate COPD increased during the study period (P < 0.0001). CONCLUSION: Based on increased registration practice of important processes of care, the present study indicates a substantial improvement in the quality of care of COPD in Danish hospitals following the initiation of a national multidisciplinary quality improvement program in 2008. In the forthcoming years, it will be interesting to observe if this will translate into a better prognosis for Danish patients with COPD.
