Peter K. Lindenauer, MD, MSc; Penelope Pekow, PhD; Shan Gao, MS; Allison S. Crawford, BA; Benjamin Gutierrez, PhD; Evan M. Benjamin, MD
Acknowledgments: The authors thank Michael Rothberg, MD, MPH, and Dale Bratzler, DO, MPH, for their comments on an earlier version of this manuscript.
Grant Support: None.
Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: Peter K. Lindenauer, MD, MSc, Division of Healthcare Quality, Baystate Medical Center, 759 Chestnut Street, P-5928, Springfield, MA 01199; e-mail, Peter.Lindenauer@bhs.org.
Current Author Addresses: Drs. Lindenauer, Pekow, and Benjamin: Division of Healthcare Quality, Baystate Medical Center, 759 Chestnut Street, P-5928, Springfield, MA 01199.
Ms. Gao and Ms. Crawford: 408 Arnold House, School of Public Health and Health Sciences, University of Massachusetts, 715 North Pleasant Street, Amherst, MA 01003-9304.
Dr. Gutierrez: Premier Healthcare Informatics, 2320 Cascade Pointe Boulevard, Charlotte, NC 28208.
Lindenauer P., Pekow P., Gao S., Crawford A., Gutierrez B., Benjamin E.; Quality of Care for Patients Hospitalized for Acute Exacerbations of Chronic Obstructive Pulmonary Disease. Ann Intern Med. 2006;144:894-903. doi: 10.7326/0003-4819-144-12-200606200-00006
Download citation file:
Published: Ann Intern Med. 2006;144(12):894-903.
Chronic obstructive pulmonary disease (COPD) affects approximately 16 million adults, accounts for more than $18 billion in annual health care costs, and is the fourth leading cause of death in the United States (1, 2). In 2002, approximately 620 000 persons were hospitalized for acute exacerbation of COPD, making this 1 of the 10 leading causes of hospitalization among U.S. adults (3).
In 1987, the American Thoracic Society became the first organization to produce clinical practice guidelines for the management of COPD (4). The number of standards has grown steadily since then, and various national and international organizations now produce guidelines (5-11). The American College of Physicians and the American College of Chest Physicians have coproduced evidence-based guidelines recommending that patients with acute exacerbations of COPD undergo a diagnostic evaluation that includes chest radiography and arterial blood gas analysis, followed by treatment with supplemental oxygen; anticholinergic bronchodilators; short-acting β2-agonists; systemic corticosteroids; antibiotics; and, in some circumstances, noninvasive positive-pressure ventilation. These guidelines identify spirometry, mucolytic agents, sputum examinations, methylxanthine bronchodilators, and chest physiotherapy to be of uncertain or no benefit, with the latter 2 treatments being potentially harmful (5).
University Hospital. Amiens. France
July 3, 2006
The Frog who Aspired to Become as Big as the Ox (1)
Improving care quality was a difficult task. Now, in comparison, Graal quest is journey arranged by a tour operator! Indeed, Lindenauer et al created a new definition for quality: "ideal care, defined as all of the recommended care processes and none of the nonrecommended ones".(2) Moreover, this term "ideal care" was confirmed in the Editor's note.
Quality is the satisfaction of a need or a requirement. Satisfaction comes from the latin "satisfacere" : "satis" = enough or sufficient + "facere" = to do. To do enough is not to do the ideal. "Quality of care is the degree to which health care is expected to increase the likelihood of desired health outcomes and is consistent with standards of health care". (3)
Jean de La Fontaine, wrote a parody to warn people about the dangers due to greediness and vanity: a puny, pretentious frog swelled up so much that she croaked.(1)
Gene therapy was an example. A few decade ago, great announcements for gene therapy are still unrealistic expectations. Quality must not repeat the same mistake. Do not hope too much, or too little, just hope for what you need.
2. Lindenauer PK; Pekow P; Gao S; Crawford A S; Gutierrez B; Benjamin EM. Quality of care for patients hospitalized for acute exacerbations of chronic obstructive pulmonary disease. Annals. 2006;144: 894-903.
Marya D. Zilberberg
Ortho Biotech Clinical Affairs, LLC
July 11, 2006
Time is on our side
To the Editor:
Kudos to Lindenauer et al. for their study on quality of care in COPD exacerbations, published in the Annals in June. Their work exemplifies the careful yet thorough health services research that is possible utilizing well-validated commercial data sources. They also rightly point out that COPD exacerbations lend themselves well to quality improvement efforts, given COPD's important clinical (4th leading cause of death, with mortality increasing over the last 2 decades ) and health economic ($16,487 per discharge, or >$10 billion nationally per year ) consequences. However, in my view the present work offers only the description of the baseline (pre-guideline) state of affairs.
The study enrolled patients discharged between 1 January 2001 and 31 December 2001 to explore adherence to a published clinical practice guideline (CPG). Given that the CPG was only published in April of 2001, is it realistic to think that this is enough time to allow for a broad implementation of the CPG recommendations into clinical practice? One need only look to several cases in the cardiology literature (e.g., beta- blockers in and lipid-lowering agents in myocardial infarction, as well as aspirin) to appreciate that translation of evidence into practice can take years, if not decades . That is not to say that we as the medical profession or consumers should accept such a protracted course. The question is, what is a reasonable minimal time period that one can expect to achieve substantial penetration of evidence into practice? Though the answer to this is unclear, given the education and the infrastructure needed to implement a new CPG at the bedside, the time frame in the current study is almost certainly not adequate.
Nevertheless, Lindenauer et al. identified a tremendous opportunity to improve the processes around COPD exacerbation management. With their study, they have provided a valuable tool for measuring current and future progress in adoption of the COPD exacerbation CPG into practice, and, more importantly, its impact on outcomes.
1. Lindenauer PK, Pekow P, Gao S et al. Quality of Care for Patients Hospitalized for Acute Exacerbations of Chronic Obstructive Pulmonary Disease. Ann Intern Med 2006; 144: 894-903
2. Mannino DM, Homa DM, Akinbami LJ et al. Chronic Obstructive Pulmonary Disease Surveillance --- United States, 1971"”2000. MMWR 2002;51(SS06);1-16
3.http://hcup.ahrq.gov/HcupNet.asp?Id=63158C7FE73B176A&Form=SelDXPR&JS=&Action=%3E%3ENext%3E%3E&_DXPR=PreRunDCCHPR1; Accessed July 11, 2006
4. Lenfant C. Clinical Research to Clinical Practice "”Lost in Translation? N Engl J Med 2003;349:868-74
Dr. Zilberberg is an employee and a stock holder of Johnson & Johnson. This letter does not necessarily represent the views of Ortho Biotech Clinical Affairs, LLC or Johnson & Johnson, its parent company.
Alec B. O'Connor
University of Rochester School of Medicine and Dentistry
July 18, 2006
Quality is not easy to measure
Lindenauer and colleagues (1) should be commended for analyzing the care of a huge number of COPD patients and attempting to measure the quality of existing care. Unfortunately, their efforts are hampered by inadequate primary research and limitations in their patient database.
Clinical research involving COPD care has not clearly defined good quality care. The guidelines manuscript that the authors used to define quality markers indicates that the evidence supporting many of the recommendations is relatively weak because of the small number of trials, often involving small numbers of patients, and because the trials frequently rely on surrogate outcomes, such as FEV1 (2).
Lindenauer and colleagues imply that patients with COPD exacerbations who do not receive oxygen, steroids, and antibiotics have received suboptimal care (1). The practice guideline is far less proscriptive. It indicates that patients should receive oxygen if hypoxic, and "our first research objectives must include untangling the questions surrounding selection of patients for antibiotic and steroid treatment" (2). Unfortunately, it does not seem that Lindenaur and colleagues' database allowed them to determine which patients were hypoxic, which had increased (or any) sputum production, or which might have had contraindications to systemic steroids.
In addition, there is no evidence to suggest that mucolytics are harmful. The authors of the guideline acknowledge that "there is a possibility that these agents improve symptoms" (2). Further, it is easy to imagine that sputum testing may have a role in some patients; for example, some severely ill patients at high risk of bronchial colonization or infection with resistant organisms may benefit from culture-directed antibiotic adjustments, and some patients in whom lung cancer is suspected may benefit from sputum cytology. Considering any use of these measures to indicate inappropriate care is too inflexible.
Guidelines are useful for guiding clinicians, but ultimately clinical judgment is required to apply the most appropriate, individualized care to a patient. We do need to strive to improve the quality of care we provide, but we should focus on measures that are unequivocally proven to benefit the patient population that we are assessing.
1. Lindenauer PK, Pekow P, Gao S, Crawford AS, Gutierrez B, Benjamin EM. Quality of care for patients hospitalized for acute exacerbations of chronic obstructive pulmonary disease. Ann Intern Med 2006;144:894-903.
2. Bach PB, Brown C, Gelfand SE, McCrory DC. Management of acute exacerbations of chronic obstructive pulmonary disease: a summary and appraisal of published evidence. Ann Intern Med 2001;134:600-620.
to gain full access to the content and tools.
Learn more about subscription options.
Register Now for a free account.
Hospital Medicine, Pulmonary/Critical Care, Healthcare Delivery and Policy, Chronic Obstructive Airway Disease.
Results provided by:
Copyright © 2016 American College of Physicians. All Rights Reserved.
Print ISSN: 0003-4819 | Online ISSN: 1539-3704
Conditions of Use
This PDF is available to Subscribers Only