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Quality of Care for Patients Hospitalized for Acute Exacerbations of Chronic Obstructive Pulmonary Disease

Peter K. Lindenauer, MD, MSc; Penelope Pekow, PhD; Shan Gao, MS; Allison S. Crawford, BA; Benjamin Gutierrez, PhD; and Evan M. Benjamin, MD
[+] Article, Author, and Disclosure Information

From Baystate Medical Center and Tufts University School of Medicine, Springfield, Massachusetts; University of Massachusetts–Amherst, Amherst, Massachusetts; and Premier Healthcare Informatics, Charlotte, North Carolina.

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.

Ann Intern Med. 2006;144(12):894-903. doi:10.7326/0003-4819-144-12-200606200-00006
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A total of 80 412 patients who were 40 years of age and older had a diagnosis of COPD during the study period, including 65 625 who had a principal diagnosis of COPD and 14 787 who had a principal diagnosis of respiratory failure and a secondary diagnosis of COPD. From this initial group, we excluded 9119 patients who had a secondary diagnosis of pneumonia, 1445 patients who were assigned to a diagnosis-related group that was not consistent with a hospitalization for COPD, 29 patients whose admission was coded as being related to childbirth, and 1 patient because of unknown sex. Of 69 820 patients remaining for analysis (median age, 70 years), 58% were women and 76% were white (Table 1). Hypertension, diabetes, and fluid and electrolyte disorders were the most commonly recorded comorbid conditions. The median length of stay was 4 days, and 1 of 4 patients was hospitalized for 1 week or longer. Overall, 2854 (4.1%) patients died during the hospitalization. Total readmission rates at 14 and 30 days were 11.1% and 17.2%, respectively, and COPD was the principal diagnosis for approximately one third of these readmissions.

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Performance data for the 360 hospitals that participated in the study.Recommended careNonrecommended careIdeal care

The line in the middle of each box represents the median performance rate for individual and composite measures across hospital(s), and the box extends to the interquartile range (IQR). The lines emerging from the box extend to the adjacent values. The upper adjacent value is defined as the largest data point less than or equal to the 75th percentile plus 1.5 times the IQR. The lower adjacent value is defined as the smallest data point greater than or equal to the 25th percentile minus 1.5 times the IQR. indicates receiving all of the following: chest radiography; supplemental oxygen; and therapy with bronchodilators, systemic corticosteroids, and antibiotics. indicates receiving 1 or more of the following: chest physiotherapy, acute spirometry, methylxanthine bronchodilator therapy; mucolytic therapy, or a sputum test. indicates receiving all of the recommended care elements (chest radiography; supplemental oxygen; and therapy with bronchodilators, systemic corticosteroids, and antibiotics) and none of the nonbeneficial measures (chest physiotherapy, acute spirometry, sputum test, or therapy with methylxanthine bronchodilators or mucolytic agents). NPPV = noninvasive positive-pressure ventilation.

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The Frog who Aspired to Become as Big as the Ox (1)
Posted on July 3, 2006
Alain Braillon
University Hospital. Amiens. France
Conflict of Interest: None Declared

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.

1. http://lafontaine.mmlc.northwestern.edu/fables/grenouille_boeuf_vv.html

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.

3. http://www.nlm.nih.gov/nichsr/hta101/ta101014.html).

Conflict of Interest:

None declared

Time is on our side
Posted on July 11, 2006
Marya D. Zilberberg
Ortho Biotech Clinical Affairs, LLC
Conflict of Interest: None Declared

To the Editor:

Kudos to Lindenauer et al. for their study on quality of care in COPD exacerbations, published in the Annals in June[1]. 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 [2]) and health economic ($16,487 per discharge, or >$10 billion nationally per year [3]) 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 [4]. 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

Conflict of Interest:

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.

Quality is not easy to measure
Posted on July 18, 2006
Alec B. O'Connor
University of Rochester School of Medicine and Dentistry
Conflict of Interest: None Declared

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.

Conflict of Interest:

None declared

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