We read with interest the recent study by Morton et al. A “National COPD Collaborative” quality improvement (QI) initiative (The Collaborative) which is currently on-going in Ireland is also evaluating the efficacy of bundles, amongst other interventions, in improving COPD care. Running from September 2018 to December 2019, the Collaborative comprises 18 consultant-led teams in 19 hospitals across the country working to improve care for patients presenting with an acute exacerbation of COPD (AECOPD). The Collaborative is being run by the Royal College of Physicians of Ireland (RCPI) in conjunction with the Clinical Strategy and Programmes Division of the Irish Health Service Executive (HSE) and the National Clinical Programme for COPD within the HSE.
COPD is a major health burden in Ireland, as in the UK; based on the 2011 census (total population 4,588,252 [1]), it is estimated that at least 440,000 people in Ireland have COPD (of whom over 180,000 have moderate or severe disease) [2]. In 2015, Ireland had the highest rate of COPD hospital admissions out of all OECD countries [3]. The cost burden of COPD on the HSE is substantial; in 2014, the total cost of COPD hospitalisations was €70,813,040.00 [4]. According to the OECD, the average length of hospital stay (LOS) for COPD in Ireland in 2017 was eight days[5].
Prior to the initiation of the National COPD Collaborative, treatment of AECOPD within the acute Irish healthcare setting was highly varied; many a...
We read with interest the recent study by Morton et al. A “National COPD Collaborative” quality improvement (QI) initiative (The Collaborative) which is currently on-going in Ireland is also evaluating the efficacy of bundles, amongst other interventions, in improving COPD care. Running from September 2018 to December 2019, the Collaborative comprises 18 consultant-led teams in 19 hospitals across the country working to improve care for patients presenting with an acute exacerbation of COPD (AECOPD). The Collaborative is being run by the Royal College of Physicians of Ireland (RCPI) in conjunction with the Clinical Strategy and Programmes Division of the Irish Health Service Executive (HSE) and the National Clinical Programme for COPD within the HSE.
COPD is a major health burden in Ireland, as in the UK; based on the 2011 census (total population 4,588,252 [1]), it is estimated that at least 440,000 people in Ireland have COPD (of whom over 180,000 have moderate or severe disease) [2]. In 2015, Ireland had the highest rate of COPD hospital admissions out of all OECD countries [3]. The cost burden of COPD on the HSE is substantial; in 2014, the total cost of COPD hospitalisations was €70,813,040.00 [4]. According to the OECD, the average length of hospital stay (LOS) for COPD in Ireland in 2017 was eight days[5].
Prior to the initiation of the National COPD Collaborative, treatment of AECOPD within the acute Irish healthcare setting was highly varied; many aspects of the COPD hospital care pathway, including the diagnosis of COPD at presentation, LOS, treatment approaches and availability of respiratory consultant-led team(s) dedicated to in-patient care of AECOPD (as opposed to out-patient care), were not standardised between hospital sites. As Morton et al imply, improving care for patients with AECOPD relies on appropriately expert clinicians reliably following evidence based practice. Therefore, the National COPD Collaborative is attempting to improve and standardise the treatment of COPD/AECOPD patients across participating hospitals, at the following stages:
1) Presentation (e.g. time from registration to first medical review; time from registration to decision to admit)
2) Admission (e.g. time from registration to first respiratory specialist review; LOS; DECAF assessment [6], documented COPD diagnosis – spirometry; chest x-ray; steroids and route [PO/IV], antibiotics and route [PO/IV])
3) Discharge (e.g. inhaler technique; script review with patient; written self-management plan; follow-up)
In order to effect improvements in the care of AECOPD across participating hospital sites, the Institute for Healthcare Improvement “Breakthrough Series Collaborative” is being used to build QI capability amongst teams. Individual teams employ the “Model for Improvement” [7] , which utilises Plan, Do, Study, Act (PDSA) cycles, to bring about change. One of the primary aims of the National COPD Collaborative is to facilitate participating acute respiratory teams in the development their QI skills which will, therefore, allow them to apply QI methods to bring about treatment improvements at a local level.
Evaluation of the Collaborative focuses on assessment of monthly patient data which is submitted by each hospital for 22 measures related to the care of AECOPD at presentation, admission and discharge (the “bundles”); these will be analysed over time using run charts for QI purposes.
The hospital phase of the National COPD Collaborative will be completed by September 2019. Morton et al note that “Staff viewed bundles positively, believing they help standardise practice and facilitate communication between clinicians. However, they lacked skills in change management, leading to inconsistent implementation”. We speculate that should any improvement in patient care be demonstrated at the end of the National COPD Collaborative, this change may be due, at least in part, to the enthusiastic engagement of sites with QI methodology which allows them to adapt QI processes to the needs of their own hospital, while standardising care for patients with AECOPD nationally.
References
1. CSO. Census through History. 2019 30 July 2019]; Available from: https://www.cso.ie/en/census/censusthroughhistory/.
2. Jennings, S., Preventing chronic disease: defining the problem. 2014, Health Service Executive
3. NPSO, National Healthcare Qualtiy Reporting System Annual Report 2018, N.P.S. Office, Editor. 2018, Department of Health.
4. COPDSI, Manifesto for COPD, C.S. Ireland, Editor. 2015.
5. OECD. Hospital average length of stay by diagnostic categories: Chronic Obstructive Pulmonary Disease and bronchiectasis. 2017 30 July 2019]; Available from: https://stats.oecd.org/index.aspx?queryid=30165#.
6. Steer, J., J. Gibson, and S.C. Bourke, The DECAF Score: predicting hospital mortality in exacerbations of chronic obstructive pulmonary disease. Thorax, 2012. 67(11): p. 970-6.
7. Langley, G., et al., The Improvement Guide: A practical Approach to Enhancing Organizational Performance. 2nd ed. 2009, San Francisco: Jossey-Bass Publishers.
It was interesting to review the findings of the study by Barker and colleagues [1] regarding airway clearance techniques (ACTs) for patients with chronic obstructive pulmonary disease (COPD). The authors suggest there may be a relative ‘under-prescription’ of simple adjunctive therapy options such as oscillatory positive expiratory pressure (OPEP) devices for the care of this patient group and reflect on the ability for ‘actual use’ registry data to inform research questions in this area. The data certainly show OPEP devices to be used less frequently and at significantly lower costs than prescription medications such as Tiotropium and Carbocisteine. This is not surprising, and is a likely accurate reflection of clinical practice.
Identification of the most important clinical question(s) to arise from this data, however, appears quite challenging owing to significant limitations that may have been under-emphasised. The true incidence of OPEP device use amongst patients with COPD will certainly have been underestimated in the data obtained from the OpenPrescribing.net resource due to the ‘hidden’ market related to private or hospital-based device purchases. While this is acknowledged by the authorship team, we feel this may be more significant than that proposed. Our experience as clinical physiotherapists working in this area suggests a large proportion (if not the majority) of airway clearance therapy is the remit of physiotherapists working in cardiorespiratory...
It was interesting to review the findings of the study by Barker and colleagues [1] regarding airway clearance techniques (ACTs) for patients with chronic obstructive pulmonary disease (COPD). The authors suggest there may be a relative ‘under-prescription’ of simple adjunctive therapy options such as oscillatory positive expiratory pressure (OPEP) devices for the care of this patient group and reflect on the ability for ‘actual use’ registry data to inform research questions in this area. The data certainly show OPEP devices to be used less frequently and at significantly lower costs than prescription medications such as Tiotropium and Carbocisteine. This is not surprising, and is a likely accurate reflection of clinical practice.
Identification of the most important clinical question(s) to arise from this data, however, appears quite challenging owing to significant limitations that may have been under-emphasised. The true incidence of OPEP device use amongst patients with COPD will certainly have been underestimated in the data obtained from the OpenPrescribing.net resource due to the ‘hidden’ market related to private or hospital-based device purchases. While this is acknowledged by the authorship team, we feel this may be more significant than that proposed. Our experience as clinical physiotherapists working in this area suggests a large proportion (if not the majority) of airway clearance therapy is the remit of physiotherapists working in cardiorespiratory medicine based primarily in (or outreached from) hospitals. This appears supported by the authors’ survey data responses, of which 72% of the 116 respondents stated they worked in hospitals. In these settings, ACTs are rarely formally ‘prescribed’ in medical registries, but rather implemented using existing resources, purchased privately or loaned / provided from the centre (as indicated in the survey instrument). Cost is a realistic barrier to OPEP device use, often resulting in education to substitute device use at home for cheaper, alternative means such as bottle-PEP (which could be performed at no cost). This would not appear on a prescription registry.
OPEP devices may also be considered clinically indicated for certain patients, but this does not necessarily mean they are prescribed. Previous data from physiotherapists across the world demonstrates considerable variability regarding ACT prescription for this patient group, particularly during acute exacerbations. The most commonly used ACTs include the active cycle of breathing technique and deep breathing exercises in the United Kingdom, Australia, New Zealand [2-4], ‘conventional chest physiotherapy’ techniques (e.g. postural drainage, percussion, vibration) in Canada [5] and even physical exercise in Australia [4], despite scarce research examining this precise effect [6]. PEP device use did not feature prominently in any of these surveys, however its use is known to be widespread in countries such as Sweden.
It is also unclear whether survey data (e.g. Table 2, Figure 1) represents opinion or actual practice patterns. Questions regarding ‘considerations’ or ‘recommendations’ may be quite different to treatment that a patient actually receives, particularly if the recommending therapist is different to the professional responsible for treatment ‘delivery’. And the survey responses, which represent only 12% of ACPRC members (and should therefore not be referred to as ‘clinical consensus’), may differ considerably from other members and/or the health professions represented in the prescription data. It would, of course, be interesting to know the extent of overlap between the two samples, however this is not likely to be possible. This uncertainty makes it challenging to comprehend the precise area in need of further research, particularly as it is possible the findings simply reflect differing views of two distinct health professions groups. For example, it is plausible the survey may primarily reflect opinions of physiotherapists but prescribing data that of general practitioners. If so, there remains a need to source more accurate information about OPEP prescription practices, potentially via closer examination of data originating from the therapists responsible for its implementation.
Finally, as stated by the authors, we currently have very little clinical data upon which to base decisions regarding long-term ACTs for patients with COPD and chronic sputum production [7]. Further research is indeed required, but it is crucial that good judgment underpins decisions regarding the most relevant clinical question(s) to investigate. Identifying patients with stable COPD and chronic sputum production (in the absence of co-existing bronchiectasis, which reportedly occurs in up to 50% of COPD cases [8]) is not without challenge, with one previous physiological investigation of PEP therapy for this patient group observing a 43% exclusion rate of those screened due to a lack of regular sputum production [9].
We feel some of the potential areas for future, clinically impactful research arising from this work may include identification of:
i) The reasons underpinning the high use of mucolytic therapy in this patient group despite a lack of consensus recommendations in international COPD guidelines [10-12];
ii) Patient acceptability regarding performance of long-term ACTs; and
iii) Distinct clinical phenotypes who may benefit most from future, high quality clinical trials of ACTs.
In conclusion, we congratulate Barker and colleagues for raising awareness of some of the challenging issues clinicians encounter when trying to deliver evidence-based care for patients with COPD and chronic sputum production. We encourage the issues to be further examined but implore a degree of caution when using inherently limited data as the foundation for future, clinically relevant research seeking to improve patient care.
1. Barker R, Laverty AA, Hopkinson NS. Adjuncts for sputum clearance in COPD: clinical consensus versus actual use. BMJ Open Respiratory Research 2017;4(1) doi: 10.1136/bmjresp-2017-000226.
2. Lee A, Button B, Denehy L. Current Australian and New Zealand physiotherapy practice in the management of patients with bronchiectasis and chronic obstructive pulmonary disease. New Zealand Journal of Physiotherapy 2008;36(2):49-58
3. Yohannes AM, Connolly MJ. A national survey: percussion, vibration, shaking and active cycle breathing techniques used in patients with acute exacerbations of chronic obstructive pulmonary disease. Physiotherapy 2007;93(2):110-13
4. Osadnik CR, McDonald CF, Holland AE. Airway clearance techniques in acute exacerbations of COPD: a survey of Australian physiotherapy practice. Physiotherapy 2013;99(2):101-6 doi: 10.1016/j.physio.2012.01.002.
5. Harth L, Stuart J, Montgomery C, et al. Physical therapy practice patterns in acute exacerbations of chronic obstructive pulmonary disease. Can Respir J 2009;16(3):86-92
6. Oldenburg FA, Jr., Dolovich MB, Montgomery JM, Newhouse MT. Effects of postural drainage, exercise, and cough on mucus clearance in chronic bronchitis. Am Rev Respir Dis 1979;120(4):739-45
7. Osadnik CR, McDonald CF, Jones AP, Holland AE. Airway clearance techniques for chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2012(3):CD008328 doi: 10.1002/14651858.CD008328.pub2.
8. Patel IS, Vlahos I, Wilkinson TM, et al. Bronchiectasis, exacerbation indices, and inflammation in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2004;170(4):400-7 doi: 10.1164/rccm.200305-648OC200305-648OC.
9. Osadnik C, Stuart-Andrews C, Ellis S, Thompson B, McDonald CF, Holland AE. Positive expiratory pressure via mask does not improve ventilation inhomogeneity more than huffing and coughing in individuals with stable chronic obstructive pulmonary disease and chronic sputum expectoration. Respiration 2014;87(1):38-44 doi: 10.1159/000348546.
10. National Clinical Guideline Centre. Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care. 2010. http://guidance.nice.org.uk/CG101/Guidance/pdf/English (accessed 15/08/2017).
11. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management and Prevention of COPD (2017 report). 2017. http://www.goldcopd.org/.
12. Yang IA, Dabscheck E, George J, et al. The COPD-X Plan: Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary Disease 2017. Version 2.50, June 2017. 2017. http://www.copdx.org.au/.
We thank the authors for their interest in our paper (1) which was designed, among other things, to be a statement of intent regarding the need to improve the evidence base concerning the use of adjunct devices for sputum clearance in patients with COPD.
The authors reiterate some limitations of the data that we had outlined in our paper. In particular we are not able, using prescribing data, to capture other pathways through which patients may have obtained devices, including purchasing them from pharmacies. Direct patient surveys would address this as might company or pharmacy data on sales, if available. We did however present data on actual use of devices, reported by survey respondents, who were mostly in hospital practice, in the preceding year (Table 3). This confirms that use of devices for COPD patients was at an extremely low level and does not support the idea that a large amount of in hospital prescribing, not captured by prescription data, has been missed. We agree that some of the huge disparity with the use of mucolytic agents may reflect overuse of those medications. Nevertheless, the central point, that current extremely limited use of these devices in COPD patients seems at odds with the likely prevalence of patient phenotypes which are believed to benefit, stands.
At present, this subject is largely ignored in clinical guidelines (2,3). Attention will be needed to address the limited evidence base and so feed into clinical guidelines and cli...
We thank the authors for their interest in our paper (1) which was designed, among other things, to be a statement of intent regarding the need to improve the evidence base concerning the use of adjunct devices for sputum clearance in patients with COPD.
The authors reiterate some limitations of the data that we had outlined in our paper. In particular we are not able, using prescribing data, to capture other pathways through which patients may have obtained devices, including purchasing them from pharmacies. Direct patient surveys would address this as might company or pharmacy data on sales, if available. We did however present data on actual use of devices, reported by survey respondents, who were mostly in hospital practice, in the preceding year (Table 3). This confirms that use of devices for COPD patients was at an extremely low level and does not support the idea that a large amount of in hospital prescribing, not captured by prescription data, has been missed. We agree that some of the huge disparity with the use of mucolytic agents may reflect overuse of those medications. Nevertheless, the central point, that current extremely limited use of these devices in COPD patients seems at odds with the likely prevalence of patient phenotypes which are believed to benefit, stands.
At present, this subject is largely ignored in clinical guidelines (2,3). Attention will be needed to address the limited evidence base and so feed into clinical guidelines and clinical practice.
1. Barker R, Laverty AA, Hopkinson NS. Adjuncts for sputum clearance in COPD: clinical consensus versus actual use. BMJ Open Respiratory Research 2017;4(1) doi: 10.1136/bmjresp-2017-000226
3. Qaseem A, Wilt TJ, Weinberger SE, et al. Diagnosis and Management of Stable Chronic Obstructive Pulmonary Disease: A Clinical Practice Guideline Update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Annals of Internal Medicine 2011;155(3):179-91. doi: 10.1059/0003-4819-155-3-201108020-00008
The excellent review by Slater et al comprehensively covers options
for add on therapy to inhaled steroid at step 4 in patients with
suboptimal asthma control .However no mention was made of the possible
role for inhaled cromoglicate . This is a drug which appears to fallen out
of favour and hardly gets a mention in guidelines . This is perhaps
surprising given its excellent therapeutic index especially in children1 .
We...
The excellent review by Slater et al comprehensively covers options
for add on therapy to inhaled steroid at step 4 in patients with
suboptimal asthma control .However no mention was made of the possible
role for inhaled cromoglicate . This is a drug which appears to fallen out
of favour and hardly gets a mention in guidelines . This is perhaps
surprising given its excellent therapeutic index especially in children1 .
We believe that inhaled cromoglicate should be considered in atopic
patients who despite treatment with inhaled corticosteroid/long acting
beta-agonist (ICS/LABA) have breakthrough symptoms, where it might be
expected to confer additional bronchoprotection against triggers such as
allergen or exercise. In this regard it has been shown that regular
exposure to LABA results in tolerance to its bronchoprotective effects
even in the presence of concomitant ICS2-4 . While the CAMP study
effectively put the final nail in the coffin for inhaled cromones as
monotherapy instead of ICS for use in children 5, we are of the opinion
that further clinical trials are indicated to look at putative
bronchoprotection conferred by cromoglicate when used as add on to
ICS/LABA .Such studies might also look at ICS sparing effects or even the
possibility of being able to stop LABA treatment 6 .
1. van der Wouden JC, Uijen JH, Bernsen RM, Tasche MJ, de Jongste JC,
Ducharme F. Inhaled sodium cromoglycate for asthma in children. Cochrane
Database Syst Rev 2008; (4): CD002173.
2. Wilson AM, Dempsey OJ, Sims EJ, Lipworth BJ. A comparison of salmeterol
and montelukast as second-line therapy in asthmatic patients not
controlled on inhaled corticosteroids. Thorax 1999; 54(SUPPL. 3).
3. Lipworth B, Tan S, Devlin M, Aiken T, Baker R, Hendrick D. Effects of
treatment with formoterol on bronchoprotection against methacholine.
American Journal of Medicine 1998; 104(5): 431-8.
4. Aziz I, Tan KS, Hall IP, Devlin MM, Lipworth BJ. Subsensitivity to
bronchoprotection against adenosine monophosphate challenge following
regular once-daily formoterol. European Respiratory Journal 1998; 12(3):
580-4.
5. Long-term effects of budesonide or nedocromil in children with asthma.
The Childhood Asthma Management Program Research Group. N Engl J Med 2000;
343(15): 1054-63.
6. Jabbal S, Manoharan A, Anderson W, Lipworth J, Lipworth B. Real-life
effect of long-acting beta2-agonist withdrawal in patients with controlled
step 3 asthma. Ann Allergy Asthma Immunol 2016.
We read with interest the recent study by Morton et al. A “National COPD Collaborative” quality improvement (QI) initiative (The Collaborative) which is currently on-going in Ireland is also evaluating the efficacy of bundles, amongst other interventions, in improving COPD care. Running from September 2018 to December 2019, the Collaborative comprises 18 consultant-led teams in 19 hospitals across the country working to improve care for patients presenting with an acute exacerbation of COPD (AECOPD). The Collaborative is being run by the Royal College of Physicians of Ireland (RCPI) in conjunction with the Clinical Strategy and Programmes Division of the Irish Health Service Executive (HSE) and the National Clinical Programme for COPD within the HSE.
Show MoreCOPD is a major health burden in Ireland, as in the UK; based on the 2011 census (total population 4,588,252 [1]), it is estimated that at least 440,000 people in Ireland have COPD (of whom over 180,000 have moderate or severe disease) [2]. In 2015, Ireland had the highest rate of COPD hospital admissions out of all OECD countries [3]. The cost burden of COPD on the HSE is substantial; in 2014, the total cost of COPD hospitalisations was €70,813,040.00 [4]. According to the OECD, the average length of hospital stay (LOS) for COPD in Ireland in 2017 was eight days[5].
Prior to the initiation of the National COPD Collaborative, treatment of AECOPD within the acute Irish healthcare setting was highly varied; many a...
It was interesting to review the findings of the study by Barker and colleagues [1] regarding airway clearance techniques (ACTs) for patients with chronic obstructive pulmonary disease (COPD). The authors suggest there may be a relative ‘under-prescription’ of simple adjunctive therapy options such as oscillatory positive expiratory pressure (OPEP) devices for the care of this patient group and reflect on the ability for ‘actual use’ registry data to inform research questions in this area. The data certainly show OPEP devices to be used less frequently and at significantly lower costs than prescription medications such as Tiotropium and Carbocisteine. This is not surprising, and is a likely accurate reflection of clinical practice.
Identification of the most important clinical question(s) to arise from this data, however, appears quite challenging owing to significant limitations that may have been under-emphasised. The true incidence of OPEP device use amongst patients with COPD will certainly have been underestimated in the data obtained from the OpenPrescribing.net resource due to the ‘hidden’ market related to private or hospital-based device purchases. While this is acknowledged by the authorship team, we feel this may be more significant than that proposed. Our experience as clinical physiotherapists working in this area suggests a large proportion (if not the majority) of airway clearance therapy is the remit of physiotherapists working in cardiorespiratory...
Show MoreWe thank the authors for their interest in our paper (1) which was designed, among other things, to be a statement of intent regarding the need to improve the evidence base concerning the use of adjunct devices for sputum clearance in patients with COPD.
Show MoreThe authors reiterate some limitations of the data that we had outlined in our paper. In particular we are not able, using prescribing data, to capture other pathways through which patients may have obtained devices, including purchasing them from pharmacies. Direct patient surveys would address this as might company or pharmacy data on sales, if available. We did however present data on actual use of devices, reported by survey respondents, who were mostly in hospital practice, in the preceding year (Table 3). This confirms that use of devices for COPD patients was at an extremely low level and does not support the idea that a large amount of in hospital prescribing, not captured by prescription data, has been missed. We agree that some of the huge disparity with the use of mucolytic agents may reflect overuse of those medications. Nevertheless, the central point, that current extremely limited use of these devices in COPD patients seems at odds with the likely prevalence of patient phenotypes which are believed to benefit, stands.
At present, this subject is largely ignored in clinical guidelines (2,3). Attention will be needed to address the limited evidence base and so feed into clinical guidelines and cli...
The excellent review by Slater et al comprehensively covers options for add on therapy to inhaled steroid at step 4 in patients with suboptimal asthma control .However no mention was made of the possible role for inhaled cromoglicate . This is a drug which appears to fallen out of favour and hardly gets a mention in guidelines . This is perhaps surprising given its excellent therapeutic index especially in children1 . We...